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Agitation after an
overdoseAUTHORDr Vember NgAugust, 2013
HKCEM College Tutorial
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Triage Findings at 20:37
▪ M/27 ▪ Found running on the street▪ Confusion ? Drunk
▪ BP 180/95, P 180/min, ▪ RR 28/min, SpO2 95% in RA, ▪ Temp 40.6oC axilla▪ GCS 11/15 with E2V4M5, pupils dilated
▪ Past Health : unknown
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Physical Findings
▪ Agitated, generalized muscle twitching▪ Dehydrated▪ GCS E2V4M5, pupils 4mm
▪ Chest: clear, ▪ Abd: soft non-tender▪ CVS: HS dual no murmur
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▪ List out the problems Fever Tachycardia Altered LOC, confusion, agitation
▪ List out the Ddx. e.g. AEIOU TIPS
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Ddx
▪ Drug toxicity▪ Infection, encephalitis, meningitis▪ Heat stroke & heat exhaustion▪ Neuroleptic malignant syndrome▪ Hyperthyroidism, thyroid storm
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What is your immediate management?
What immediate investigations will you order?
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▪ ABC
▪ Restraint (Physical/ Chemical)
▪ Hstix 6.7
▪ CXR : lungs clear, no cardiomegaly
▪ ECG
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ECG
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What is your further management ?
Any other investigations ?
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Any other tests may be useful ?
▪ ABG▪ Electrolyte▪ CK (rhabdomyolysis)▪ Baseline L/RFT, CBC, cardiac enzymes▪ CT Brain▪ Toxicology screen▪ Bedside urine immunoassay kit (e.g. ACON) ▪ AXR (possibility of body packer)
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Bedside urine immunoassay kit (e.g. ACON)
▪MET (Methamphetamine) Positive
▪ Interpretation? Positive results are generally expected up to
several days after their uses Clinical utility of bedside kit is limited as both
false positive or false negative are common
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Management in AED
▪ ABC +/- Intubation +/- GI decontamination▪ Oxygen▪ IVF▪ Passive cooling (How?)▪ Physical Restraint▪ Chemical Restraint▪ How about tachycardia ? (Use of beta-blocker?)▪ ICU consultation
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Chemical Restraint
▪Which Drugs ?
▪Which Benzodiazepine ?
▪ Dose?
▪ Any other alternatives ?
▪ Is it safer to use more physical restraint instead of high dose sedation ?
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Progress
▪ Diazepam 10mg IVI was given
▪ Still grossly agitated
▪What will you do next?
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Progress
▪ Another Diazepam 20mg IVI was given
▪ Still grossly agitated
▪What will you do next?
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▪ If further Diazepam up to 100mg given,
▪What will you do next ?
▪ Consider, e.g. - More Diazepam- Midazolam infusion- Lorazepam- Morphine- Propofol infusion- RSI…..
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Progress of our patient
▪ Clinically improving after diazepam 50mg given ▪ No need for intubation (AC not given)
▪ AXR: no FB seen
▪ Cr up to 199, CK 10324, Urine myoglobin +ve▪ Vigorous IVF given
The next day ▪ regained full consciousness ▪ Upon re-questioning, patient admitted that he had taken
some “ice” before collapse
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Drug Abuse
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Drug of Abuse (Conventional)
Types Examples
CNS Stimulants Amphetamines and its derivativesCocaine / Crack cocaine
CNS Depressants BenzodiazepinesOrganic solvent inhalationOpioids Gamma-Hydroxybutyrate (GHB)EthanolBarbiturates
Dissociatives KetamineDextromethorphan (e.g. cough mixture)Phencyclidine
Hallucinogens CannabisAnticholinergicsLysergic acid diethyamide (LSD)
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Emerging Drug of Abuse
▪ Designer drugs, a major component of emerging drug abuse, are drugs produced by illicit chemists to avoid existing drug laws▪ By preparing analogs or derivatives of existing drugs, or less commonly by
finding drugs that mimics the illegal drug effect
▪ Pharmacology, toxicokinetics & toxicodynamics are not well characterized
▪ Difficult to predict the toxicities & the risks involved with their use are often unknown. These drugs are usually more dangerous.
