Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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.