Transcript Drugs - Autumn Symposium

Recreational Drugs
The PAH ED
Perspective
Julia Kelly
Autumn Symposium 2016
• What
we see at Princess Alexandra Hospital
• Complications
• Acute
Behavioural Disturbance
• Management
• Disposition
Our Data
• Clinical
Toxicology Unit established Feb 2014 at PAH
• Database
set up May 2014
• 2015
saw 1787 presentations & referrals to Clinical
Toxicology Unit
 601 clearly identified presentations
 Does not include unidentified stimulants, psychoactives etc
What we see
• THC
 Synthetic cannabis
 Cannabinoid hyperemesis syndrome
• Amphetamines
 Speed
 Ice (Methamphetamine)
 MDMA/MDA
• Heroin
• Phenethylamines
• Bath
Salts **
No. patient presentations
Recreational Drug Presentations to PAH ED 2015
(total = 601)
250
200
150
224
100
50
0
113
110
6
64
17
42
23
2
Cannabinoid Presentations
2015
Cannabinoids
• 113
presentations in
2015
• Does not represent use
in community
• Marijuana
 Often in combination with
other drugs
 5 of 84 required oral
sedation (diazepam) –
anxiety
90
80
70
60
50
40
30
20
10
0
84
9
20
Synthetic Cannabinoids
•
More potent at cannabinoid receptors
•
Clinical effects
 unpredictable and more toxic than THC






Tachycardia, hypertension, agitation, irritability
Drowsiness/lethargy/confusion/hallucinations or delusions
Nausea, vomiting, dizziness, vertigo
Chest pain, MI, acute cerebral ischaemia
Seizures and catatonia
AKI – ATN, interstitial nephritis
Not detected in routine drug screening
• PAH
•
 3 of 9 had seizures
 Increasing presentations 2014-2015 but still a very low number
Cannabinoid Hyperemesis Syndrome
• 20
presentations in 2015
 Some recurrent presenters at PAH and other hospitals
• Complications
 AKI (6/20)
 Electrolyte derangements




