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Talk i gave at ICEN in Melbourne on Street Drugs - clinical update for the emergency nurse.
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Street Drugs
Kane Guthrie FCENA
Clinical Update
• Synthetic canabinoids• Designer amphetamines• Nurofen plus abuse
Street Drugs - Australia
ED’s biggest bain remains:– ETOH– Smoking
Emerging concerns:– Prescription drug abuse– Synthetic derivatives of old
Street Drugs in ED
• Resource intent• Challenging personas
Stats:• Amphetamines in ED 1.2% presentations
(Gray, 2007, MJA)
• July 2010-12 Vic ambulance • 318% increase in amphetamine related call outs
• (Helibourne, 2013, MJA)
The Web
Big Business/Clever People
Case 1
• 28 female• Known polysubstance abuse• Presents agitated, & diaphoretic• Vitals: BP 172/89, HR 128, RR 30, Temp 37.9• Given IVIH, IV Diazepam – symptoms settle
• Admits to smoking “spice”
Synthetic Canabinoids
• “K2” “Spice” – “legal Marijuana”
• Typically sold – “incense” “room fresheners”
• Labeled - not for human consumption
• Sold OTC or Internet - $20-30
Synthetic Canabinoids
• Difficult to detect
Contains:• Herbs/vegetables sprayed chemicals• Target CB1 receptors in brain
Generally smoked– Can be injected (tea), baked (cookies)
The Symptoms
• Agitation - Psychosis• Tachycardia• Hypertension• Arrhythmia's• Metabolic derangements• Seizures
ED Management
• Supportive care• Give Benzo’s – agitation, anxiety• Monitor temp• Fluids – dehydration• Look for co-ingestions
Case 2
• 22 male BIB Police• Found - agitated, palpitations, paranoid• Smoke some “Crystals”• Brought it of the net!• Vitals: BP 185/96, HR 142, Temp 38.2
Designer Amphetamines
• Mephedrone. • “Meow-Meow”, “Bath Salts”• Synthetic derivative – cathinone– Derived leaves Khat plant
Mephedrone
Synthetic stimulant:• Euphoric & psychostimulant effects• Similar to MDMA, Cocaine, Methamphet
• Illegal in Australia– Easily available over net!
Mephedrone
Presents:– Clear white powder– Crystals (bath salts), capsules , pills
Taken:– Ingested, injected, smoked
Cost:$20-$50 a hit!
Mephedrone
• Short half life – 30-90mins• Effects last 2-4 hours• Results in compulsive re-dosing
Causes pronounced peripheral vasoconstriction
ED Management
• Supportive care– Hydration, bladder care
• Give benzo’s - agitation, HR, HT, temp• Monitor Temp >39 risk MOF• Monitor for seizures, hyponatraemia
• Caution with antipsychotics
Case 3
• 35 female
Presents to ED with 2/52 hx:– Weakness– Thirst– Nausea
• Appears dehydrated, generalised weakness in all 4 limbs.
Blood Gas
Her ECG
Further History
• Admits to using 4g Nurofen+/day• Addicted to opioids
Nurofen Plus Abuse
• Emerging problem• Its all about the codeine• Cheap – available OTC• Each tablet 200mg nurofen/12.8mg codeine• Reports pt’s abusing 60-100 tablets/day
The Issues
• Renal tubular acidosis
• Metabolic complications:– Hypokalaemia– Hyperchloraemia– Hypophosphataemia
• GI Bleeds
Renal Tubular Acidosis
Essentially failure of:– H+ excretion or– HCO3 reabsorption
Causes:– Chronic renal disease, autoimmune, genetic, – Drugs – lithium, ibuprofen, toluene
ED Management
• Treat medical complications• Often require ICU/HDU • Electrolyte replacement – K, Mg
• Surgery/scopes - if bleeding• Opioid withdrawal• Excellent supportive care
Remember
‘”Every Turkey has a terminal event””
“Always consider medical causes”
Further Info/Resources
Street Drugs in 2013
• Countless new agents– Cheap & easily available
• Generally structurally variants of old• Toxicity somewhat predictable • Management principles largely the same
Questions
Thankyou