LSD and other Hallucinogens- Expected Lecture Outcomes Respond to the threat of intoxication of LSD and other hallucinogens. List various means of possible exposure. Develop a protocol for managing toxic ingestions, and the antidotes and treatments associated with their pathology.

LYSERGIC ACID DIETHYLAMIDE(LSD) AND OTHER HALLUCINOGENS Hallucination is a false perception of something that is not really there. Hallucinations may be visual, auditory, tactile, gustatory (of taste) or olfactory (smell). Any agent which has the potential of producing intense hallucinogen is called hallucinogens. Also called as entactogens (to touch within). Used as addictive substance and in clinics to conduct pschotherapeutic interviews.

LYSERGIC ACID DIETHYLAMIDE(LSD) AND OTHER HALLUCINOGENS Mechanism of toxicity: LSD stimulates 5HT2 receptors and other agents act by altering serotonin and dopamine activity in brain. MDMA (methylene dioxy methamphetamine), also called as Ecstasy cause direct neurotoxicity.

Mild to moderate intoxication: A person experiencing a "bad trip" is conscious, coherent, and oriented but is anxious and fearful and may display paranoid (Thought process influenced by anxiety or fear) or bizarre reasoning. The patient may also be tearful, combative or self-destructive. Delayed intermittent "flashbacks" may occur after the acute effects have worn off and are usually precipitated by use of another mind-altering drug.

Life threatening Toxicity: Intense sympathomimetic stimulation can cause seizures, severe hyperthermia, hypertension, intracranial hemorrhage, and cardiac arrhythmias. Hyperthermic patients are usually obtunded, agitated or thrashing about, diaphoretic, and hyperreflexic. Hyperthermia has been associated with LSD, methylene dioxyamphetamine (MDA), MDMA, and paramethoxyamphetamine. Severe hyponatremia has been reported after use of MDMA and may result from both excess water intake and inappropriate secretion of antidiuretic hormone. The use of 2,5-dimethoxy-4-bromoamphetamine (DOB) will result in ergot-like vascular spasm, circulatory insufficiency, and gangrene

Treat agitation or severe anxiety states with diazepam or midazolam . TREATMENT Treat agitation or severe anxiety states with diazepam or midazolam . Butyrophenones such as haloperidol are useful despite a small theoretic risk of lowering the seizure threshold. Treat seizures , hyperthermia, rhabdomyolysis, hypertension, and cardiac arrhythmias if they occur.

MARIJUANA Expected Lecture Outcomes Respond to the threat of intoxication of Marijuana. List various means of possible exposure. Develop a protocol for managing toxic ingestions, and the antidotes and treatments associated with their pathology.

MARIJUANA Marijuana consists of the leaves and flowering parts of the plant Cannabis sativa and usually is smoked in cigarettes ("joints" or "reefers") or pipes or added to food (cookies or brownies). Resin from the plant may be dried and compressed into blocks called hashish. Marijuana contains a number of cannabinoids; the primary psychoactive one is delta-9-tetrahydrocannabinol (THC). THC is also available in capsule form (dronabinol or Marinol) as an appetite stimulant used primarily for AIDS-related anorexia and as treatment for vomiting associated with cancer chemotherapy.

Mechanism of Toxicity: THC, which binds to anandamide receptors in the brain, may have stimulant, sedative, or hallucinogenic actions, depending on the dose and time after consumption. Both catecholamine release (resulting in tachycardia) and inhibition of sympathetic reflexes (resulting in orthostatic hypotension) may be observed.

CLINICAL PRESENTATIONS: Physical findings may include tachycardia, orthostatic hypotension, conjunctival injection, incoordination, slurred speech, and ataxia. Stupor with pallor, conjunctival injection, fine tremor,and ataxia has been observed in children after they have eaten marijuana cookies. Other health problems include salmonellosis and pulmonary aspergillosis from use of contaminated marijuana. After smoking a marijuana cigarette, symptoms include euphoria, palpitations, heightened sensory awareness and altered time perception followed after about 30 minutes by sedation. More severe intoxication may result in impaired short-term memory, depersonalization, visual hallucinations, and acute paranoid psychosis.

