Download Acute poisonings with substance of abuse

Acute poisonings with
substances of abuse
Identification of intoxication
Suspition of intoxication
Preliminary CNS evaluation
Agitation
Midriasis, normal photoreaction
Psichostimulants
Suppression
Normal pupils, photoreaction
Ethanol
Myosis, no photoreaction
Opioids
THC
Vilnius toxikology clinic 2003
Opioids
Natural
(opiates)
Morphine
Codeine
Semisynthetic
Heroin
Hydromorphone
Oxymorphone
Oxycodone
Synthetic
Methadone
Meperidine
Levorphal
Fentanyl
3-methylfentanyl
Propoxyphene
Tramadol
Opioids
Pharmacology
Generally, all opioid agonist drugs
exert the same pharmacological
effects in the CNS and periphery,
but differ in pharmacokinetic
properties, e.g. duration of action,
potency, ability to cross bloodbrain-barrier
Opioid overdose
CNS Symptoms I
• Respiratory depression, intensive central
cyanosis (bradipnoe 2-4/min.)
• Sedation and drowsiness, unconsciousness
up to coma
• Miosis
• Hypothermia
Opioid overdose
CNS Symptoms II
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Suppression of cough
Suppression of pain
Nausea and vomiting
Euphoria or dysphoria
Seizures
Opioid overdose
Periphery Symptoms
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Cardiovascular: vasodilatation, hypotension
Urinary tract: urinary urgency and retention
Skin: urticaria from histamine release
GI tract: constipation
Uterus: decreased contractions
Opioid overdose
Treatment
• CPR (cardiopulmonary resuscitation)
• Naloxone – bolus 2 mg I/V (0,4-2mg) to
10 mg (If no I/V access - sublingual,
endotracheal, i/m), continous infusion
• In-patient monitoring at least 12 hours
• Heating
Cocaine
Neurochemical actions
• Blockade of reuptake of NE, DA and
serotonin:
– Low dose: preferential action on NE reuptake
– Moderate dose: NE and DA reuptake
– High doses: NE, DA and serotonin reuptake
• Local anesthetic action:
– blockade of sodium channels
Cocaine
I
Neurotransmission
http://drugabuse.gov
Cocaine
Neurotransmission II
http://drugabuse.gov
Cocaine
Neurotransmission III
http://drugabuse.gov
Cocaine overdose
Symptoms I
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Agitation to psychosis
Halucinations
Mydriasis
Hypertermia (>41OC)
Hypertension
Tachycardia
Seizures
Coma
Cocaine overdose
Symptoms II
• Ischemic complications (vasospasm)
– Myocardial infarction, cerebral infarction, etc.
• Haemorrhagic complications
(hypertension)
– Subarachnoid, intracerebral hemorrhage,
aortic dissection, etc.
• Dysrhytmias to ventricular
fibrilation
Cocaine overdose
Treatment
No antidotes
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• CPR
• Agitation, psychosis, seizures, hypertension,
tachycardia BZD (Diazepam 10-100 mg)
• Hyperthermia external cooling (<41OC)
• Severe hypertension phentolamin, nitropruside
• SVT - Ca antagonists
• VT - lidocaine
• No β-blockers
Heroin+Cocaine overdose
Symptoms
• Changing clinical signs (swing)
Cocaine ↔ opioids
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Coma
Respiratory depression
Midriasis
Tachycardia
Heroin+Cocaine overdose
Treatment
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CPR
Naloxone: bolus 2 mg i/v + continous infusion
In-patient monitoring at least 12 hours
Symptomic treatment
Benzodiazepines
Body packing and stuffing
Is it the same?
• Packing – action,
when a person
transports illicit
drugs in a body
orifice. The risk of
package rupture is
more remote.
