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Amphetamine-Related
Presentations to EDColleen Taylor CME 15th May 2014
What we will cover
A little bit of history
A little bit of epidemiology
Case study
Acute and chronic complications of amphetamine
use
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
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)
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)
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
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
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
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
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
Acute complications - CVS
Tachycardia
HTN
Dysrhythmias
Acute coronary syndrome
Acute cardiomyopathy
Acute pulmonary oedema
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
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
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)
Acute Complications -
NeurologicalAgitation/Aggressive behaviour
Psychosis
Movement disorders
Seizures
Intra-cerebral haemorrhage
Acute Complications -
NeurologicalAgitation/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
Acute Complications -
NeurologicalMovement 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
Acute Complications -
NeurologicalIntra-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)
Acute Complications -
OtherHyperthermia
- 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
Acute Complications -
OthersRhabdomyolysis
Dirty hit
Foreign body embolus
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
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!
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. Toxicol1986; 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 Aust2007; 186 (7): 336-339
5. http://drugaware.com.au/Drug-Information/Amphetamines/Amphets-And-The-Ed.aspx. Accessed 14/05/2014.
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