TREATMENT Most psychological disturbances can be managed by simple reassurance, possibly with adjunctive use of lorazepam, diazepam, or midazolam. Sinus tachycardia usually does not require treatment but, if necessary, may be controlled with beta blockers. Orthostatic hypotension responds to head-down position and intravenous fluids. Administer activated charcoal orally if conditions are appropriate. Gastric lavage is not necessary if activated charcoal can be given promptly.

Nicotine Expected Lecture Outcomes Respond to the threat of intoxication of Nicotine. List the various means of possible exposure. Develop a protocol for managing toxic ingestions, and the antidotes and treatments associated with their pathology.

NICOTINE Nicotine intoxication arises when Nicotine chewing gum (Nicorette), transdermal delivery formulations (Habitrol, Nicoderm, Nicotrol, Prostep, and generics), and nicotine nasal spray, inhalers, and lozenges are widely available as adjunctive therapy for smoking cessation. Alkaloids similar to nicotine (anabasine, cytisine, coniine, and lobeline) are found in several plant species and can contribute to Nicotine-like toxicity. Accidental or suicidal ingestion of nicotine-containing pesticides (such as Black Leaf 40, which contains 40% nicotine sulfate), and occasionally after cutaneous exposure to nicotine, such as among tobacco harvesters ("green tobacco sickness") may also result in Nicotine toxicity.

Mechanism of toxicity: Nicotine binds to nicotinic cholinergic receptors, resulting initially, via actions on ganglia, in predominantly sympathetic nervous stimulation. With higher doses, parasympathetic stimulation and then ganglionic and neuromuscular blockage may occur. Direct effects on the brain may also result in vomiting and seizures.

TOXIC DOSE: Absorption of 40-60 mg in an adult is said to be lethal, although this dose spread throughout the day is not unusual in a cigarette smoker. Cigarette tobacco contains about 1.5% nicotine, or 10-15 mg of nicotine per cigarette. Transdermal nicotine patches deliver an average of 5-22 mg of nicotine over the 16-24 hours of intended application, depending on the brand and size. Transdermal patches may produce intoxication in light smokers or in nonsmokers, particularly children to whom a used patch inadvertently sticks. Ingestion of a discarded patch may also potentially produce poisoning.

CLINICAL PRESENTATION: Nicotine intoxication commonly causes dizziness, nausea, vomiting, pallor, and diaphoresis. Abdominal pain, salivation, lacrimation, and diarrhea may be noted. Pupils may be dilated or constricted. Confusion, agitation, lethargy, and convulsions are seen with severe poisonings. Initial tachycardia and hypertension may be followed by bradycardia and hypotension. Respiratory muscle weakness with respiratory arrest is the most likely cause of death.

TREATMENT: Nicotine and its metabolite cotinine are detected in comprehensive urine toxicology screens. Maintain an open airway and assist ventilation if necessary. Administer supplemental oxygen. Treat seizures, coma, potension,hypertension, and arrhythmias if they occur. Observe for at least 4-6 hours to rule out delayed toxicity, especially after skin exposure. Mecamylamine (Inversine) is a specific antagonist of nicotine actions; however, it is available only in tablets, a form not suitable for a patient who is vomiting, convulsing, or hypotensive. Signs of muscarinic stimulation (bradycardia, salivation, wheezing, etc), if they occur, may respond to atropine.

Decontamination: Rescuers should wear appropriate skinprotective gear when treating patients with oral or skin exposure to liquid nicotine. Administer activated charcoal orally if conditions are appropriate. Gastric lavage is not necessary after tobacco ingestion if activated charcoal can be given promptly. Consider gastric lavage for large recent ingestion of liquid nicotine.