370 30AccidEmergMed 1996;13:370-372 J Accid Emerg Med: first published as 10.1136/emj.13.6.370 on 1 November 1996. Downloaded from LEADERS

Management of drug abuse emergencies

The doctor in the accident and emergency (A&E) depart- possession of them. The drugs are usually poorly wrapped, if ment can be confronted with a wide range of acute situations at all, and the onset of symptoms tends to be within two requiring urgent management, and this is particularly true hours. In these cases the police will usually be heavily involved when considering drug and substance abuse, which has a high from the beginning, and may press for diagnostic details or for prevalence of acute physical morbidity. The range ofmedical samples to be taken. In cases such as this the clinical care of problems presenting for diagnosis or urgent management the patient comes first, and although the police should be includes acute intoxication leading to cardiac or respiratory allowed to maintain a guard over their detainee, minute by complications, acute behavioural disturbances, the secondary minute bulletins on the patient's clinical situation are not in effects oftrauma, infection or rhabdomyolysis, and the recog- anybody's interest. nition and management ofdrug seeking behaviour. This arti- "Body packers" are those who swallow or insert into body cle briefly reviews the presentation and management of drug orifices carefully sealed packets of illicit drugs in order to abuse emergencies as they can occur in an accident and avoid detection by customs officers at national borders. Ifthe emergency department. packets leak, these people tend to present with an acute illness and a history ofair travel, though cross channel rail travel and The drug and the diagnosis ferries also see their share of illicit drug smuggling. In these Behavioural disturbances, clinical signs, or biochemical abnor- cases, a relatively small leak from one of a number of packets malities may suggest that the patient is suffering from the com- may be enough to cause life threatening symptoms, and plications of illicit drug use. Injection marks, syringes, powders, urgent management is required to stabilise the patient's clini- or tablets are a strong pointer. Where the patient or friends pro- cal condition and prevent progression oftoxicity. Endoscopic vide a history, or where the physical signs and circumstances removal may be indicated for packets in the stomach, while indicate drugs as the cause of the patient's problem, a worling whole gut ravage, though rarely performed in accident and diagnosis can be made immediately, bearing in mind that the emergency departments, is generally considered as the most contents and concentrations of illicit drugs vary markedly. For appropriate method for rapidly progressing the packets example, street heroin may range between 10% and 80% pure, through the intestine,"2 provided the patient does not have while amphetamine sulphate is usually 2-5% pure, though ileus. Surgical removal is best avoided but may occasionally stronger varieties with around 20% purity are also on sale. be Cocaine hydrochloride is usually about 20-80% pure, and necessary.'

"crack" crystals are often 80-90% pure cocaine base. LSD http://emj.bmj.com/ squares or microdots contain about 30-150 pg ofLSD (and the Opioids duration and intensity of effects may vary accordingly). Opioid toxicity produces the classical triad of reduced Substances sold as ecstasy usually contain MDMA or similar consciousness, pinpoint pupils, and slowing of respiration. drugs, but fraudulent dealers may sell binary mixtures of, for These should be enough to lead to a rapid working diagnosis example, ephedrine and LSD in order to recreate some of the of opioid toxicity, and naloxone (initial dose 0.8-2 mg as an effects that MDMA might produce, while in some cases the intravenous bolus) can be used as a diagnostic and therapeu- preparation sold contains no active ingredients at all. "Herbal" tic trial. A partial response is an indication for a further dose, substances are also marketed, but ecstasy substitutes tend to though the patient may be sedated by another central nervous on September 30, 2021 by guest. Protected copyright. have less toxicity than the drug itself. Some other drugs are not a system agent, such as alcohol or a benzodiazepine, or may common cause