Emergency Department Presentations of Substance Use Craig Smollin MD Medical Director California Poison Control System, SF Division Associate Professor of Emergency Medicine University of California, San Francisco Nothing to Disclose Poisoning is the leading cause of death from injuries in the U.S. From the National Center for Health Statistics, 2011 Poisoning is the leading cause of death from injuries in the U.S. Overdose Death Rates Pattern of Overdose Deaths Case #1 • A 36 year-old male brought to the emergency department by EMS after ingesting Hydrocodone/Acetaminophen. • Obtunded (grumbles/withdraws to pain). • Pupils 1 mm and reactive bilateral. • Respiratory rate is 8/min. • Improved after 2 mg of naloxone. What is the general approach? First and foremost, Poisoned Patients Need Good Supportive Care. ABCDE… • Airway • Breathing • Circulation A B C ABCDE… • The three D’s: – Dextrose • Check finger stick glucose – Drugs • Consider naloxone, flumazenil – Decontamination • Consider activated charcoal/ WBI Rule out hypoglycemia Naloxone • Rapidly reverses opioid intoxication – Onset < 1-2 min • Downside – Acute opioid withdrawal – Pulmonary Edema • T1/2 = 60 min (lasts 1-2 hours) Case #1 • A 36 year-old male brought to the emergency department by EMS after ingesting hydrocodone/acetaminophen. • Obtunded (grumbles/withdraws to pain). • Pin point pupils. • Respiratory rate is 8/min. • Improved after 2 mg of naloxone. Miosis – Not Just Opioids • Sympatholytic drugs – Clonidine – Benzos and others • Alpha-adrenergic blockers – Chlorpromazine – Quetiapine Miosis – Not Just Opioids • Cholinergic agents – Organophosphates – Carbamates • CNS lesions – Cerebellopontine angle infarct – Subarachnoid hemorrhage Case #1 continued • 1.5 hrs later the patient developed recurrent symptoms with respiratory depression, and a decline in oxygen saturation to 90%. • Sxs improved after repeat dose of 6 mg naloxone. Case #1 continued • 1.5 hrs later the patient developed recurrent symptoms with respiratory depression, and a decline in oxygen saturation to 90%. • Sxs improved after repeat dose of 6 mg naloxone. Onset, Duration of Effect, and Potency of Selected Opioids Opioid Analgesic Onset of effect Duration of Potency (route) (min) effect (hrs) Morphine (IV) 5-10 3-6 1 Oxycodone (PO) 10-15 4-6 0.5 Hydrocodone (PO) 30-60 4-6 0.33 Hydromorphone (IV) 15 4-6 6.66 Methadone (PO) 30-60 6-12 1 Fentanyl (IV) Immediate 0.5- 1 100 Buprenorphine (PO) 60 4-12 ? Meperidine (IV) 1-5 2-4 0.1 Naloxone (IV) 1-2 1-2 High Naloxone Requirements • Higher potency opioids may require larger doses of naloxone – Poklis A. Fentanyl: a review for clinical and analytical toxicologists. J Toxicol Clin Toxicol. 1995;33(5):439-47. – Schumann H, Erickson T, Thompson TM, Zautcke JL, Denton JS. Fentanyl epidemic in Chicago, Illinois and surrounding Cook County. Clin Toxicol (Phila). 2008;46(6):501-6. Case #1 continued • 1.5 hrs later the patient developed recurrent symptoms with respiratory depression, and a decline in oxygen saturation to 90%. • Sxs improved after repeat dose of 6 mg naloxone. • Urine toxicology screen negative. Urine Drug Screening • Rapid immunoassays for – Cocaine – Amphetamines – Opiates – Benzodiazepines – ….and depending on the kit: • Barbiturates, THC, TCAs, PCP Urine Drug Screening: Opiates USUALLY DETECTED USUALLY NOT DETECTED • Morphine • Oxycodone2 • Heroin • Methadone2 • Codeine • Fentanyl • Hydrocodone1 • Meperidine • Hydromorphone1 • Buprenorphine2 • Tramadol 1 Depending on the assay 2 Specific assays available Urine Drug Screening: Benzodiazepines USUALLY DETECTED USUALLY NOT DETECTED • Diazepam • Lorazepam • Oxazepam • Clonazepam • Chlordiazepoxide • Zolpidem • Alprazolam Important drugs not detected on UDS • GHB • Carisoprodol • Newer antidepressants • Most other pharmaceuticals • “Designer” drugs (NPS) – Methcathinone derivatives (“Bath salts”) – Synthetic cannabinoids (“K2, spice”) Case #1 continued • 1.5 hrs later the patient developed recurrent symptoms with respiratory depression, and a decline in oxygen saturation to 90%. • Sxs improved after repeat dose of 6 mg naloxone. • Urine toxicology screen negative. • Acetaminophen level negative. Laboratory Analysis: Fentanyl 3.5 mg Promethazine 2.3 mg Acetaminophen 39.2 mg Novel Psychoactive Substances and Opioids • W18 • Furanylfentanyl • Acetylfentanyl • MT-45 • 3-methylfentanyl (TMF) • 4-methoxybutyrofentanyl Case #2 • 25 year-old male found running down the street naked. • EMS reports incoherent speech and agitation. • Patient has generalized tonic clonic seizure. • In ED he is confused and agitated requiring 4 point restraints Case #2 • Vital Signs: – HR 140/min, BP 156/80, RR 25, Temp 106 – Pupils 8 mm – Skin profusely diaphoretic • Labs – CPK 3,500 – Serum