Acute poisonings with substances of abuse

Identification of intoxicationSuspition of intoxication

Vilnius toxikology clinic 2003

Preliminary CNS evaluation

SuppressionAgitation

Opioids

THC

EthanolPsichostimulants

Midriasis, normal photoreaction Normal pupils, photoreaction Myosis, no photoreaction

OpioidsNatural(opiates)

MorphineCodeine

SemisyntheticHeroinHydromorphoneOxymorphoneOxycodone

SyntheticMethadoneMeperidineLevorphalFentanyl3-methylfentanylPropoxypheneTramadol

Opioids Pharmacology

Generally, all opioid agonist drugs exert the same pharmacological effects in the CNS and periphery, but differ in pharmacokinetic properties, e.g. duration of action, potency, ability to cross blood-brain-barrier

Opioid overdoseCNS Symptoms I

• Respiratory depression, intensive central cyanosis (bradipnoe 2-4/min.)

• Sedation and drowsiness, unconsciousness up to coma

• Miosis

• Hypothermia

Opioid overdoseCNS Symptoms II

• Suppression of cough

• Suppression of pain

• Nausea and vomiting

• Euphoria or dysphoria

• Seizures

Opioid overdose Periphery Symptoms

• Cardiovascular: vasodilatation, hypotension• Urinary tract: urinary urgency and retention• Skin: urticaria from histamine release • GI tract: constipation• Uterus: decreased contractions

Opioid overdoseTreatment

• CPR (cardiopulmonary resuscitation) • Naloxone – bolus 2 mg I/V (0,4-2mg) to

10 mg (If no I/V access - sublingual, endotracheal, i/m), continous infusion

• In-patient monitoring at least 12 hours

• Heating

Cocaine Neurochemical actions

• Blockade of reuptake of NE, DA and serotonin:– Low dose: preferential action on NE reuptake– Moderate dose: NE and DA reuptake– High doses: NE, DA and serotonin reuptake

• Local anesthetic action:– blockade of sodium channels

Cocaine Neurotransmission I

http://drugabuse.govhttp://drugabuse.gov

Cocaine Neurotransmission II

http://drugabuse.govhttp://drugabuse.gov

Cocaine Neurotransmission III

http://drugabuse.govhttp://drugabuse.gov

Cocaine overdoseSymptoms I

• Agitation to psychosis• Halucinations• Mydriasis• Hypertermia (>41OC)• Hypertension • Tachycardia• Seizures• Coma

Cocaine overdoseSymptoms II

• Ischemic complications (vasospasm)– Myocardial infarction, cerebral infarction, etc.

• Haemorrhagic complications (hypertension)– Subarachnoid, intracerebral hemorrhage,

aortic dissection, etc.

• Dysrhytmias to ventricular

fibrilation

Cocaine overdoseTreatment• No antidotes

• CPR• Agitation, psychosis, seizures, hypertension,

tachycardia BZD (Diazepam 10-100 mg)

• Hyperthermia external cooling (<41OC)

• Severe hypertension phentolamin, nitropruside

• SVT - Ca antagonists

• VT - lidocaine

• No β-blockers

Heroin+Cocaine overdoseSymptoms

• Changing clinical signs (swing)

Cocaine ↔ opioids

• Coma

• Respiratory depression

• Midriasis

• Tachycardia

Heroin+Cocaine overdoseTreatment

• CPR• Naloxone: bolus 2 mg i/v + continous infusion

• In-patient monitoring at least 12 hours

• Symptomic treatment

• Benzodiazepines

Body packing and stuffing Is it the same?

• Packing – action, when a person transports illicit drugs in a body orifice. The risk of package rupture is more remote.

• Stuffing – action, when a person places drugs in a body orifice in a moment of imminent danger. In this case drugs are not well packaged for transportation, hence the high risk for leakage

Body packing and stuffing Investigations

• Ultrasonography• Contrast X-ray of

the bowel• Computerized

tomography• Drug detection in

urine and blood

• Clinical observation• Light solid diet• Free assumption of

liquids• Surgical removal, if

mechanical obstruction occurs

• Treatment of systemic symptoms

Body packing and stuffing Investigations

Study Indications Sensivity Comments

Plain abdominal radiography

Screening test 85-90% Sensivity for finding small numbers of packets may be lower. May miss substantial numbers of packets

Ultrasonography

Screening test No established

Has the potential to be very useful, large studies needed

CT Used if equivocal results obtained on initial screening test. Used to document that GT is clear

No established

Large studies needed

Contrast enhanced abdominal radiography

Used if equivocal results obtained on initial screening test. Used to document that GT is clear

