Updates on clinical management of recreational drug use: what s new and how do we treat it?

Transcription

1 Updates on clinical management of recreational drug use: what s new and how do we treat it? Matt Noble, MD MPH Oregon Poison Center OHSU Department of Emergency Medicine

2 Objectives Review the basic conceptual framework for recognizing and stabilizing toxic patients Highlight new and emerging recreational drugs and drug use trends Discuss the clinical management of patients using these new recreational drugs

3 Epidemiology Over 4 million poisonings occur annually 10% of ED visits and EMS responses involve toxic exposures 70% of accidental poisonings occur in children under 6 years old 80% of attempted suicides involve a drug overdose

4 What is a poison (toxin)? Can be any drug or substance A SUBSTANCE becomes a POISON (TOXIN) when the quantity of the substance exceeds the ability of the body to detoxify it

5 Objectives Review the basic conceptual framework for recognizing and stabilizing toxic patients Highlight new and emerging recreational drugs and drug use trends Discuss the clinical management of patients using these new recreational drugs

6 How do people get poisoned? By age group 1-5 years accidental 5-18 accidental drug experimentation and suicide attempts Adult Intentional overdose Accidental occupational exposure Incorrect dosing (elderly)

7 How do people get poisoned? Inhalation Absorption Injection Ingestion

8 Routes of Toxic Exposure Inhalation Absorption occurs via the capillary alveolar membrane in the lungs Common agents: Toxic gases, vapors, fumes, aerosols Carbon monoxide, ammonia, chlorine Tear gas

9 Routes of Toxic Exposure Absorption Occurs through capillaries in the skin Common agents: Poison ivy, oak, or sumac Organophosphates Hydrofluoric acid

10 Routes of Toxic Exposure Injection Substance enters directly into the body through an intentional break in the skin Common agents: Animal / insect venom Injection of illicit drugs

11 Routes of Toxic Exposure Ingestion Absorption occurs in the small intestine Common agents: Most medications Household products Petroleum-based agents Cleaning agents Cosmetics Drugs, plants, or foods

12 Handling the Toxic Patient Assure your own safety (!!) Primary assessment of the patient ABCs History, History, History Physical Exam Vitals, mental status, pupils, skin, bowel sounds, reflexes

13 History WHAT was ingested? WHEN was it ingested? HOW MUCH was ingested? Pill counts can be helpful Any VOMITING? CO-INGESTANT? Reported, nearby bottles Any ANTIDOTE given?

14 Toxidromes The mainstay of clinical toxicology Allows categorization of the patient Aids diagnosis and treatment Facilitates communication

15 Toxidromes Toxicologic syndromes Constellation of symptoms that suggest a particular class of drugs as the etiology of the presentation. Sympathomimetic Cholinergic Anticholinergic (antimuscarinic) Opioid Serotonin

16 Hyperthermia Tachycardia Hypertension Warm/moist skin Agitated delirium Sympathomimetic Seizures Paranoia/hallucinations Agitation

17 Sympathomimetic Hyperthermia Tachycardia Hypertension Warm/moist skin Agitated delirium Seizures Paranoia/hallucinations Agitation Causes: Cocaine Amphetamine / Meth Phencyclidine (PCP) Withdrawal Alcohol Benzodiazepines GHB Barbiturates

18 Photo: Robert G. Hendrickson, MD

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21 Photo: Robert G. Hendrickson, MD

22 Cholinergic Toxidrome Muscarinic Nicotinic CNS

23 Cholinergic Toxidrome Muscarinic: Diarrhea/diaphoresis Urination Miosis Bradycardia/bronchorrhea Emesis Lacrimation Salivation SLUDGE Nicotinic: Tremor Fasciculation Paralysis *Sympathetic ganglia CNS: Sedation/confusion Seizures

24 Cholinergic Toxidrome Causes: Pesticides Organic Phosphorous compounds (OPs) Carbamate insecticides Nerve Agents VX, soman, sarin, tabun Pilocarpine, muscarine

