You may be surprised at how patients present in your ED
Rapid down, rapid up, without any emergence phenomena. This is the scenario that many EDs are facing with a club drug, gamma hydroxyl butyrate (GHB), also known as "Liquid X." ED visits related to GHB, ketamine (commonly called "Special K" or "K"), and methylenedioxymethamphetamine (MDMA, also known as ecstasy) each have risen more than 2,000% from 1994 to 2001, according to the Rockville, MD-based Drug Abuse Warning Network.1
The presentation of club drugs such as GHB can be puzzling. Consider this scenario: A 17-year-old white male is brought in after being found unconscious at a local dance club. Emergency medical service staff members state he took an unknown substance called "Liquid X." His friends report that he has had several drinks as well. On arrival, the patient is unresponsive, with decreased respirations. The only significant finding on exam is the presence of coma, without other neurological findings. Due to the depressed level of consciousness, he is given rapid sequence intubation with cervical-spine precautions. Approximately 90 minutes after arrival, the patient suddenly sits up and pulls out his endotracheal tube. He admits to consuming three teaspoons GHB and some alcohol, and remembers nothing else.
Such scenarios point to the need for ED clinicians being up-to-date on presentations for club drugs. "Although MDMA and GHB are getting all the press, there are certainly other drugs to keep an eye on," says Matthew Sztajnkrycer, MD, assistant professor of emergency medicine at the Mayo Clinic in Rochester, MN.
Here are vital management tips you must know to address growing caseloads from five top "club drugs."
• MDMA.
Always check the patient’s hydration status, advises Allison A. Muller, PharmD, CSPI, clinical managing director for the Poison Control Center at The Children’s Hospital of Philadelphia. Patients may try to compensate for dehydration by drinking a lot of water, Muller says. "If you give IV fluids, you will worsen their pre-existing hyponatremia," she says. The drug doesn’t always show up as a positive amphetamine result on a toxicology screen, adds Muller. "If it doesn’t come up positive, don’t let that lead you astray," she says. Keep in mind that the patient may have taken the drug in combination with something else, such as GHB or alcohol, says Muller. "This may result in loss of consciousness," she says.
• Ketamine.
This drug blocks the effects of the predominant excitatory neurotransmitter in the central nervous system and results in analgesia, amnesia, and sensory loss without actual loss of consciousness, says Sztajnkrycer. "In its extreme, the result is a so-called dissociative state,’" he says. This is a sedated and trance-like state, says Muller. "The patient may be looking at you but isn’t all there, with a zombie-like appearance," she says. Patients also may present with tachycardia, altered mental status, anxiety, nystagmus, mydriasis, and hypertension, says Sztajnkrycer. "Seizures and respiratory arrest have rarely been reported, and death from isolated ketamine overdose is rare," he adds.
Because patients often present with anxiety, liberal use of benzodiazepines are recommended, says Muller. "Placing the patient in a dark, quiet room with minimal disturbances also may be helpful," she adds.
It’s important to keep the patient calm and monitor for agitation, says Sztajnkrycer. "Failure to control agitation can contribute to hyperthermia and also to rhabdomyolysis and subsequent renal failure," he says.
• 2C-T-7 ("Blue Mystic").
This is a psychedelic phenethylamine with a structure similar to mescaline, says Sztajnkrycer. Toxicity manifests as delirium, dissociation, and evidence of the sympathomimetic toxidrome seen with agents such as cocaine, amphetamine, and MDMA, says Sztajnkrycer. Patients may present with hypertension, tachycardia, agitation, mydriasis, diaphoresis, and hyperthermia, he says. Three deaths have been reported to date, with two occurring after insufflation and one occurring as a result of a mixed ingestion with MDMA, says Sztajnkrycer.
• GHB.
Statistics show that use of GHB is continuing to increase, says Muller. "Seizures have been variably reported, but this is not a hallmark sign and presents more like muscle stiffness," she says. Patients often present in a deep coma and may have bradycardia, she says. "The tip-off [to GHB use] is that patients have rapid resolution of their coma," Muller notes. "You may be ready to intubate them, and suddenly there is spontaneous recovery."
• Dextromethorphan (DXM).