ofemergency presentations in Europe. Phencyc- already have suffered a degree ofhypoxic cerebral damage, in lidine can cause agitation, hallucinations, violence, and hyper- which case the pupils would be expected to be dilated. The thermia, but is rarely found in Britain. Cannabis is now possibility that the patient may be an addict, and that extremely widely used but does not usually cause medical com- naloxone might precipitate withdrawal symptoms should not plications unless use is heavy enough to lead to psychosis; over- be considered a contraindication to its use. Opioid toxicity is dosage can cause a hallucinatory state. life threatening, but opioid withdrawal does not kill. Clearly, Analytical confirmation of suspected substances or sam- with opioid toxicity, the first priority is to ensure that respira- ples of biological fluids is not usually feasible in the short tion and circulation are adequate, and ifthe patient appears to term, though it is frequently helpful to confirm retrospec- be close to respiratory arrest, attention to the airway and pro- tively the cause of a clinical problem. Where brain damage vision of respiratory and cardiovascular support is more has occurred against a background of drug or substance urgent than giving naloxone. Once the patient's condition is abuse, toxicological analyses are usually indicated. Urine is under control and a response to naloxone has been seen, it the best medium for testing for the presence of a drug, and may be worth setting up an infusion ofnaloxone at a suitable a positive result can usually be found for 36-48 hours after dose in order to prevent the patient from deteriorating. exposure (an exception is cannabis, which may be detected Naloxone usually has low toxicity and few complications, but in urine up to three weeks after use). Measurement of one prospective review of 453 cases where it was given found blood concentrations can be carried out on lithium heparin a 1.3% incidence of serious complications (one subject had plasma samples (fluoride oxalate tubes are preferred for asystole, three had convulsions, one had pulmonary oedema, measurement of cocaine or ethanol). and one had immediate violent behavour).4 Other problems seen with opioid toxicity include pulmonary aspiration, Stuffers and packers pulmonary oedema (rare, though commonly mentioned in "Body stuffers" are individuals who swallow drugs which are textbooks), and non-traumatic rhabdomyolysis or compart- in their possession in order to avoid being apprehended in ment syndromes. Management ofdrug abuse emergencies 371 J Accid Emerg Med: first published as 10.1136/emj.13.6.370 on 1 November 1996. Downloaded from Benzodiazepines hallucinating, particularly in the long term heavy user. The Temazepam is widely abused, and is sometimes injected. most important effects are on the cardiovascular system, Ischaemic complications from accidental intra-arterial and there may be marked hypertension and tachycardia. injection are now less commonly seen because of changes Cerebrovascular accidents occur. Hyperthermia, rhab- in formulation. Although flumazenil is not licensed in Brit- domyolysis, and acute renal failure have been reported ain for the reversal of benzodiazepine toxicity because of with some regularity over the years, but are now more the possibility of precipitating convulsions in, for example, commonly associated with ecstasy use. Management of a patient who has taken benzodiazepines together with tri- cardiac arrhythmias includes the use of c blockade with cyclic antidepressants, flumazenil can be useful in a atenolol or esmolol. manner analogous to the use of naloxone as a diagnostic Ecstasy and sometimes as a therapeutic tool. However, there is a Several drugs are marketed as ecstasy. They are usually distinct chance of precipitating convulsions if the clinical amphetamine derivatives (MDMA, 3,4-methylene- features are not typical. In one series, convulsions occurred dioxymethamphetamine; MDA, 3,4-methylenedioxyam- in five out of 26 such cases.5 phetamine; MDEA, 3,4-methylenedioxyethamphetamine; Cocaine and MBDB, methyl-benzodioxolbutanamine. The effects Cocaine may be taken by inhalation or by intravenous injec- of these drugs tend to be similar and the major problems tion, and crack cocaine is smoked, leading to the additional encountered will be