25 Photo: Abbas Foroutan, MD; Courtesy Greenberg s Text-Atlas of Emergency Medicine

26 Antimuscarinic Toxidrome Hyperthermia (HOT) Tachycardia/Hypertension Red, hot, dry skin (DRY,RED) Mydriasis (BLIND) Absent Bowel Sounds Urinary retention Confusion/hallucinations (MAD)

27 Antimuscarinic Toxidrome Causes: Antihistamines Antipsychotics Atropine/scopolamine Tricyclic antidepressants Skeletal muscle relaxants

28 Photo: Robert G. Hendrickson, MD

29 7mm with light shining in her eyes Photo: Robert G. Hendrickson, MD

30 Eyes Mydriasis (dilated) Miosis (constricted)

31 Opioid Toxidrome Miosis CNS depression Respiratory depression Causes: Opiates: Morphine, codeine Opioids: Hydromorphone Methadone Meperidine Oxycodone Hydrocodone Fentanyls

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33 Serotonin syndrome Increased serotonin in synapse Drugs that block serotonin reuptake (e.g. antidepressants [SSRIs, SNRIs], cocaine, fentanyl, bupropion, etc) Drugs that increase serotonin release (e.g. MDMA, amphetamine, cocaine, lithium) Drugs that inhibit serotonin metabolism (e.g. MAOIs, linezolid)

34 Serotonin syndrome NEJM 2005; 352:

35 Basics of Clinical Toxicology Supportive care Intubation/ventilation, vasopressors Limit absorption Decontamination, gastric lavage, activated charcoal, whole bowel irrigation Enhance elimination Chelation, urine alkalinization Antidotal therapies Specific to toxin

36 Decontamination Remove patient from agent Be sure the patient cannot take additional medications Physical decon remove clothes clean with water

37 Supportive Care ABCs: Airway Breathing Circulation Photos: Robert G. Hendrickson, MD

38 Limit absorption Physically remove toxin from the stomach Gastric Lavage (GL) Block absorption (by adsorbing) Activated charcoal (AC) Decrease transit time Cathartics (e.g. sorbitol added to charcoal) Whole Bowel Irrigation (WBI)

39 Limit absorption when? Indications: Toxin is still present in GI tract Contraindications: Risk outweighs the benefit: Toxin already absorbed Non-toxic exposure Specific therapy not effective (e.g. lithium / charcoal)

40 Gastric Lavage Empty the stomach

41 Gastric Lavage Mechanism: Mechanical removal Indications: Life threatening ingestion No antidote <1 hour after ingestion OR evidence that pills are in the stomach Photo: Robert G. Hendrickson, MD

42 Gastric Lavage - method

43 Photo: Robert G. Hendrickson, MD

44 Photo: Robert G. Hendrickson, MD

45 Gastric Lavage Complications: Esophageal /gastric perforation Aspiration Propulsion of toxin into small bowel Contraindications: Hydrocarbons, caustics Children (tubes are too small to pull back pills) Photo: Int J Surg 2009; 19(1)

46 Activated Charcoal Limit absorption

47 Activated Charcoal Photo: Robert G. Hendrickson, MD

48 Activated Charcoal Carbon Ash Treated with steam and CO2 ( activated ) to produce tiny pores on the surface Photo courtesy of OHSU/CROET

49 Activated Charcoal Medications become lodged in pores and held by weak bonds: Van der Waals, hydrogen, ion-ion, dipole forces/bonds (Adsorption)

50 Activated Charcoal Dose 1 g/kg orally, or 10:1 charcoal to drug ratio

51 Activated Charcoal Indications: Potentially harmful ingestion Toxin is adsorbed by activated charcoal < 1-2 hours after ingestion Complications: Vomiting (7%) Aspiration (1.6%)