Creatinine 1.8 – Urine Drug Screen (+) amphetamines Urine Tox: Amphetamines USUALLY DETECTED OFTEN NOT DETECTED Methamphetamine • MDMA, MDA and other meth derivatives Amphetamine • Methcathinone and other Ephedrine Khat derivatives Pseudoephedrine • Other synthetic stimulants (eg, “bath salts”) Some amphetamine false positives • Bupropion • Chlorpromazine • Labetalol • Ranitidine • Sertraline • Selegiline • Trazodone Sympathomimetic Toxidrome • Features: – Hypertension, tachycardia – Agitation/psychosis – Dilated pupils – Increased muscle activity – Diaphoresis • Common causes: – Cocaine – Methamphetamine, MDMA, etc – “Bath salts” and “Spice/K2” Severe Hyperthermia (T>>104 F) Potentially disastrous!! Brain damage Cardiovascular collapse Rhabdomyolysis Multiple organ failure Aggressive cooling: Sedation NM paralysis External cooling Stimulant Complications and Treatments Complication Treatment(s) Agitation, psychosis Benzos, antipsychotics Seizures Benzos, barbs, propofol Hypertension Benzos, vasodilators Rhabdomyolysis IV fluids, monitor for hyperK+ Hyperthermia Aggressive cooling Case Conclusion • Intubated, paralyzed and sedated • Externally cooled with cool mist and fans • Vigorous IV hydration • CK peaked at 75,000, Creatinine peaked at 2.9 • Extubated on hospital day 3 • Admits to using…. Dimethoxybromo-amphetamine (DOB) Methamphetamine DOB Case #3 • 16 year-old male with altered mental status and fever. • Actively hallucinating in the ED • Physical Exam – BP 130/80, HR 125/min, RR 20 , Temp 101.3 – Pupils 6 mm – Dry mucous membranes – Dry Skin – Agitated, confused, trying to pull out IV. Anticholinergic syndrome Common features: Agitation, delirium Mad as a Hatter Dry, flushed skin Red as a Beet Dilated pupils Blind as a Bat Tachycardia Dry as a Bone Urinary retention Hot as a Hare Many causes: Atropine, scopolamine, antihistamines Tricyclic antidepressants Some plants and mushrooms Case #3 – Further Information Jimson Weed – Datura Species Plant species containing belladonna alkaloids Hyoscyamus Niger Atropa Belladonna Mandragora Officianarum (Henbane) (deadly nightshade) (mandrake) • Classic presentation of anticholinergic toxidrome • Symptoms may persist for an extended period (24-48 hrs) Should We Use Physostigmine? Short-acting cholinesterase inhibitor Reverses central and peripheral deficits Works better than benzos for anticholinergic agitated delirium Risks of physostigmine Seizures Bradycardia, heart block, asystole Stimulant vs. Anticholinergic? Pt #2: BP 156/80, HR 140, pupils dilated, agitated, diaphoretic. Pt #3: BP 130/90, HR 125, pupils dilated, delirious, dry flushed skin Case #4 • 51 year-old male with 2 days of double vision • Also complains of difficulty swallowing, upper extremity weakness and shortness of breath • Physical exam – Ptosis – Decreased respiratory effort – 3/5 strength in bilateral upper and lower extremities – Unable to ambulate Clinical Exam Findings Bilateral Ptosis “Skin popping” Black Tar Heroin Incidence of Wound Botulism in California 1951-1998 Werner S B et al. Clin Infect Dis. 2000;31:1018-1024 Wound Botulism • Clostridium botulinum – gram positive spore-forming bacillus • Toxin irreversibly inhibits release of acetylcholine at synapse • Clinical presentation – Acute Descending paralysis, autonomic and cranial nerve involvement (dysarthria, dysphagia, dyspnea, diplopia) – Can require intubation • Differential dx: – Myasthenia Gravis, Guillian Bare, Paralytic shellfish poisoning Other skin and soft tissue injuries • Abscess – Skin popping – Booting – Speedballs – More frequent injections – Untreated HIV – Non-sterile needles – Poor skin hygeine Other skin and soft tissue injuries • Abscess • Cellulitis Other skin and soft tissue injuries • Abscess • Cellulitis • Necrotizing fascitis Necrotizing Fasciitis • Erythema without sharp margins; swollen, warm, shiny; exquisitely tender, subcutaneous gas • Progresses rapidly: red-purple blue-gray patches, bullae, gangrene (3-5 days) • High fever, systemic toxicity in advanced infection • Marked edema, swelling compartment syndrome, myonecrosis • Early surgical intervention: debridement, fasciotomy • IV antibiotics: pip-tazo (anaerobes), clinda + PCN for GAS • High mortality, case-fatality rate 24% Case #5 • 54 year-old woman presents with 2 days of painful rash • Began on extremities and spread to ears and face • Labs – Absolute neutrophil count = 1070 – Urine drug screen (+) cocaine Urine Tox: Cocaine IT’S COCAINE ! What is the diagnosis? Levamisole and cocaine • Antihelminthic and immunomodulator. • Prevalent adulterant of cocaine. • Classic reticulated and bullous pattern • Most common sites: – Lower extremity (84%) – Ears (73%) – Upper extremity (68%) – Face (52%) • Associated with arthralgias and neutropenia