Transcript rose-methgrandroundsx

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Care for the
MethamphetamineExposed Child
Jenny Rose, MD
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Disclosure
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I do not have a financial interest, arrangement, or affiliation
with one or more organizations that could be perceived as
real or apparent conflict of interest in the context of the
subject of this presentation.
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I do not anticipate discussing the unapproved or
investigative use of a commercial product or device during
this activity or presentation.
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What is Methamphetamine?
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A mood and energy-enhancing stimulant
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Rapid onset of symptoms with long duration (~24 hours)
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Inexpensive
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Highly addictive
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Illegal, schedule 2 drug
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Snorted, smoked, ingested, injected
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Can be made from household items
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How does it work?
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Blocks reuptake of dopamine
and norepinephrine
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Promotes release of dopamine
into synaptic cleft
Image: http://research-chemicals.us/tag/dopamine/
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Image: http://www.pbs.org/wgbh/pages/frontline/meth/body/methbrainflash.html
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How is Meth made?
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How much does meth cost?
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$25 per hit
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Average $105 per gram
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Varies based on location and purity
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Mexico vs. Clandestine lab
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Production: depends on recipe
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Profit margin for sellers: 3000-4000%
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Cost to society: Estimated $23.4 billion in US (2005)
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Is it dangerous to be near a meth
“cook”?
Chemical
class
Method of
exposure
Adverse effects
Ammonia
Inhalation
Eye, nose, throat irritation; dyspnea, chest pain,
pulmonary edema
Dermal
Skin burns, vesiculation, frostbite
Inhalation
Pneumonitis, pulmonary edema
Topical exposure
Caustic burns
Ingestion
Gastric perforation, esophageal damage with later
strictures, nausea, vomiting
Solvents
Inhalation and
ingestion
Liver and kidney damage, respiratory irritation, CNS
effects, aspiration, headache
Iodine
Inhalation
Respiratory distress, mucous membrane irritation
Ingestion
Corrosive gastritis
Phosphorus
Ingestion
Gastrointestinal irritation, liver damage, oliguria
Phosphine gas
Inhalation
Ocular irritation, nausea, headache, fatal respiratory
effects
Acids and bases
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The teddy bear experiment
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Controlled “cook” experiment
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12 inches from production area
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Phosphine, iodine and HCl
released and measured
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pH of bear’s torso 1.0
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Sweater and underlying fur
positive for methamphetamine
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Meth: the next drug craze
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2nd only to marijuana as most widely used illegal drug in the
world
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2nd largest drug threat in U.S. in 2011 report by National Drug
Intelligence Center
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20% of methamphetamine-related arrests have children
associated with the case
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Treatment of meth abuse/addiction has more than doubled
since 2000
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Clandestine meth lab seizures on the rise
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Meth lab seizures 2005-2011
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Meth… AKA
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Blue meth
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Stove top
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Trash
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Yaba
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Granulated
orange
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Cinnamon
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Crystal
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Geep
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Ice
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Lemon drop
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Peanut butter
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Super ice
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Wash
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Yellow barn
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Crank
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Crystal meth
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Glass
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Tick tick
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Crink
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Working
 Sketch
man’s cocaine
 Yellow
Desocsins
powder
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OZs
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Chalk
Chicken feed
Hillbilly crack
Hot ice
Speed
Spoosh
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LA glass
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Infants and children: signs and
symptoms of exposure to meth
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Agitation, tachycardia, and crying
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Vomiting +/- abdominal pain
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Hyperthermia
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Hypertension
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Ataxia
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Midriasis
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Seizures
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Roving eye movements
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Differential diagnosis
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Sepsis, meningitis, encephalitis
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Intracerebral hemorrhage or infarction
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Hyper/Hypoglycemia
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Hyperthermia
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Temporal lobe epilepsy
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Thyrotoxicosis
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Pheochromocytoma
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Psychosis
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Differential diagnosis (cont.)
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Other toxin ingestion/exposure: PCP, cocaine,
anticholinergics, salicylates, lithium, MAOI, theophylline,
caffeine, LSD, TCAs, Amoxapine, Isoniazid,
monomethylhydrazine
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Confused for scorpion envenomation
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Serotonin syndrome, neuroleptic malignant syndrome
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Ethanol/sedative withdrawal
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If you see caustic ingestion/injury, consider meth exposure!
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Case presentation
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6 yo male discovered living in a mobile home where meth
was “cooked.” He has had irregular school attendance and
has been experiencing academic difficulties and behavioral
outbursts.
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DTF performs the “bust,” and decontaminates the child on
the scene. He is then transferred to a CPS worker, who takes
the patient to the nearest ED.
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Decontamination
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Removal of clothing and warm shower with soap
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On scene by Drug Task Force if significant fire/explosion and
child medically stable. They should wear proper PPE!
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In ED if asymptomatic child
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Clothing may be submitted to police for evidence
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All toys, personal items, clothing, etc. must be left at the site
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May keep eye glasses, hearing aids, durable medical
equipment
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Child delivered to DCS CPS worker on site, then taken to ED
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Focused History
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What? Where? When? How? Why?