Hyponatraemia
Hypokalaemia
Hypomagnesaemia
Hypochloraemia
 Seizure – secondary to hyponatraemia
Cannabinoid Hyperemesis Syndrome
•
First described in 2004 in South Australia
 Increasing awareness in literature and clinically
•
Unknown pathophysiology – many theories
 Chronic cannabis use -> downregulation of CB1-R
 Genetic variation in cannabinoid metabolism
 Long term use -> accumulation of lipophilic THC in cerebral fat ->
vomiting
 Effect on HPA axis
 Balance between enteric (proemetic) and CNS (antiemetic) effects
 Excessive stimulation of CB1-R in gut -> vasodilation -> abdo pain
 Impaired thermoregulation
Proposed Diagnostic Criteria –
Simonetto 2012
•
Essential
 Long term cannabis use
•
Major
 Severe cyclic nausea and
vomiting
 Resolution of Sx with cannabis
cessation
 Relief of Sx with hot
showers/baths
 Abdominal pain
(epigastric/periumbilical)
 Weekly use of marijuana
•
Supportive
• Age < 50yrs
• Weight loss >5kg
• Morning predominance of
symptoms
• Normal bowel habits
• Negative laboratory,
radiographic and endoscopic
test results
3 phases
•
Prodromal
 Anxiety, agitation
 Autonomic Sx, severe nausea, abdominal pain, minimal hot showers
•
Vomiting
 Incapacitating nausea and vomiting – not responsive to conventional
Rx
 Compulsive hot showering - pathognomonic
 Orthostasis, abdominal tenderness, excessive thirst
•
Recovery
 Resolution of Sx 24-48hrs with supportive cares and cessation of
cannabis
 Resume normal diet
 Stop bathing behaviours
Management
•
Supportive cares
•
IV fluid rehydration
•
Electrolyte replacement
•
Anti-emetics
•
Allow access to hot showers (with care) – non judgemental
approach
•
LOS 2.93 – 65.68hrs
 Droperidol – assists with anxiety
 Steroids (other units experience)
 Benzodiazepines
Heroin
• 100
• 39
presentations
patients required naloxone
•1
seizure
•2
cardiac arrest
•5
intubations (includes 1 of above OOHCA)
 1 death
• 11
required chemical sedation with concurrent
naloxone infusions
Amphetamines, Sympathomimetics &
Stimulants
• Total
347 presentations in 2015
 Increasing presentations of methamphetamine
• Complications
 Acute behavioural disturbance (251)
 Seizures (5)
 AKI (9)
 Rhabdomyolysis (3)
 Intracranial haemorrhage (2)
 Myocardial injury (1)
 Traumatic foot amputation (1)
Acute Behavioural Disturbance
• 179
– benzodiazepines (PO diazepam)
• 32
– IM chemical sedation – droperidol +/- ketamine
• 40
– benzodiazepines AND chemical sedation
•
Only 1 patient requiring sedation was intubated – amphetamines
-> MVA + self inflicted stab wounds. Needed urgent control for
management.
ABD Sedation
Sedation for ABD based on DORM and DORM2
• Droperidol and Ketamine
• Failure rate very low
• Low intubation rate
Disposition
• 27
required psychiatric admission (8%)
• 13
discharged into custody of police
•1
transferred to LCCH
• 306
•
Home
Take home points
 Good sedation protocol
 Diazepam
 Droperidol
 Ketamine
 Acute intoxication ≠ mental illness
Hallucinogens
•
LSD - 23
•
Phenethylamines/Research chemicals – 2
•
Complications
 Seizures
 Acute behavioural disturbance
 Phenethylamines
 Benzodiazepines – 2
 LSD
 5 – chemical sedation + BZD
 1 – chemical sedation alone
 9 – BZD alone
•
Disposition
 2 with QPS
 23 home
25I-NBOMe
•
Hallucinogen
•
Used as recreational drug since 2010
 Carbon-11 labelled version – discovered in 2003 as radiotracer for PET
scanning
•
Derivative of 2C family of phenethylamines
 More potent, full agonist at 5-HT2A receptors than 2CI
•
Similar to amphetamines → Noradrenaline and dopamine release
•
Buccal/sublingual/inhalational/IV/IM/rectal
•
Tolerance and cross tolerance with other hallucinogens
25I-NBOMe
• Effects
 Euphoria, stimulation
 Tachycardia, hypertension, pupillary dilatation,
hyperpyrexia
 Agitation, aggression, confusion
 Auditory and visual hallucinations
 Seizures
 Elevated WCC, CK, metabolic acidosis, AKI
 Memory difficulties in longer term regular use
 Death
Our experience
•2
cases in 2015
 16yo M
 WCC 16.0 LDH 404
 Generalised tonic seizure
 Prehospital midazolam
 22yo M
 WCC 16.5 normal LDH
 Tachycardia, hypertension
 Visual hallucinations, paranoia, agitation
 Oral sedation with diazepam
Summary
• 1/3
of toxicological presentations are by people
affected by recreational drugs
• Increasing
burden on ED staff
• Good
supportive care and a non-judgemental
approach achieves good outcomes for patients
• Not
all people with drug intoxication will require
mental health assessment. Most don’t.
References
•
Mills, B., et al., 2015, Synthetic Cannabinoids. Am J Med
Sci, vol 350 pp 59-62.
•
Richards, J.R.,et al. 2010, Treatment of toxicity from
amphetamines, related derivatives, and analogues: A
systematic clinical review. Drug Alcohol Depend.
Available from URL:
http://dx.doi.org/10.1016/j.drugalcdep.2015.01.040
•
Isbister, G., et al. 2010, Randomised Controlled Trial of
Imtramuscular Droperidol Versus Midazolam for
Violence and Acute Behavioural Disturbance: The DORM
Study, Ann Emerg Med, vol 56, pp 392-401.