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Amphetamine related presentations to the ED

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Amphetamine related presentations to the ED

  1. 1. Amphetamine-Related Presentations to ED Colleen Taylor CME 15th May 2014
  2. 2. What we will cover A little bit of history A little bit of epidemiology Case study Acute and chronic complications of amphetamine use
  3. 3. What are Amphetamines? Synthetic psychoactive drug Phenylethylamine derivative Stimulates the release of catacholamines and inhibits reuptake of monoamines. Increase in central + peripheral NA, DA and 5HT Prescription formulations e.g. dexamphetamines, methylphenidate (Ritalin) Or illegal formulations: Ice, speed, tablets
  4. 4. History of Amphetamines First synthesised in Germany in 1887 (1) Used medically in 1930’s as stimulant for nasal decongestion, which progressed to treatment for narcolepsy, hyperemesis and hyperactivity in children (2) Widely used in WWII to improve concentration and endurance Rendered an illicit drug 1970’s (3)
  5. 5. How Common is Amphetamine use? Multiple sources state that amphetamines are the second most common drug of abuse in Australia after cannabis (1, 3, 4) Lifetime use 7.7% in men vs 4.9% in women (1) Study at RPH in 2005 showed 1.2% of all attendances related to amphetamines, with high acuity (66% triage 1-3) and 1/3 of all needing psychiatric assessment (4) Between 2006 and 2010, there were 2062 persons with a primary diagnosis of amphetamine-related psychosis in outpatient and inpatient services of metropolitan hospitals in WA (5)
  6. 6. Case Study 34 year old man PMH: Cluster B personality disorder, ? Bipolar affective disorder Long history of polysubstance abuse mainly alcohol and methamphetamines Abstained from amphetamine use for past 3 months, but took several amphetamine tables orally the night before presenting to Charlies ED
  7. 7. Case Study Complaining of sudden onset of severe left sided chest pain, both dull and sharp. Radiated to the left of the chest and through to the back Associated with shortness of breath, sweating and nausea No cough, fever, haemoptysis Had some numbness in all 4 limbs, which may have been slightly worse in the left arm and leg than the right No weakness, no slurred speech or facial droop. No headache Recent flu-like illness 5/7 ago
  8. 8. Case Study O/e: - A = Patent - B = RR 18 sats 89% RA, Clear chest, no chest wall tenderness - C = CRT <2, pulse 140, BP 141/60 (L), 147/85 (R), CV I+II+O - D = GCS 15, normal neuro examination with no reduced sensation to light touch or pinprick - E = Temp 37.6, Soft abdomen, no obvious track marks
  9. 9. Case Study Bloods: - WCC 13.5, otherwise normal - U+E normal - LFT normal - Troponin 34/23 CXR: normal ECG: Sinus tachy with no ST changes CT Aortogram: Normal
  10. 10. Case Study Treatment: - IV diazepam - IV opiates - Anti emetics - Fluids After period of observation, chest pain settled, tachcardia settled, blood pressure reduced. Diagnosis of acute amphetamine toxicity
  11. 11. Acute complications - CVS Tachycardia HTN Dysrhythmias Acute coronary syndrome Acute cardiomyopathy Acute pulmonary oedema
  12. 12. Acute Complications - CVS Tachycardia and HTN - Use titrated doses (2.5 -5mg) of IV benzodiazepines - If unresponsive, consider use of nitrites - Beta-blockers are contra-indicated Dysrhythmia's: - Treat with benzodiazepines and conventional measures - Correct hypoxia, acidosis, electrolyte disturbances
  13. 13. Acute Complications - CVS Acute Coronary Syndrome - Mechanism may be increased myocardial oxygen demand, coronary artery spasm, platelet aggregation, and thrombus formation secondary to elevated catacholamine levels (9) - ACS diagnosed in 25% of patients presenting to the ED with chest pain after methamphetamine use (6) - The population attributable risk suggests that amphetamine abuse is responsible for 0.2% of acute myocardial infarction (6) - Manage ACS conventionally but consider CT brain should be performed prior to anticoagulation or angiography if headache is a feature
