Transcript Adolescent Medicine - NCC Pediatrics Residency @ Walter

Adolescent Medicine
16 May 2006
0900 Routine Appt
Case 1
TC a 16 y/o male
CC: Allergies per mother
HPI
His mother comes back to the room
and says his eyes have been red
for the last 4 months
She thinks he has allergies.
He doesn’t think there is any
problem.
What do you want to know?
Symptoms
FH
Medications
HEADSS
LABS
Physical
HEADSS
Parents recently divorced
Failing independent studies.
Hanging out with friends
Smokes
Has had 1 LTP
Not suicidal
PE
Alert normal vital signs
Presence of gynecomastia
Otherwise normal exam
Marijuana
Marijuana
Tools of use
“New” Marijuana
Marijuana of the 60’s had a THC
concentration of 0.5% to 1%
Marijuana of today has been
engineered to have a THC
concentration of 6% to 15%
Effects
Elation
Euphoria
Impaired short-term memory
Divided attention tasks difficult
(e.g. driving)
Loss of critical judgment
Distortion of time perception
Bad effects
Visual hallucinations
Perceived body distortions
Panic attacks
Paranoia
Amotivational syndrome
Clinical manifestations
Lowered
temperature
Tachycardia
Hypertension
Tachypnea
(experienced user)
Plasma testosterone
suppression
Lowers sperm count
Gynecomastia
Questionable
physiologic
dependency
Back to TC
His mom said she wants a
drug test
Marijuana drug screen
Detection window 7 to 30 days
Screen
RIA/EIA
Confirmation
GC / MS
Interpretation
Second-hand exposure
foods
2230 Sat
Case 2
CC a 17 year old boy
Stat consult to ER for
strange behavior
HPI
17 Y/O male being restrained in the
E.D. Says the terrorists are after
him.
What do you do?
ABCDE
PE
LABS
Meds
PE
Pulse 160
BP 180/100
Temp 101
Agitated
His pupils are dilated.
UDS
AMPHETAMINES……………….PENDING
BENZODIAZEPINES……………PENDING
COCAINE…………………………PENDING
OPIATES………………………….PENDING
THC(CANNABINOIDS)………… PENDING
BARBITUATES………………….. PENDING
PCP(PHENCYCLIDINE)……….. PENDING
METHADONE…………………….PENDING
TCAs(DeWitt)
Cocaine
Epidemiology
Use dropped from 1985 – 1990
5.8 million to 1.6 million users
(use in prior 30 days)
High school seniors (Ever used)
17.3% (1985)
5.9% (1994)
8.7% (1997)
4.7% (2003)
Crack is about ½ of total cocaine use
Cocaine
Cocaine
Cocaine
Cocaine
Clinical manifestations
Euphoria
Increased motor activity
Decreased fatigability
Paranoid ideation (occasionally)
Cocaine
Clinical manifestations
Pupillary dilatation
Tachycardia
Hypertension
Hyperthermia
Death
“Speedball”
Cocaine injected with heroin
Cocaine Drug Screen
Detection period 2-4 days, 8 days for
long-term use
Metabolized to benzoylegonine and
ecgonine methyl ester
Plasma 1/2-life of cocaine is 1 hour,
metabolites 7.5 and 3.6 hours
FALSE positive with Health Inca Tea
(HIT)
10:00 Routine Appt
Case 3
LD - 16 y/o male
CC: Mom wouldn’t say
HPI
Mom reports that Saturday night he
was very silly and confused
Spontaneously laughed
Said he saw sound but then changed
his story
He’s acting fine now
What now?
PMH
FH
HEADSS
PE
LABS
Hallucinogens
LSD
MDMA (Ecstasy)
GHB
PCP
Ketamine
1997
15.1% seniors tried in lifetime
13.6% - LSD
6.9% - MDMA
3.9% - PCP
12.8% MDMA 2003
LSD
Lysergic acid diethylamide
“Acid,” “big ‘D,’” “blotters”
Rye fungus
Highly potent
Can be applied to small objects (stamps)
Onset 30-60 minutes
Lasts 10-12 hours
Mechanisms of action unknown
LSD
LSD
LSD
Clinical manifestations
Somatic
Nausea
Dizziness
Dilated pupils
Fever
Flushing
Tachycardia
LSD
Clinical manifestations
Perceptual
Synesthesia
“Seeing” smells
“Hearing” or “tasting” colors
Psychic
Delusions
Body distortion
Suspiciousness
Toxic psychosis
In Service question often
missed!
How do you treat a bad trip?
LSD
Treatment
“Bad trip”
User terrified, panicked
Remove person from setting
Attempt to re-establish contact with reality
Calm verbal interaction
“Flashbacks”
LSD-induced states after drug worn off
No withdrawal syndrome
0100 Sat Morning
Case 4
PP is 16 Y/O female brought in to ED
after being “found” at a friends
house.
What now?
ABCDE
PE
LABS
PE
Pinpoint pupils, poor response to
stimulation.
Arms with multiple small scars and
needle marks
Opiates
Epidemiology
Use decreased during 1980s
Seniors use
0.9% 1991
2.1% 1997
2.9% 2003
Increase may be related to route
Snort and smoke more often
Heroin
Pharmacology
Heroine hydrolyzed to morphine
Onset of action
Inhaled (snorting): 30 min
SQ (skin-popping): few minutes
IV (mainlining): immediate
Tolerance
Yes to euphoric effect
No to inhibit of smooth muscle
Constipation and miosis
Heroin
Clinical manifestations
Euphoria
Diminution of pain
Pinpoint pupils
Loss of libido
Poppy
Heroin
Opiates Drug Screen
Detection period 1-2 days
heroin only 8 hours
Screen positive with morphine,
codeine, dihydrocodeine,
hydrocodone, hydromorphone,
oxycodone, poppy seeds
GC-MS confirmatory test for 6-MAM
no false positive
Prescription and OTC
Vicodin, Percocet, Oxycontin, etc
Dextromethorphan
Coriciden
Robotripping
11:00 Routine Appt
Case 4
Crystal 16 y/o female
CC: needs counseling
HPI
“Out of control.”