described. MDMA was widely used in complications of black sputum, chest pain from tracheal irri- the United States in the 1980s,8 but there were few reports tation, and lung damage. The effects produced are based on of serious toxicity. In Britain, the drug has tended to be the pharmacological properties of cocaine. In the central used as a dance drug at parties and "raves".9 This has led nervous system, cocaine blocks the reuptake of the neuro- to a number of cases of severe and fatal hyperthermia.'01' transmitters noradrenaline, serotonin, and dopamine. This is Subsequently, reports began to appear of hyponatraemia responsible for the agitation, confusion, paranoia and aggres- caused by excessive fluid ingestion compounded by failure sion which may occur in the cocaine user. of renal water elimination, due to inappropriate secretion There are frequently marked cardiovascular effects with of antidiuretic hormone; these cases were in some measure tachycardia, hypertension, chest pain, and sometimes a result of harm limitation messages, encouraging drug ischaemic changes on the electrocardiograph. Syncope, users to drink fluid to prevent hyperthermic complications. coma, and convulsions may occur. Repeated cocaine use The hyperthermic patient usually presents with collapse or can lead to vasculitis. There may be cerebral, renal, or car- convulsions plus a history of ecstasy ingestion (and some- diac vasculitis, and in cocaine sniffers, the nasal vessels times also of amphetamine ingestion) accompanied by develop vasculitis. Cocaine is associated with an increased continuous dancing for several hours. Examination shows incidence of myocardial infarction related to the extreme dilated pupils, sweating (though in severe cases this may have stress on the cardiovascular system produced by hyperten- ceased), a marked sinus tachycardia (rates of 140-160 beats sion, plus possible coronary vasculitis and also accelerated per minute are not uncommon), hypotension, and a core atheroma, which has been reported in the United States.6 temperature of39-42°C. Cases such as this represent an acute A further property of cocaine is its local anaesthetic effect, medical emergency. Once a high core temperature has been which in overdose depresses myocardial contractility. This confirmed, one litre of 0.9% saline should be given immedi- can lead to a profound fall in cardiac output and is quite ately, without delaying to measure central pressure. If this http://emj.bmj.com/ often the cause of death in cases of overdose. brings down the pulse rate and raises the blood pressure, a Although the pathology and symptomatology, caused by further litre can be given, after which the central pressure cocaine may be complicated, the management is relatively should be measured and further fluids given as required. straightforward. There is no direct antidote for cocaine Control of convulsions can usually be achieved with toxicity, but it is now accepted that diazepam will antago- diazepam. One important feature about these cases is that nise the central stimulant and hypertensive effects of the dantrolene reduces the calcium requirement for excitation drug, so that high dose intravenous diazepam is the most contraction coupling, and once the patient has developed on September 30, 2021 by guest. Protected copyright. appropriate first line treatment.7 Nitroprusside should be hyperthermia, further heat production may occur. This used for severe hypertension. Calcium antagonists should should be prevented by administration ofdantrolene, which is be used for ischaemic pain or electrocardiographic indicated if the core temperature is above 39°C. Dantrolene changes. Antiarrhythmic drugs (but not negatively ino- acts as a calcium antagonist, at a cellular and subcellular level, tropic ones) should be used for cardiac arrhythmias; * but its use should not take precedence over facilitating blockade with atenolol or esmolol should be considered. thermoregulation by restoring fluid volume. Another problem seen in ecstasy users is acute hyponat- LSD raemia with mute states, headache, and vomiting, second- LSD (lysergic acid diethylamide) is widely available, ary to excessive fluid ingestion."21' Severe symptoms may usually as small printed paper squares, and is taken orally. develop with a plasma sodium of 130 mmol/litre or below, It produces