This narcotic is found in many over-the-counter cough suppressants, says Muller. "This drug is an opioid derivative, but the commonly used antidote naloxone does not always reverse its effects," she says. It is available over the counter and by prescription, and it often is formulated with other medications such as antihistamines, she says. The typical presentation is similar to ketamine, says Muller. "Patients present ataxic, possibly with hallucinations and nystagmus," she says. "In higher doses, they present with the opioid picture."
Warning: Don’t miss life-threatening symptoms
You always must consider the possibility of coexistent cervical spine injury, head trauma, or hypoglycemia in any patient with altered mental status, urges Sztajnkrycer. "Obviously, there could be liability issues for all involved if any of the above are missed," he says. Check a finger stick blood sugar level on every patient with altered mental status, says Sztajnkrycer. "Depending on the clinical scenario, a head [computerized tomography scan] may be indicated," he adds. "You also need to protect the C-spine with intubation."
To avoid missing hyperthermia, you must aggressively determine the patient’s temperature, stresses Sztajnkrycer. "If you are concerned about this, a core temperature should be obtained, especially if the patient has altered mental status or other findings for a sympathomimetic or anticholinergic toxidrome," he recommends.
Patients also may have a hypertensive crisis or cardiac arrhythmias, says Muller. "You definitely need to do an EKG and close cardiac monitoring for many of these agents," she advises.
Here are ways to improve management of overdose patients:
— Watch for hyperthermia and rhabdomyolysis. Increased motor activity can cause profound hyperthermia and rhabdomyolysis significant enough to affect kidney function, warns Sztajnkrycer. These adverse effects can be exacerbated if you try to restrain an already agitated patient, says Sztajnkrycer. "Physical restraint may rapidly cause both," he says. "Chemical restraint using phenothiazines may impair heat dissipation, as well as lower seizure thresholds and potentially increase cardiotoxicity."
— Know when benzodiazepines are indicated. Benzodiazepines would be the antidote of first choice for the following, according to Sztajnkrycer:
- patients with psychomotor agitation;
- patients with most toxin-induced seizures, especially when club drugs are involved;
- patients with sympathomimetic toxicity. By decreasing central stimulation, benzodiazepines reduce peripheral effects, explains Sztajnkrycer.
— Avoid the use of neuroleptics in the management of intoxicated patients with psychomotor agitation. These agents can lower seizure thresholds, impair heat dissipation, and may have some cardiotoxic effects due to their effects on the QT interval and the tachycardia that they cause, says Sztajnkrycer.
— Avoid beta-blockers in cases of sympathomimetic overdose. By blocking the beta-2 receptors responsible for vasodilation, beta-blockers actually may worsen hypertension in sympathomimetic toxicity, by resulting in unopposed alpha stimulation, says Sztajnkrycer. It typically is recommended that labetalol be avoided for the same reason, as it has predominantly beta-blocking effects, he adds. Beta-blockade has been demonstrated to worsen outcomes in cocaine-induced myocardial ischemia, for similar reasons, says Sztajnkrycer. "Benzodiazepines would be the drug of choice for sympathomimetic overdose, by decreasing the central overstimulation which results in the peripheral manifestations of hypertension and tachycardia," he says.
Reference
1. Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2002. Emergency Department Trends from the Drug Abuse Warning Network, Final Estimates 1994-2001. DAWN Series D-21, DHHS Publication No. 02-3635; Rockville, MD.
Resources
For more information about treatment of "club drug" overdoses in the ED, contact: Matthew Sztajnkrycer, MD, Assistant Professor of Emergency Medicine, Mayo Clinic, 200 First St. S.W., Rochester, MN 55905. Telephone: (507) 255-9559. Fax: (507) 255-6592. E-mail: [email protected].
Reports on ED visits related to drug abuse can be downloaded at no charge at the Drug Abuse Awareness Network (DAWN) web site. Go to www.samhsa.gov/oas/dawn.htm#EDcomp. Click on "The DAWN Report: Club Drugs, 2001 Update" and "The DAWN Report: Major Drugs of Abuse in ED visits, 2001 update."
Here are vital management tips you must know to address growing caseloads from five top club drugs - MDMA, ketamine, 2C-T-7, GHB, and dextromethorphan.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content