Run-away numerous times.
Brought in by police after missing
for 8 days.
Paranoid and angry.
Has not slept in 7 days.
Methamphetamine
Names
Ice,Crystal,Meth,Tweek,Crank, Batu
Ease of absorption
Snort, smoke, oral, across mucus
membranes (e.g. vaginal)
Methamphetamine
Home Labs
Methamphetamine
Better CNS penetration than
amphetamine
Affects release and breakdown of
catecholamines
Euphoria, hypomania and
hypersexuality (nonfunctional)
Effects
Hyperalert state
Talkative
Restlessness
elevated temp
Anorexia
Nausea
dry mouth
dilated pupils
Sweating
dizziness
hyperactive reflexes
Tremor
Insomnia
AGGRESSION
skin
picking(formication)
Hypertension
Tachycardia
arrhythmias
Methamphetamine
Treatment
Agitation and delusional behaviors
Haloperidol or droperidol
Cooling blanket for hyperthermia
Treatment of hypertension,
arrhythmias
Amphetamines
Detection period: 1-2 days
Positive screening test with:
amphetamine, dextroamphetamine,
methamphetamine, pseudoephedrine,
phentermine, ephedrine,
phenylpropanolamine, phenylephrine,
selegiline(Parkinson’s med)
some will dectect MDMA (ecstacy)
most will not
Amphetamines
Urinary excretion is pH dependent;
acidification can reduce plasma 1/2life to 7-8 hours, alkinization may
increase the 1/2-life to over 33 hours
Lack of specificity of screening test
makes confirmatory test essential
Toxidromes
Sedative-Hypnotic
Anticholinergic
Sympathomimetic
Cholinergics
Hallucinogens
Phenothiazines
Opiates
Mixed
19 Y/O male brought in by
ambulance from a local dance club.
Witnesses report he was dancing at
the club when he suddenly fainted
and then had seizure-like activity.
A friend reported he was acting
“strange” – very affectionate and
had been so “in” to the music he
hadn’t left the dance floor all night
Toxidrome Question
What class of drug is he using?
Sedative-Hypnotic
Anticholinergics
Sympathomimetic
Hallucinogens
Opiates
Cholinergics
Phenothiazines
Mixed
Toxidrome Question
This picture fits that of a “mixed” drug with
both sympathomimetic and hallucinogenic
properties
What is the most likely substance?
Alcohol
Marijuana
Amphetamine
PCP
MDMA
LSD
Heroin
Jimson Weed
Mushrooms
Ephedra Alkaloids
Toxidrome Question
MDMA (ecstacy)
Disinhibition of thermoregulation with
resultant dehydration, hyperthermia
and seizures are the risk of acute use.
Long-term memory impairment is the
chronic risk
Methylenedioxy
methamphetamine
MDMA
Ecstasy
E
XTC
X
Adam
Effects
Relaxed, euphoric state
Increased self-esteem
Heightened senses
More in tune with music
Light shows more spectacular
Sense of touch enhanced
Increased empathy, breakdown of social
barriers
Feelings of understanding and accepting others
Negative effects
Muscle Hypertonicity
Jaw-clenching
Disinhibition of thermoregulation
Hyperthermia
Sweating
Dehydration - hyponatremia
Seizures
arrhythmias
More Badness
Hypertension
Nausea
Dizziness
Ataxia
Tremor
Nystagmus
Difficulty
Concentrating
With higher or
repeated doses
Anxiety
Paranoia
Hallucinations
Suicidal Depression
DanceSafe.org
Many proponents of “safe” ecstasy
use
Feel that recreational use at dances
(classically raves), while ensuring
proper rehydration, should be legal
Claim no long term negative effects
Long-term
New research:
Long-term damage to 5-HT cells. They
do regenerate, but abnormally, with
abnormal function (PET scans)
Long term memory deficits, even with
only occasional, recreational use
Toxidrome Question
14 Y/O male brought in by parents because he’s
“acting weird.” Pupils normal, conjunctiva red, lateral
nystagmus on exam, nonconvergence to close object,
sleepy, slurring of speech. Rapid Urine Drug screen
is negative.
What class of drug is he using?
Sedative-Hypnotic
Anticholinergics
Sympathomimetic
Hallucinogens
Opiates
Cholinergics
Phenothiazines
Mixed
Toxidrome Question
Sedative-Hypnotic effects from the
history
What is the most likely substance?
Alcohol
Marijuana
Amphetamine
PCP
MDMA
LSD
Heroin
Jimson Weed
Mushrooms
Ephedra Alkaloids
Toxidrome Question
Alcohol intoxication. The red eyes with
nystagmus and nonconvergence
Sleepiness, slurred speech and negative
urine drug screen fit best with alcohol
Toxidromes
Recognizing the potential drugs
It also helps to decide what drugs a person
may have used in the past based on the
description
You will see these types of questions on Inservice and Board exams
Toxidromes
If you have questions about any of
these drugs or their presentations,
please contact one of the Adolescent
Staff (not for samples)
THANKS!
Questions?
None ordered