Basics
Description
- Predominantly alters perception, cognition, and mood
- All hallucinogens potentiate neurotransmitter release or bind directly to receptors:
- Serotonin (5-hydroxytryptamine; 5-HT): Many hallucinogens are agonists or antagonists at 5-HT receptor subtypes.
- Norepinephrine, N-methyl-D-aspartate (NMDA), dopamine
Etiology
- Most exposures are intentional
- Common hallucinogens:
- Indoleamine:
- Lysergic acid diethylamide (LSD) (duration 6-12 hr)
- Morning glory (Ipomoea spp.)
- Tryptamines:
- Psilocybin (Psilocybe mushrooms); frequently adulterated with LSD
- N, N-dimethyltryptamine (DMT); 5-MeO-DMT ("foxy-methoxy"¯), and other tryptamine congeners
- Phenylethylamines (hallucinogenic amphetamines):
- Methylenedioxyamphetamine (MDA)
- Methylenedioxymethamphetamine (MDEA)
- Methylenedioxymethamphetamine (MDMA; "ecstasy"¯; duration 8-12 hr)
- Paramethoxyamphetamine
- Dimethoxyamphetamine
- Mescaline (peyote cactus); frequently adulterated with LSD (duration 6-12 hr)
- Arylcycloalkylamines:
- Phencyclidine (PCP), (duration is variable 11-96 hr in 1 report)
- Ketamine, (duration depends on route of administration 30-120 min)
- Anticholinergic:
- Deadly nightshade (Atropa belladonna)
- Jimsonweed (Datura stramonium)
- Other:
- Piperazines: Benzyl piperazine (BZP) and trifluoromethyl phenylpiperazine (TFMPP)
- Dextromethorphan (DXM), (duration 3-6 hr)
- Marijuana
Diagnosis
Signs and Symptoms
- Considerable individual variation; effects may last 4-12 hr and ā‰¤96 hr depending on agent/dose
- Symptoms characterized by sympathetic arousal
- Usually oriented and able to give history of exposure even while having delusions
- Initial symptoms:
- Nausea, flushing, chills, tremor
- Neurologic symptoms:
- Restlessness and dizziness early after ingestion
- Desire to laugh (especially with Psilocybe mushrooms)
- Anxiety, despair, helplessness, dread
- Intensified perceptions, visual distortions/intensification
- Tactile distortions (especially with mescaline)
- Synesthesia (blending of sensory modalities, e.g., seeing sounds)
- Religious or mystical experiences
- Sleep disruption
- Neurologic signs:
- Unusual/bizarre behavior
- Speech disruption
- Mydriasis
- Piloerection
- Hyperreflexia
- Coma with massive exposure
- Convulsions:
- Hallucinogenic amphetamines
- Children who become hyperpyrexic after Psilocybe mushroom ingestion
- Pulmonary:
- Mild tachypnea
- Respiratory arrest (with massive exposure)
- Cardiovascular:
- Tachycardia
- HTN (with hallucinogenic amphetamines)
- Dysrhythmia (with hallucinogenic amphetamines)
- Intracerebral hemorrhage (with hallucinogenic amphetamines)
- GI:
- Nausea/vomiting (especially with mescaline)
- Metabolic:
- Hyperpyrexia:
- Especially with MDMA use at "rave"¯ clubs
- Hepatic failure, renal failure, and disseminated intravascular coagulopathy may follow.
- May be lethal
- Hyponatremia: Has been reported with MDMA use
- Hematopoietic:
- Coagulopathies and hemorrhage at high doses owing to disruption of platelet serotonin function
History
Identity of agent or agents used including:
- Method of usage
- Quantity
- Time of exposure
- Knowledge of place of exposure
Physical Exam
- Obtain accurate vital signs including temperature.
- Perform detailed neurologic and psychiatric exam
Essential Workup
- Core temperature measurement and other vital signs
- ECG monitoring
- Determination of risk of rhabdomyolysis:
- Creatine kinase level
- Urine dip or myoglobin level
Diagnosis Tests & Interpretation
Lab
- Electrolytes, BUN, creatinine, glucose levels, coagulation screen, arterial, or venous blood gas
- Urine toxicology screen:
- Rarely indicated
- Distinguishing between hallucinogens is of little value
- Most hallucinogenic substances are not tested for on routine drug screens
- Amphetamine screen is frequently negative for hallucinogenic amphetamines (e.g., MDMA)
Imaging
- Consider chest x-ray if looking for aortic dissection, pulmonary aspiration, or trauma-related injury
- Consider CT of head if looking for intracranial bleeds or lesions
- Consider abdominal x-ray if there is suspicion of ingested packets
Differential Diagnosis
- Hypoglycemia
- Meningitis, encephalitis
- Sepsis
- Intracranial bleeds or lesions
- Withdrawal (ethanol, sedative-hypnotic, baclofen)
- Serotonin syndrome (especially with concomitant serotonergic agents involved)
- Psychiatric illnesses:
- LSD associated with prolonged psychoses resembling schizoaffective disorders
- Chronic amphetamine/cocaine abuse
- Steroids
- Infectious/febrile seizures in hyperpyretic child
Assess parent-child relationships for possibility of neglect or abuse.