▪ Clinical experience in managing these drugs poisoning is limited
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Emerging Drug of Abuse
Types Group Examples
Stimulants • Piperazine-based • Cathinone derivatives
• TFMPP (3-trifluoromethylphenylpiperazine)• BZP (1-benzylpiperazine)• MDPV (Methylenedioxypyrovalerone )• Mephedrone (4-methylmethcathinone)
Hallucinogens • Tryptamine-based • Phenethylamine-based • Ketamine-like• Synthetic Cannabinoids
• 5-methoxy-di-isopropyltryptamine• Mescaline• Methoxetamine• Spice / K2
Others • Salvia divinorum (Salvinorin A)• Poppers (Alkyl Nitrite)
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Amphetamines and its derivatives
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>200 amphetamine derivatives or amphetamine-like substances
冰 凍嘢( 甲基安非他命 ))
E 仔 , 糖
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Methamphetamine
▪ A common recreational drug abused for its stimulant and euphoric effects
▪ The commonest form is crystal, but it can be formulated into “ectasy-like pills” or in the liquid form
▪ Street names include 冰 , ice, crystal meth, speed, crank etc.
▪ The commonest administrative route is smoked through an under-water bottle, however it can be snorted, orally taken, injected and even used per rectal.
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Methamphetamine
路德會青怡中心提供
©LutheranEvergreenCentre
“僕”冰
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Methamphetamine
▪ Primary mechanism of action - release of endogenous monoamines (e.g. noradrenaline, serotonin and
dopamine), resulting in sympathomimetic poisoning and psychomotor agitation
▪ Different amphetamines and its derivatives have different potencies
▪ Rapidly absorbed from GI tract, nasal mucosa and respiratory tract, mainly metabolized by liver and excreted in urine
▪ Typically, inhalational and parenteral injection routes give faster and more intense effects than ingestion. The effects usually occur within mins. Acute effects may last > 24 hrs
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Clinical Features▪ Classical sympathomimetic toxidrome: ▪ psychomotor agitation, tachycardia, hypertension, diaphoresis, mydriasis
and hyperthermia
Reported major end-organ toxicity:
▪ CNS : Seizure, intracranial bleeding, TIA, infarct.
▪ CVS : ACS, hypertensive emergencies, acute aortic syndrome, arrhythmias, vasospasm
▪ Respiratory :Pneumothorax, pneumomediastinum
▪ Psychiatric: Aggression, paranoid psychosis, mood disturbances
▪ Others : Serotonin syndrome, hyponatremia, hyperthermia, DIC, rhabdomyolysis, ARF, met-bug (delusion of parasitosis)
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Management
▪ Rapid “Cooling”, use of benzodiazepines and supportive measures are the mainstay of treatment
▪ Consider GI decontamination if presented promptly after an oral overdose
▪ Rapid cooling measures for hyperthermia
▪ Adequate hydration & other supportive measures
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Treatment for agitation
▪ Liberal use of benzodiazepines in titrated manner- Start with 5-10mg diazepam IVI- From experience, 1-2 mg/kg diazepam or its equivalent in the
first 30 min may be required to achieve adequate control of agitation.
▪ Prolonged physical restrain without chemical restrain is dangerous
▪ Closely monitor for rhabdomyolysis and hyperthermia
▪ Antipsychotics use in control of agitation in intoxication of amphetamines are generally NOT recommended
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Treatment for seizure
▪ Benzodiazepine
▪ Phenytoin is NOT recommended
▪ Rule out hyponatriemia & intracranial pathology
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Treatment for hypertensive emergencies
▪ Benzodiazepine and “calm down” the patient is the 1st line treatment
▪ Titrate with short acting nitrate e.g. nitroprusside▪ Consider phentolamine if inadequate response
▪ Beta-blockers should be avoided since unopposed alpha-adrenergic properties may lead to hypertensive crises
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