  14. 14. Acute complications - CVS Aortic dissection - Amphetamine abuse is significantly associated with aortic dissection. In one study odds ratio = 3.33, 95% CI = 2.37-4.69, P < .0001 (7) - Another study suggests 20% of all patients with aortic dissection under the age of 50 years are due to amphetamine misuse (8)
  15. 15. Acute Complications - Neurological Agitation/Aggressive behaviour Psychosis Movement disorders Seizures Intra-cerebral haemorrhage
  16. 16. Acute Complications - Neurological Agitation/behavioral disturbance - Mild: PO diazepam 10-20mg +/-olanzapine wafer. Consider review of benzodiazepines after more than 60mg required - Moderate/severe/refusing PO meds: IV benzodiazepines +/- droperidol. If failing to respond, consider IM olanzapine
  17. 17. Acute Complications - Neurological Movement disorders - Increased muscle tone or repetitive movements e.g. bruxism/choreoathetoid movement - Treat with PO/VIV benzodiazepines Seizures - Treat with PO/VIV benzodiazepines - Consider barbituates as a second line agent - Correct reversible causes as per normal seizures
  18. 18. Acute Complications - Neurological Intra-cerebral haemorrhage - Headache should be considered as a red flag in amphetamine users; early CT is a priority - Many factors could be involved including vasospasm, cerebral vasculitis, enhanced platelet aggregation, cardioembolism, and hypertensive surges. Around 40% of patients have pre-existing lesions (10)
  19. 19. Acute Complications - Other Hyperthermia - Temperature >38.5°C: continuous core-temperature monitoring, IV benzodiazepines and passive cooling with tepid sponging/cool spray/fluids - Temperature >39.5°C: Consider intubation and ventilation for rapid active cooling. Paralysis if intubated. Hyponatraemia - If >120mmol, no seizures/change in GCS, manage conservatively with fluid restriction. If any of above, consider 3% hypertonic saline - Think about glucose and K+ abnormalities
  20. 20. Acute Complications - Others Rhabdomyolysis Dirty hit Foreign body embolus
  21. 21. Chronic complications Increased risk of septic emboli e.g. endocarditis, lung/brain abscesses Increased risk of stroke Increased risk of cardiovascular disease including cardiomyopathy Increased mental health issues Poor socioeconomic outcomes
  22. 22. Conclusions Amphetamine use is common Look for features of amphetamine toxicity including tachycardia, HTN, sweating and agitation Headache, chest pain and hyperthermia are all red flags and should be thoroughly assessed and managed If in doubt, give benzodiazepines!
  23. 23. References 1. Greene, SL, Kerr F and Braitberg, G. Review article: Amphetamines and related drugs of abuse. EMA 2008; 20: 391-402 2. http://www.cesar.umd.edu/cesar/drugs/amphetamines.pd. Accessed 14/05/2014. 3. Ellatt EC, Montgomery S, Nemiki T, Noguchi T. Misrepresention of stimulant street drugs: a decade of experience in an analysis program. J. Toxicol. Clin. Toxicol 1986; 24: 441–50. 4. Gray SD, Fatovich, DM, McCoubrie DL and Daly, FF. Amphetamine-related presentations to an inner-city tertiary emergency department: a prospective evaluation. Med J Aust 2007; 186 (7): 336-339 5. http://drugaware.com.au/Drug- Information/Amphetamines/Amphets-And-The-Ed.aspx. Accessed 14/05/2014.
  24. 24. 6. Turnipseed SD, Richards JR, Kirk JD,Diercks DB, Amsterdam EA. Frequency of acute coronary syndrome in patients presenting to the emergency department with chest pain after methamphetamine use. J Emerg Med. 2003;24(4):369-373. 7. Westover AN and Nakonezny PA. Aortic dissection in young adults who abuse amphetamines. Am Heart J. 2010 Aug; 160(2):315-21. doi: 10.1016/j.ahj.2010.05.021. 8. Wako, E., LeDoux, D., Mitsumori, L. and Aldea, G. S. (2007), The Emerging Epidemic of Methamphetamine-Induced Aortic Dissections. Journal of Cardiac Surgery, 22: 390–393. doi: 10.1111/j.1540- 8191.2007.00432.x 9. Nolan J and Ghuran A. The cardiac complications of recreational drug use. West J Med. Dec 2000; 173(6): 412–415. 10. Pozzi M, Roccataglitan D and Sterzi R. Drug abuse and intracranial haemorrhage, Neurol Sc. 2008; 29 (issue 2): 269-270

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