52 Activated Charcoal Contraindications: Unprotected airway Caustic / hydrocarbon ingestion Toxin is not adsorbed by charcoal: Metals Alcohols Iron Lithium

53 Decrease Transit Time Cathartics Whole Bowel Irrigation

54 Cathartics Cathartics accelerate defecation Laxatives soften stool ( ease defecation ) Sorbitol (mixed with activated charcoal) Magnesium citrate / sulfate Do they work? not really Can they be dangerous? yes

55 Whole Bowel Irrigation

56 Whole Bowel Irrigation (WBI) Polyethylene glycol 3350 (Go-Lytely) Via NGT 1-2 Liters per hour Endpoint: until effluent is clear PEG 3350 is NOT absorbed

57 WBI - Indications Sustained release medications Body packers / body stuffers (?) Medications that do not bind to charcoal Photo: Robert G. Hendrickson, MD

58 WBI - contraindications Bowel dysfunction: Ileus / obstruction / perforation / GIB Hemodynamic instability? Intractable vomiting Photo: Robert G. Hendrickson, MD

59 Photo: Robert G. Hendrickson, MD

60 Decontamination summary Gastric Lavage <1 hr after life threatening OD Charcoal mainstay of GI decontamination Cathartics only one dose (0 in children) WBI for things not bound by charcoal (Li, Iron) and sustained release products (e.g SR, ER, XL)

61 Objectives Review the basic conceptual framework for recognizing and stabilizing toxic patients Highlight new and emerging recreational drugs and drug use trends Discuss the clinical management of patients using these new recreational drugs

62 Marijuana/Cannabis Increased prevalence/use seen after legalization Oregon Poison Center data

63 Marijuana/Cannabis Unintentional ingestions in children Particularly edibles (Edibles are a major problem for adults too) CNS sedation in children CNS excitation in adults Anxiety, agitation, lightheadedness/dizziness, weakness, syncope Mixed effects in adolescents

64 Marijuana/Cannabis Supportive care Respiratory support in young children

65 Synthetic cannabinoids Spice, K2, JWH-018 Bind cannabinoid receptors Sympathomimetic clinical effects Dissimilar to marijuana

66 Synthetic cannabinoids Aggressive supportive care Benzodiazepines!! Cooling may be necessary

67 Heroin Yup, good ol fashioned heroin National Early Drug Warning System report, 2016, King County

68 Fentanyl Analogs Fentanyl is times more potent than heroin (50-100x morphine) Known vs unknown adulterant Analogs as the latest and greatest More intense highs

69 Fentanyl >80% fentanyl seizures in 2014 from Northeastern US Ohio, Massachusetts, Pennsylvania, Maryland, New Jersey, Kentucky, Virginia, Florida, New Hampshire, Indiana

70 Fentanyl 2016: >60,000 overdose drug deaths in US ~20,000 from synthetic opioids (up from 3,000 in 2013) Increase primarily attributed to fentanyl >50% opioid deaths involved fentanyl (July-Dec 2016) Maine, Massachusetts, New Hampshire, Rhode Island, Missouri (60-90%) Midwest and Southern states (30-55%) 14% opioid deaths involved fentanyl analogs carfentanil > furanylfentanyl > acetylfentanyl

71 Fentanyl and analogs Treat with naloxone (Narcan) just maybe more of it and sooner

72 Imodium Loperamide Mu-opioid receptor agonist in large intestine Poor bioavailability and BBB crossing Cardiotoxicity in massive overdose Na, K, and Ca channel blockade QRS and QTc prolongation Polymorphic ventricular tachycardia Torsades

73 Body Stuffers Heroin and meth most common History is notoriously unreliable Important to ascertain how much patient usually uses Activated charcoal? Whole bowel irrigation? Admission?

74 Conclusions When possible, use a systematic approach to evaluating, describing, and treating a toxic patient Beware marijuana, heroin, fentanyl analogs, loperamide, and body stuffers Please call the Poison Center

75 Oregon Poison Center