Treatment
Pre-Hospital
- Controversies:
- Sedation with benzodiazepines vs. haloperidol vs. physical restraints:
- Benzodiazepines are generally preferred
- Sedation masks symptoms and may limit history
- Cautions:
- Sedate or restrain patient to ensure safe transport
- For hyperthermic patient:
- Use sedation rather than physical restraint
- Begin cooling measures
Initial Stabilization/Therapy
- Management of ABCs
- Aggressive cooling if hyperthermic
- IV access/rehydration with isotonic fluids for significant fluid loss or evidence of rhabdomyolysis
- Naloxone, Accu-Chek, dextrose, and thiamine if patient has altered mental status
Ed Treatment/Procedures
- Cooling measures:
- Cool mist and fans
- Benzodiazepines if agitated
- Paralytics with intubation if needed (generally not succinylcholine)
- Sedate for agitation or autonomic signs:
- Benzodiazepines
- Rarely neuroleptics:
- May intensify hallucinogenic experience
- Possibly lower seizure threshold
- Activated charcoal (AC) is not expected to be helpful for most agents owing to rapid absorption and delayed patient presentation:
- Consider AC for oral ingestions within 2-3 hr in patients with intact protective airway reflexes; especially for anticholinergics or seeds owing to delayed GI motility/absorption
- Place in a quiet, calm environment
- Maintain urine output of 2-3 mL/kg/hr and consider urine alkalinization for treatment of rhabdomyolysis
Medication
- Benzodiazepines (diazepam): 5-10 mg IV (peds: 0.2-0.5 mg/kg) IV or lorazepam: 1-4 mg IV/IM (peds: 0.02-0.05 mg/kg) IV/IM, may repeat as needed
- Dextrose (D50W) for hypoglycemia: 1 ampule: 25 g/50 mL (peds: D25W, 0.5-1 g/kg or 2-4 mL/kg) IV, may repeat as needed
- Haloperidol (Haldol): 2.5-5 mg IV or IM may repeat every 30-60 min until calm, usual max. dose is 10-20 mg; not recommended for children
- Naloxone (Narcan): Initial dose: 2 mg (peds: 0.01-0.1 mg/kg) IV or IM, may repeat as needed
- Sodium bicarbonate infusion for rhabdomyolysis: 3 ampules in 1 L of D5W; infuse at 1.5-2 times maintenance rate (keep urine pH > 7.5)
- Thiamine (vitamin B1): 100 mg (peds: 25 mg) IV or IM — 1 dose
Follow-Up
Disposition
Admission Criteria
- Severely intoxicated
- Atypical presentation
- Prolonged symptoms (>12 hr after exposure)
- Prolonged periods of agitation and hyperthermia:
- Risk of rhabdomyolysis or organ damage
Discharge Criteria
After receiving supportive therapy and observation, most patients can be discharged once they are asymptomatic.
Suspected cases of child abuse or neglect require referral to child protective services.
Followup Recommendations
Upon discharge, patients should receive follow-up care from their PCP, psychiatrist, or drug counseling facility.
Pearls and Pitfalls
- Do not delay in the diagnosis and treatment of hyperthermia. Once hyperthermia is identified, aggressively lower body temperature.
- Use appropriate physical and chemical restraints to control violent and agitated patients to protect the patient and staff from physical injury.
- Conduct serial exams and vital signs (especially temperature). Do not assume once a violently agitated patient is calm that the patient is recovering. The patient may be progressing to serious illness.
Additional Reading
- Babu KM. Hallucinogens. In: Nelson LS, Lewin NA, Howland MA, et al., eds. Goldfranks Toxicologic Emergencies. 9th ed. New York, NY: McGraw-Hill; 2011:1166-1176.
- Greene SL, Kerr F, Braitberg G. Review article: Amphetamines and related drugs of abuse. Emerg Med Australas. 2008;20(5):391-402.
- Hall AP, Henry JA. Acute toxic effects of "ecstasy"¯ (MDMA) and related compounds: Overview of pathophysiology and clinical management. Br J Anaesth. 2006;96:678-685.
- Liechti ME, Kunz I, Kupferschmidt H. Acute medical problems due to Ecstasy use. Swiss Med Wkly. 2005;135:652-657.
- Richardson WH 3rd, Slone CM, Michels JE. Herbal drugs of abuse: An emerging problem. Emerg Med Clinic North Am. 2007;25:435-457.
Codes
ICD9
- 968.3 Poisoning by intravenous anesthetics
- 969.6 Poisoning by psychodysleptics (hallucinogens)
- 969.72 Poisoning by amphetamines
- 988.2 Toxic effect of berries and other plants eaten as food
ICD10
- T40.8X1A Poisoning by lysergide, accidental (unintentional), init
- T40.901A Poisoning by unsp psychodyslept, accidental, init
- T43.621A Poisoning by amphetamines, accidental (unintentional), init
- T62.2X1A Toxic effect of ingested (parts of) plant(s), acc, init
- T40.8X4A Poisoning by lysergide, undetermined, initial encounter
- T40.904A Poisoning by unsp psychodysleptics, undetermined, init
- T40.991A Poisoning by oth psychodyslept, accidental, init
- T40.994A Poisoning by oth psychodysleptics, undetermined, init encntr
- T43.624A Poisoning by amphetamines, undetermined, initial encounter
- T62.2X4A Toxic effect of ingested (parts of) plant(s), undet, init
SNOMED
- 85975005 Poisoning by psychodysleptic (disorder)
- 67893003 Poisoning by lysergide (disorder)
- 212670004 Ecstasy poisoning (disorder)
- 29824007 Atropa belladonna poisoning (disorder)
- 291260003 Ecstasy poisoning of undetermined intent (disorder)
- 41136005 Phencyclidine poisoning
- 81270000 Poisoning by psilocybin (disorder)