• Stuffing – action, when
a person places drugs
in a body orifice in a
moment of imminent
danger. In this case
drugs are not well
packaged for
transportation, hence
the high risk for leakage
Body packing and stuffing
Investigations
• Ultrasonography
• Contrast X-ray of
the bowel
• Computerized
tomography
• Drug detection in
urine and blood
• Clinical observation
• Light solid diet
• Free assumption of
liquids
• Surgical removal, if
mechanical
obstruction occurs
• Treatment of
systemic symptoms
Body packing and stuffing
Investigations
Radiographic Approaches to the Identification of Body packing
Study
Indications
Sensivity
Comments
Plain
abdominal
radiography
Screening test
85-90%
Sensivity for finding small
numbers of packets may be
lower. May miss substantial
numbers of packets
Ultrasonogra
phy
Screening test
No
established
Has the potential to be very
useful, large studies needed
CT
Used if equivocal results
obtained on initial screening
test. Used to document that
GT is clear
No
established
Large studies needed
Contrast
enhanced
abdominal
radiography
Used if equivocal results
obtained on initial screening
test. Used to document that
GT is clear
96%
Reported sensitivity based
on 1 study
Body packing and stuffing
Levels of packages security
• I - 1 protective layer
• II - 2 protective layers;
in our case
• III – machine-made (4-7
protective layers)
Body packing and stuffing
First detected case in Lithuania
• A 31 year old male was brought to the
Department of Toxicology by customs
officers after disembarking at the Vilnius
International Airport suspecting of
cocaine transport
Body packing and stuffing
First detected case in Lithuania
• There were no any complaints and examination
of patient didn’t show any pathology
• All blood tests were normal
• Patient refused endoscopy, but agree to
contrast X- ray investigation
• Foreign bodies were detected in the
gastrointestinal tract by X-ray photography
• Toxicological analysis for narcotics of urine and
blood were done
Body packing and stuffing
First detected case in Lithuania
• Observation (blood pressure, heart
frequency, temperature, neurological
assessment every hour)
• Mild laxative in conjunction with
sufficient beverages
Body packing and stuffing
First detected case in Lithuania
Fill defects
“double condom’’ sign
Body packing and stuffing
First detected case in Lithuania
39 packets were excreted on the first day, 10 –
on the second day, 3 – at the third day
X-ray 3 days later revealed foreign bodies in the
gastrointestinal tract (“double condom’’ sign)
Because of customs officers demand the
patient was transferred to the Hospital of
Prison, despite staff objection. 62 cocaine
packets were excreted during the next 3 days
Body packing and stuffing
First detected case in Lithuania
Forensic analysis
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Condoms were filled with 3-8 g of cocaine each
114 packages, weight 438,63 g,purity – 57%
2 of cocaine packets were slightly injured
Blood sample – no answer, urine analysis –
“possibility of cocaine metabolites”
Body packing and stuffing
Management
•In no way endoscopic removal of the package should be
attempted. The patient in whom only one packet fails to
pass the pylorus may be the exception
•Conservative management during spontaneous evacuation
of the containers is the first choice approach to the bodypacking
•Surgery is indicated for patients with acute cocaine
poisoning or gastrointestinal obstruction or perforation
•Observation till the last package removes is obligatory
Amphetamine
Neurochemical actions
• Dose-related increase in release of
norepinephrine, dopamine and serotonin:
– low dose: preferential action on NE release
– moderate dose: NE and DA release
– high dose: NE, DA and serotonin release
• Blockade of reuptake of NE, DA and serotonin
• Inhibition of MAO
Amphetamine
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Symptoms
Agitation to psychosis
Halucinations
Mydriasis
Tachycardia
Hypertension
Mild hypertermia
Seizures
Coma
Amphetamine
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Treatment
No antidotes
CPR
GI decontamination gastric lavage, activated charcoal
Benzodiazepines
Severe hypertension phentolamin, nitropruside
External cooling
SVT Ca antagonists
VT lidocaine
• No β-blockers
“Ecstasy” (MDMA):
a hallucinogenic amphetamine
• Combination of psychostimulant effects
with stronger hallucinogenic effects
(serotonin component)
• Common acute adverse effects: muscle
tension and bruxism
• Hyperthermia
• Increase HR and BP
• Acne-like rash
Cannabinoids
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Symptoms
Impairment of cognitive function
Disorientation, talkativness
Anxiety to panic
Headache
• Ataxia
“Exploding chest”
• Tremor
Sedation
• Dry mouth
• Tachycardia
• Injected
conjunctive
Cannabinoids
• Benzodiazepines
• Symptomic treatment
• Psychoterapy
Treatment
LSD
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(Lysergic Acid Diethylamine)
Anxiety, agitation
Hallucinations
Moist and pale skin
Mild hypertension
Tachycardia
Hypertermia
Symptoms
LSD
(Lysergic Acid Diethylamine)
Treatment
• Benzodiazepines
• In severe cases – the same as
amphetamines
Gamma-hydroxybutyric acid
Symptoms
• CNS depression
(GCS of 3 is not uncommon)
• Extreme combativeness and
agitation
• Bradycardia
• Decreased systemic vascular
resistance, hypotension
• Profound respiratory depression.
Gamma-hydroxybutyric acid
Treatment
• Airway protection and
aspiration precautions
• Use atropine to treat
symptomatic bradycardia that
is unresponsive to stimulation
Solvents
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Agitation, joy
Vertigo, coordination damamge
Sneeze, hypersalivation
CNS depression, delusions
Sense of invulnerability
Respiratory depression
Tachycardia
Seizures, coma
Symptoms
Solvents
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Oxygen
CPR (if needed)
Benzodiazepines
Symptomic treatment
Treatment
Milestones in treatment of
drug overdose
Naloxone
Benzodiazepines
Life support measures