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Symptoms of exposure
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Prior presentations
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Indicators of abuse/neglect
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PMH: asthma, breathing problems, GI or Neuro issues
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Family hx: drug abuse/addiction, psych disorders
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Social hx: caregiver hx
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Focused Physical
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Vitals and growth parameters
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Neurologic
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Tachypnea, inhalation/chemical pneumonitis, wheezing
Cardiovascular
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Altered mental status, confusion, agitation, irritability, seizure,
excessive crying, midriasis
Respiratory
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Fever, tachycardia, hypertension, tachypnea, failure to thrive
Hypertension, tachycardia
Skin
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Burns, sores, unusual bruises
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Workup
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UDS
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Fingerstick glucose
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CMP
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Hyperkalemia, metabolic acidosis, elevated BUN/Cr, elevated LFT
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Lead level
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EKG for meth-induced ischemia
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Creatinine phosphokinase, serum lactate
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Hair drug testing
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Consider Hep B, Hep C, RPR, HIV, STI testing if sexual abuse is
suspected
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Hospital care
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Acute symptoms may persist for ~24 hours
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Monitor vitals and place on telemetry
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May require intubation
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Control hyperthermia
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Anti-hypertensives - avoid beta-blockers!
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Sedation – benzos first line
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Maintain urine output
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Enlist social and child protection services
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Contact CAC within 72 hours of removal from site
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Social risks to consider
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Physical abuse
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Neglect
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Malnutrition
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Exposure to criminal behaviors
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Sexual abuse – high risk due to hypersexual behaviors
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Prostitution
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Bottom line: Meth abuse is not conducive to adequate
parenting!
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Considerations for the primary
care provider
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Developmental delays
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Learning problems, ADHD, school problems
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Growth failure
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Psychological complications are extensive
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Look out for subtle presentations!
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Unexplained increased lead level
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Repeated asthma exacerbation
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Above problems
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Is Meth really a problem in our
area?
© 2006 Mayo Foundation for Medical Education and Research
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Methamphetamine incidents in TriCities area, 2011
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Local news
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Mount Carmel man facing meth charge – March 2013
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JC police: Incident involved meth, lighter fluid, Taser, fire –
March 2013
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Meth dump site discovered in Hampton – March 2013
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JC police: Two charged with child neglect following meth
incident – March 2013
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Carter police say three meth labs found in one day – Feb
2013
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Four people charged after meth lab found in vehicle – Dec
2012
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What is TN doing?
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TN Meth Offender Registry (2005)
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Pharmacy restrictions on sale of pseudoephedrine (MethFree TN Act, 2005)
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Knowingly allowing a child to be present within a structure
where the act of creating methamphetamine is occurring is
included in the definition of “severe child abuse” TCA § 371-102(b)(21)
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7/2011 - “Aggravated child endangerment” if cooking meth
in front of a child (I Hate Meth Act)
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Methfreetn.org
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Other meth-related topics beyond
scope of this lecture
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Prenatal meth exposure
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Meth use in the adolescent
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Acknowledgements
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Dr. Debra Q. Mills
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Dr. Karen Farst
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Nakia Woodward
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Questions?
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References
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Boyer EW and C Hernon. Up To Date Online. “Methamphetamine
intoxication.” Last updated 17 Feb 2011.
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Grant P, Bell K, Steward D, et al. “Evidence of Methamphetamine
Exposure in Children Removed from Clandestine
Methamphetamine Laboratories.” Pediatr Emerg Care. (26):1, Jan
2010.
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Lineberry TW and M Bostwick. “Methamphetamine Abuse: A
Perfect Storm of Complications.” Mayo Clin Proc. 2006;81:77-84.
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McGuinness TM and D Pollack. “Parental Methamphetamine
Abuse and Children.” J Ped Health Care. 2008;22, 152-8.
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Grant P and NH Lebanon. “Evaluation of Children Removed from
a Clandestine Methamphetamine Laboratory.” J Emerg Nursing.
2007;33:31-41.
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References
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Farst K, JA Reading Meyer, T Mac Bird, et al. “Hair drug
testing of children suspected of exposure to the manufacture
of methamphetamine.” J Forensic and Legal Med. 2011;18:1104.
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Farst K, JM Duncan, M Moss, et al. “Methamphetamine
Exposure Presenting as Caustic Ingestions in Children.” Ann
Emerg Med. 2007;49:341-343.
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Kolecki P. “Inadvertent methamphetamine poisoning in
pediatric patients.” Ped Emerg Care 1998;14(6):385-7.
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Washington County DCS. “Guidelines for Managing Children
Found at Clandestine Methamphetamine Laboratory Sites for
the 1st Judicial District.” April 2006.
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References
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Mountain States Health Aliance. “Orders for Pediatric Patient
Exposure to Methamphetamine Laboratory.” 05 May 2006.
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Tennessee Bureau of Investigation. “Tennessee Crime
Statistics Online.”
<http://www.tbi.tn.gov/tn_crime_stats/crime_stats_online.sh
tml>
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National Alliance for Drug Endangered Children.
<http://www.nationaldec.org/home.html>
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U.S. Dept of Justice, National Drug Intelligence Center.
“National Drug Threat Assessment, 2011.”
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References
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CDC MMWR. “Epidemiologic Notes and Reports Lead
Poisoning Associated with Intravenous-Methamphetamine
Use.” Oregon, 1988.
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Drug Enforcement Agency, Office of Diversion Control.
“Methamphetamine.” July 2012.
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Nicosia N, Rosalie L Pacula, B Kilmer, Russell Lundberg and
James Chiesa. The Economic Cost of Methamphetamine Use
in the United States, 2005. Santa Monica, CA: RAND
Corporation, 2009.
http://www.rand.org/pubs/monographs/MG829.