a hallucinogenic state and sometimes extreme and the urine is inappropriately concentrated with a raised agitation and violence. There are few physical signs apart osmolality, due to excessive production of arginine from dilated pupils, piloerection, tachycardia, and hyper- vasopressin.4 In most cases supportive management is suf- tension following high doses. Physical restraint may be ficient, but in severe cases intravenous mannitol, diuretics, required to prevent the patient injuring himself or attend- or hypertonic saline may be required. ants. Sedation with haloperidol may be appropriate, but in Other problems which occur in ecstasy users are acute the first instance the patient should be kept in a quiet renal failure due to rhabdomyolysis, hepatitis,'5 cerebrovascu- atmosphere with dim lighting. Deaths from direct toxicity lar accidents, and acute psychiatric disturbances.'6 The are virtually unknown, but death may result from accidents incidence of long term psychiatric complications is unknown, or violence while under the influence of the drug. though there is a definite incidence ofpsychiatric illness. Amphetamine Conclusion Amphetamine sulphate is widely used as a stimulant, and The rise in illicit drug abuse has seen an accompanying produces a euphoriant effect. The patient may be talkative, increase in the incidence of medical complications. The excitable, and confident, but may be paranoid or range of substances used as dance drugs means that junior 372 Henry J Accid Emerg Med: first published as 10.1136/emj.13.6.370 on 1 November 1996. Downloaded from medical staff need to have a grasp of the drugs used and 6 Escobedo LG, Ruttenber AJ, Anda RF, Sweeney PA. Coronary artery disease, left ventricular hypertrophy, and the risk ofcocaine overdose death. their pharmacology.'7 Resuscitation and immediate man- Coronary Artery Dis 1992;3:853-7. agement in the accident and emergency department can be 7 Goldfrank LR, Hoffman RS. The cardiovascular effects of cocaine. Ann Emerg Med 199 1;20:165-75. critically important in preventing complications and 8 Peroutka SJ. Incidence of recreational use of 3,4- ensuring a successful outcome. An understanding of the methylenedioxymethamphetamine (MDMA, Ecstasy) on an undergradu- ate campus. NEnglJ7Med 1987;317:1542-3. toxic mechanisms involved can enable one to employ a 9 Randall T. Ecstasy-fueled 'rave' parties become dances of death for English more rational approach to the clinical management of the youths. JAMA 1992;268: 1505-6. 10 Henry JA, Jeffreys KJ, Dawling S. Toxicity and deaths from 3,4- acutely ill drug abuser. methylenedioxymeth-amphetamine ("ecstasy"). Lancet 1992;340:384-7. JOHN A HENRY 11 O'Connor B. Hazards associated with the recreational drug 'ecstasy'. Br Medical Toxicology Unit, Guy's Hospital, London SEI 9RT JHosp Med 1994;52:507-14. 12 Maxwell DL, Polkey MI, Henry JA. Hyponatraemia and catatonic stupor 1 Hoffman RS, Smilkstein MJ, Goldfrank LR. Whole bowel irrigation and the after taking "ecstasy". BMJ 1993;307:1399. cocaine body-packer: a new approach to a common problem. Am J Emerg 13 Matthai SM, Davidson DC, Sills JA, Alexadrou D. Cerebral oedema after Med 1990;8:523-7. ingestion of MDMA ("ecstasy") and unrestricted intake of water. BMJ 2 Pollack CV, Biggers DW, Carlton SB, et al. Two crack cocaine body stuffers. 1996;312: 1359. Ann Emerg Med 1992;21:1370-80. 14 Holden R. Jackson MA. Near-fatal hyponatraemia coma due to vasopressin 3 Lancaster MJR, Legg PK, Lowe M, Davidson SM, Ellis BW Surgical oversecretion after "ecstasy" (3,4-MDMA). Lancet 1996; 347: 1052. aspects of international drug smuggling. BMJ 1988;296:1035-7. 15 Ellis AJ, Wendon JA, Portmann B, Williams R. Acute liver damage and 4 Osterwalder JJ. Naloxone - for intravenous heroin and heroin mixtures - ecstasy ingestion. Gut 1996;38:454-8. harmless or hazardous? A prospective clinical study. Clin Toxical 16 McGuire PK, Cope H, Fahy TA. Diversity of psychopharmacology associ- 1996;34:409-16. ated with use of 3,4-methylenedioxymethamphetamine ("Ecstasy"). Br J 5 Gueye PN, Hoffman JR, Taboulet P. Vicaut E, Baud FJ. Empiric use of Psychiatry 1994;165:391-5. flumazenil in comatose patients: limited applicability of criteria to define 17 Brown ERS, Jarvie DR, Simpson D. Use of drugs at "raves". Scot Med Y low risk. Ann Emerg Med 1996;27:730-5. 1995;40:168- 71.

