20 year old male delivered to the ED by an acquaintance

1
20 year old male delivered to the ED by an
acquaintance     Initial signs and
symptoms   Delusions Diaphoretic Paranoia
Piloerection Tachycardia Mydriasis Hypertension
Hyperreflexic Hyperpyrexic     What is this
toxidrome?   What compounds may induce this type
of syndrome?
2
Anticholinergic Syndrome
Cholinergic Syndrome
Sympathomimetic syndrome
Opioid / Ethanol / Sedative Toxidrome
3
Further history       The acquaintance relates
that the patient had ingested a party drug 2
hours previously, but he could not remember
what.         What group of drugs does the
compound likely belong to?  
4
Amphetamine/amphetamine-like compounds
Amphetamine-like compounds increase
neurotransmission in central noradrenaline,
dopamine and serotonin systems. While they
produce similar pharmacological actions, there
are differences in effect on individuals
depending on the relative stimulation of the
various neurotransmitter systems (e.g. increased
serotonin causes increased hallucinogenic effect).
5
Amphetamine/amphetamine-like compounds
Neurotransmitter release Low dose preferential
action on noradrenaline release Moderate dose
noradrenaline and dopamine release High dose
noradrenaline, dopamine and serotonin
release Blockade of re-uptake (noradrenaline,
dopamine and serotonin) Inhibition of monoamine
oxidase Note There is variation between the
various sympathomimetic drugs
6
Amphetamine/amphetamine-like compounds
Amphetamines   Amphetamine   Amphetamine
derivatives / Amphetamine-like drugs   Methampheta
mine (P pure crystal methamphetamine)  
7
3,4-Methylenedioxymethamphetamine MDMA, Ecstasy,
XTC 3,4-Methylenedioxyamphetamine MDA, Love
drug 3,4-Methylenedioxyethamphetamine MDEA,
Eve Para-methoxyamphetamine PMA   3,4-methylened
ioxy-phenyl-N-methylbutanamine MBDB
8
2,4,5-Trimethoxyamphetamine TMA-2
  4-Methyl-2,5-dimethoxyamphetamine DOM/STP,Sere
nity, peace, Tranquility 4-Bromo-2,5-dimethoxyamp
hetamine DOB   4-Bromo-2,5 methoxyphenylethylamin
e 2CB, MFT   Methcathinone Khat, cat, quat,
gat, jeff Ephedrione
9
Plants
Khat, (Catha edulis) cathine (norpseudoephedrine)
Ma-huang, (Ephedra ma-huang) Ephedra Pey
ote cactus, (Lophophora Williamsii) Mesculine
10
Therapeutic
Dexamphetamine Benzphetamine Diethylpropion Phente
rmine Fenfluramine Pseudoephedrine
Methylphenidate Phendimetrazine Pemoline Propylhex
adrine Dexfenfluramine
 
11
The acquaintance gets off a cell-phone and tells
you the drug is P.       What is
P?       What range of signs and symptoms can
be expected from this drug?
12
What is P?     Pure crystal methamphetamine.
What range of signs and symptoms can be expected
from this drug?  
13
What range of signs and symptoms can be expected
from this drug? 
Mild Euphoria Increased alertness Bruxism Alte
red mental status Tachycardia Hypertension
Moderate Agitation Paranoia Hallucination Diap
horesis Vomiting   Abdominal pain Palpitations
Chest pain
14
What range of signs and symptoms can be expected
from this drug? 
Severe  Hyperthermia  Ischaemia/vascular
rupture  Metabolic acidosis  Rhabdomyolysis  Hyper
kalaemia  Acute renal failure  Coma  Death
15
How should a patient suffering an
amphetamine-like compound overdose be
managed?     Emergency stabilisation?   Decontamin
ation?     Antidote?     Enhanced
Elimination?     Supportive Care?
16
Emergency stabilisation?
Vascular spasm/rupture
Acute Coronary Syndrome
Arterial Spasm (arterial injection)
Hyperthermia
17
Emergency stabilisation?
Vascular spasm/rupture
A range of acute cardiovascular emergencies may
occur due to vasospasm or vascular rupture. Such
events include hemorrhagic or ischemic stroke,
cardiac dysrhythmia/arrest, dissection of large
vessels including the aorta.   Intracerebral
hemorrhage is well recognized and may be related
to acute hypertension associated with arterial
spasm and vascular rupture. Patients with
arteriovenous malformations, or with drug induced
cerebral vasculitis, appear particularly prone.
Patients with severe headache should be fully
investigated.
18
Emergency stabilisation?
Acute Coronary Syndrome
Myocardial ischemia may occur following
sympathomimetic overdose due to coronary artery
vasoconstriction, thrombus formation and platelet
aggregation. Myocardial ischemia can progress to
infarction. Use of beta-adrenergic receptor
blockers is contra-indicated.   Recommended
management of this condition includes Benzodiazep
ine Nitroglycerin Phentolamine
19
Emergency stabilisation?
Arterial Spasm (arterial injection)
Arterial spasm may occur following direct
amphetamine injection, with resultant ischemia
and potentially tissue necrosis. Management
should include immediate intra-arterial injection
of an alpha-adrenergic blocking agent such as
phentolamine.
20
Emergency stabilisation?
Hyperthermia
Muscular Movement
Serotonin Syndrome
21
Sympathomimetic syndrome   Sometimes confused
with the anticholinergic syndrome, but the later
is associated with dry skin and diminished bowel
sounds.   Mechanism   A drug mimicking the action
of the sympathetic system Alpha/beta adrenergic
stimulation
What compounds may induce this type of
syndrome?   Cocaine Amphetamines and
amphetamine-like compounds OTC decongestants
(pseudoephedrine, ephedrine, phenylpropanolamine)
Theophylline, caffeine 
22
Anticholinergic Toxidrome     Mechanism  Blockade
of muscarinic receptors preventing interaction
with acetylcholine.
Signs and symptoms
Delirium Tachycardia Dry, flushed
skin Mydriasis Myoclonus Elevated
temperature Urinary retention Decreased bowel
sounds Seizures Dysrhythmias
Hot as a hare Blind as a bat Dry as a bone Red as
a beet Mad as a hatter Bloated as a bladder
23
Anticholinergic Toxidrome  
Common causes 
Atropine Antiparkinsonian drugs Scopolamine Fly
agaric
Tricyclic antidepressants Datura Antihistamines An
tipsychotic agents
24
Cholinergic Toxidrome
Mechanism
Over stimulation of cholinergic receptors
(muscarinic and nicotinic)
Signs and symptoms
Urinary and faecal incontinence Gastrointestinal
cramping Emesis Diaphoresis Bradycardia Seizures
Confusion CNS depression Miosis Weakness Salivatio
n Lacrimation Pulmonary oedema
25
Opioid / Ethanol / Sedative Toxidrome
Mechanism
Various depending on primary intoxicant
Signs and symptoms
Coma Respiratory depression Miosis Hypotension Bra
dycardia
Hypothermia Pulmonary oedema Decreased bowel
sounds Hyporeflexia
26
Cholinergic Toxidrome
Mnemonics for muscarinic effects
D Diarrhoea U Urination M Miosis B Bronchorrhoea/B
radycardia/Bronchospasm E Emesis L Lacrimation S S
alivation S Salivation L Lacrimation U Urination
D Diarrhoea G Gastrointestinal upset E Emesis
27
(No Transcript)
28
(No Transcript)
29
(No Transcript)