see also:

• amphetamine (speed) and related substances - metamphetamine (ice), MDMA(Ecstasy), MDA (Adam), MDEA (Eve), cocaine (crack), PMA, PMMA, flakka, etc
• toxicology
• sympathomimetics

• tachycardia, hypertension, arrhythmias, vasospasm, aortic dissection, acute coronary syndrome, hypotension (late), acute cardiomyopathy

• agitation, panic states, paranoia, euphoria, hallucinations and psychosis, bruxism, hyper-reflexia, intracrebral haemorrhage, choreoathetoid movements, anorexia, delirium, seizures, coma

• mydriasis, diaphoresis, tremor, tachypnoea

• non-cardiogenic pulmonary oedema / ARDS

• hepatitis, nausea, vomiting, diarrhoea, GIT ischaemia

• hyponatraemia - dilutional or syndrome of inappropriate ADH secretion (SIADH); acidosis
• hyperkalaemia (suggests PMA)
• hypoglycaemia

• hyperthermia, muscle rigidity, rhabdomyolysis, serotonin syndrome (clonus with hyper-reflexia) may occur especially if on SSRI's, tramadol, metoclopramide, etc.

• behavioural/psychiatric illness, cardiomyopathy, cardiac valve disease, pulm. hypertension, vasculitis

• seizure, focal neurologic deficit, reduced level of consciousness, abnormal motor movements, hyperthermia, arrhythmias, hypotension, hypertension, coronary artery spasm, autonomic instability or other major disturbance of homeostasis.

• cocaine, anticholinergics, tricyclic antidepressants, theophylline, SSRI, serotonin syndrome, MAOI, caffeine, salicylates, LSD

• thyrotoxicosis, delirium, sepsis, phaeochromocytoma, heat stroke, meningitis, encephalitis, temporal lobe epilepsy, intracranial haemorrhage

• benzodiazepines
• Aust. Govt guidelines to Emerg. Depts 2005 for Mx of psychostimulant toxicity advise either:
  • protocol 1 using oral diazepam:
    • 10-20mg o diazepam initial dose
    • if behavioural control or a state of rousable drowsiness is achieved within 30min of 1st dose, no more sedation needed.
    • insufficient clinical response by 30min, a further dose of 10mg o diazepam should be given
      • repeat this regime until a state of rousable drowsiness or a total of 60mg o diazepam (only exceed 60mg if no obvious resp. depression evident. Do not exceed 120mg in a 24 hour period).
  • protocol 2 using iv diazepam:
    • diazepam is the preferred agent iv over midazolam but diazepam is not suitable for im use
    • 2.5-5mg iv diazepam initial dose
    • if behavioural control or a state of rousable drowsiness is achieved within 10min of 1st dose, no more sedation needed.
    • insufficient clinical response by 10min, a further dose of 5-10mg iv diazepam should be given
      • repeat this regime until a state of rousable drowsiness or a total of 60mg diazepam (only exceed 60mg if no obvious resp. depression evident. Do not exceed 120mg in a 24 hour period).
  • protocol 3 using im midazolam when iv access not available:
    • 5mg im midazolam initial dose
    • if behavioural control or a state of rousable drowsiness is achieved within 10min of 1st dose, no more sedation needed.
    • insufficient clinical response by 10min, a further dose of 10mg im midazolam or 2.5-5mg iv midazolam should be given
      • repeat this 2nd dose for a 3rd dose if needed and if still inadequate response, resort to 2nd line.
      • NB. absorption of im doses is unreliable and may be delayed response - iv is preferable if iv access is possible.

• consider use of these earlier if paranoia or hallucinations are prominent
• Aust. Govt guidelines to Emerg. Depts 2005 for Mx of psychostimulant toxicity advise either:
  • droperidol 2.5mg-5mg iv every 20min as needed to max. dose 20mg in 24hr period
    • preferably after checking QTc is not prolonged, and beware seizures, sudden hypotension and laryngeal dystonia
    • do not give to antipsychotic naive patients unless an adequate benzodiazepine regime has been exhausted
  • olanzapine 10mg IM or oral wafer

• exclude hyponatraemia
• see seizures and anticonvulsants
• avoid phenytoin as it may have cardiac effects from its own properties as well as its diluent (propylene glycol).

• benzodiazepines as per usual

• phenobarbitone 20mg/kg iv
• sedation with airway control - thiopentone or propofol

• exclude hyponatraemia, hypoglycaemia
• protect airways and support respiration as per usual
• CT brain

• may occur due to either:
  • water intoxication from excess water intake at rave parties
  • drug effects of MDMA or PMA
    • the combination of hyponatraemia + hypoglycaemia or hyperkalaemia suggests PMA toxicity
• beware central pontine myelinolysis
• avoid hypotonic fluid administration
• fluid restrict in non-dehydrated patients
• hyponatraemia should be corrected over a similar time frame to it occurring but not at a rate > 0.5mM/hr during a 24hr period.
• cautious administration of 3% saline if Na < 115mM and only to Na of 120mM - seek advice
  • sodium required to obtain 120mM = (120-sodium concentration) x 0.6 x weight in kg, or,
  • X ml/kg of 3% saline will raise the serum sodium by X mM
• monitor U&E at least 4hrly initially

• Rx aggressively if temp > 39.5degC
• benzodiazepines
• active cooling measures - ice packs or baths
• NM blockade
• 5HT2 antagonists if possible serotonin syndrome and no co-ingestion of anti-muscarinic anticholinergic agents, eg:
  • cyproheptadine 12mg o or via NGT although limited evidence
  • chlorpromazine (Largactil) can be tried but risk of hypotension
  • olanzapine

• maintain urine output > 1.5-2ml/kg/hr
• urinary alkalinisation but beware this will increase amphetamine half life

• hypertension is often transient and does not usually require Rx unless severe.
• avoid beta blockers as blockade of beta 2 receptor which mediates skeletal vasodilatation may result in uncontrolled hypertension in a setting of unopposed alpha stimulation.
• benzodiazepines
• vasodilators eg. GTN infusion (5mcg/min then titrate) or nitroprusside infusion (0.25-10mcg/kg/min)
• rarely, may need to resort to alpha-adrenergic blockers - prazosin 2-5mg o or phentolamine 5mg slow iv

• usual Mx of SVT but avoid beta blockers - if must use them, try iv esmolol
• Mx options:
  • adenosine
  • verapamil (Isoptin) - 5mg iv beware of hypotension
  • flecainide - 2mg/kg iv over 30min
  • DC reversion

• standard protocols VT and VF

• usually more of an issue with cocaine but may occur with amphetamines
• avoid aspirin as risk of subarachnoid haemorrhage (SAH) if uncontrolled hypertension
• avoid beta adrenergic blockers as risk of uncontrolled hypertension
• sublingual GTN reverses cocaine-induce coronary vasospasm
• consider benzodiazepines if anxiety, tachycardia or hypertensive as they reduce BP and HR, and thus reduce myocardial oxygen demand in addition to their anxiolytic effects.

• use of cocaine or amphetamines are considered a strong risk factor for stroke (CVA) or subarachnoid haemorrhage (SAH)
• avoid aspirin as risk of subarachnoid haemorrhage (SAH)
• avoid corticosteroids as may be harmful
• Mx complications on their merits otherwise

• Greene et al. Review article: Amphetamines and related drugs of abuse. EMA 2008 20:391-402
• Qld health dept - Mx of psychostimulant toxicity March 2008 (pdf) - essentially the same as Aust. Govt guidelines in 2005.
• Mx of patients with psychostimulant toxicity - Aust. Govt guidelines to Emerg. Depts 2005