Management issues in accident and emergency medicine

Management is a part of the job of any consultant in the are frequent problems in A&E, and a variety oflegal and ethi- NHS, but for accident and emergency (A&E) consultants it is cal dilemmas regularly confronts the A&E consultant. a crucial, often dominant, and generally stressful part oftheir Handling claims of clinical negligence and the avoidance of work. It is also extremely time consuming. A leading these by clinical risk management are also important and time consultant in the early eighties publicly stated that manage- consuming parts ofthe consultant's duties. ment issues occupied 80% ofhis working week, and although The A&E clinical team will not function effectively the situation may have changed somewhat with the advent of unless it is provided with the facilities to do so. The fabric multiconsultant departments, it remains as important as ever and maintenance of the department must be attended to, to deal with these issues as effectively and as efficiently as as must the updating of equipment and the purchasing of possible so that there is time for the consultant to maintain a new equipment changing for clinical needs. Provision of a http://emj.bmj.com/ visible presence in the department, teach the junior staff, and safe working environment is a particular issue in most A&E conduct research and audit. departments as the incidence ofverbal and physical assault To the uninitiated, the term "management" conjures up on staff increases. an unappealing vista of boring committee meetings, intru- Given the enormous variety and significance of issues sive administrators, and accountants demanding improved such as these, it is scarcely surprising that newly appointed performance and diminishing expenditure. As with most A&E consultants find management the most challenging caricatures, there are elements oftruth within this view, but part of their work. Trainees rightly expect that they should management is really much more than this. It is, in the receive proper training in this important area of their on September 30, 2021 by guest. Protected copyright. words of John Harvey Jones, about "making things future activities, and this demand led to my organisation of happen", and this entails learning how to deal effectively the first management course specifically for A&E trainees with people. Within the A&E department, this involves in 1988. Since then, various other initiatives have begun, forming, leading, and nurturing an effective clinical team. and the demand for the original course (run on a two Junior medical staff need to be selected, trained, and yearly basis) has grown to the point where it appears that it assessed, and positive and effective relationships with our will need to be run annually. The importance of nursing colleagues and others working in the department management in A&E has recently been recognised by the need to be forged and maintained so that a "them and us" Faculty of Accident and Emergency Medicine, which situation does not develop. includes management problems in its exit examinations. Relationships with those outside the department are Training people in management is complex; there are equally important. The way duty teams behave in the depart- frequently no "right" or "wrong" answers, and the correct ment and the support they provide to our junior staff need methods of dealing with difficult situations are generally continuous examination, sometimes involving difficult nego- derived from shared experience rather than from textbooks tiations with consultant colleagues. Local general practition- or direct instruction. The series on "Management issues in ers, often neglected in the past by A&E staff, quite naturally accident and emergency" that starts with this issue of the expect more and better information about their patients' Journal is thus warmly to be welcomed. Not only will it attendances at A&E departments. Many newsworthy events serve to reinforce management training already in tend to occur in A&E departments and local news media are progress, but it should also provide a forum for the likely to pay a periodic interest in activities there and request experience of established consultants to be shared. It is to interviews with staff involved. be hoped that the opinions expressed in the series generate A&E is surrounded by a morass of legal issues which may some lively correspondence. STEPHEN A D MILES prove particularly for the daunting newly appointed Accident & Emergency Consultant, consultant. Relationships with the police and the nature and Royal Hospitals NHS Trust, quantity ofpatient information that may be released to them London El