96% Reported sensitivity based on 1 study

Radiographic Approaches to the Identification of Body packing

Body packing and stuffing Levels of packages security

• I - 1 protective layer• II - 2 protective layers;

in our case• III – machine-made (4-7

protective layers)

Body packing and stuffing First detected case in Lithuania

• A 31 year old male was brought to the Department of Toxicology by customs officers after disembarking at the Vilnius International Airport suspecting of cocaine transport

Body packing and stuffing First detected case in Lithuania

• There were no any complaints and examination of patient didn’t show any pathology

• All blood tests were normal• Patient refused endoscopy, but agree to

contrast X- ray investigation• Foreign bodies were detected in the

gastrointestinal tract by X-ray photography• Toxicological analysis for narcotics of urine and

blood were done

Body packing and stuffing First detected case in Lithuania

• Observation (blood pressure, heart frequency, temperature, neurological assessment every hour)

• Mild laxative in conjunction with sufficient beverages

Body packing and stuffing First detected case in Lithuania

“double condom’’ signFill defects

Body packing and stuffing First detected case in Lithuania

39 packets were excreted on the first day, 10 – on the second day, 3 – at the third day

X-ray 3 days later revealed foreign bodies in the gastrointestinal tract (“double condom’’ sign)

Because of customs officers demand the patient was transferred to the Hospital of Prison, despite staff objection. 62 cocaine packets were excreted during the next 3 days

Body packing and stuffing First detected case in Lithuania

• Condoms were filled with 3-8 g of cocaine each

• 114 packages, weight 438,63 g,purity – 57%

• 2 of cocaine packets were slightly injured

• Blood sample – no answer, urine analysis – “possibility of cocaine metabolites”

Forensic analysis

Body packing and stuffing Management

•In no way endoscopic removal of the package should be attempted. The patient in whom only one packet fails to pass the pylorus may be the exception•Conservative management during spontaneous evacuation of the containers is the first choice approach to the body-packing•Surgery is indicated for patients with acute cocaine poisoning or gastrointestinal obstruction or perforation•Observation till the last package removes is obligatory

AmphetamineNeurochemical actions

• Dose-related increase in release of norepinephrine, dopamine and serotonin:– low dose: preferential action on NE release– moderate dose: NE and DA release– high dose: NE, DA and serotonin release

• Blockade of reuptake of NE, DA and serotonin• Inhibition of MAO

AmphetamineSymptoms

• Agitation to psychosis• Halucinations• Mydriasis• Tachycardia • Hypertension • Mild hypertermia• Seizures• Coma

AmphetamineTreatment

• No antidotes• CPR• GI decontamination gastric lavage, activated charcoal• Benzodiazepines• Severe hypertension phentolamin, nitropruside• External cooling• SVT Ca antagonists

VT lidocaine• No β-blockers

“Ecstasy” (MDMA): a hallucinogenic amphetamine

• Combination of psychostimulant effects with stronger hallucinogenic effects (serotonin component)

• Common acute adverse effects: muscle tension and bruxism

• Hyperthermia• Increase HR and BP• Acne-like rash

CannabinoidsSymptoms

• Impairment of cognitive function • Disorientation, talkativness• Anxiety to panic• Headache• “Exploding chest”• Sedation

• Ataxia• Tremor• Dry mouth• Tachycardia• Injected

conjunctive

CannabinoidsTreatment

• Benzodiazepines

• Symptomic treatment

• Psychoterapy

LSD Symptoms

• Anxiety, agitation

• Hallucinations

• Moist and pale skin

• Mild hypertension

• Tachycardia

• Hypertermia

(Lysergic Acid Diethylamine)

LSD Treatment

• Benzodiazepines

• In severe cases – the same as amphetamines

(Lysergic Acid Diethylamine)

Gamma-hydroxybutyric acid Symptoms

• CNS depression (GCS of 3 is not uncommon)• Extreme combativeness and

agitation• Bradycardia • Decreased systemic vascular

resistance, hypotension• Profound respiratory depression.

Gamma-hydroxybutyric acid Treatment

• Airway protection and aspiration precautions

• Use atropine to treat symptomatic bradycardia that is unresponsive to stimulation

Solvents Symptoms

• Agitation, joy• Vertigo, coordination damamge • Sneeze, hypersalivation• CNS depression, delusions • Sense of invulnerability • Respiratory depression • Tachycardia• Seizures, coma

Solvents Treatment• Oxygen• CPR (if needed)

• Benzodiazepines

• Symptomic treatment

Milestones in treatment of drug overdose

Naloxone

Benzodiazepines

Life support measures