BENZODIAZEPINES
Definition
• GABA agonists
History
• Usually suicidal gesture or abuse, hypnotic/sleep agents (zaleplon, zolpidem, eszopiclone) have similar effects as BZD in overdose
Physical Findings
• CNS, respiratory depression, slurred speech, ataxia, hyporeflexia, midpoint/small pupils, hypothermia, hypotension
Evaluation
• Glucose, ABG, Serum/urine tox screen, end-tidal CO2 monitor, Tele, pulse ox
Treatment
• Supportive (airway protection if needed), Flumazenil 0.1–0.2 mg, repeat up to 3 mg → may precipitate szs, indications are rare, use only to reverse when known benzo is overadministered as part of procedural sedation & must be reversed for life-threatening sxs, monitor for resedation after 1–2 h, may require repeat dose
• Decontamination: Activated charcoal if ingestion occurred w/i 30 min
Disposition
• Home (rarely require admission) if resolution of symptoms after a period of monitoring
Pearls
• Monitor for withdrawal, which is similar in presentation (agitation, szs) & tx to EtOH withdrawal
• Isolated benzo OD rarely life-threatening although usually presents as combination OD
GAMMA-HYDROXYBUTYRATE (GHB)
Definition
• GABA & GHB receptor agonist
Physical Findings
• Initial euphoria, CNS/obtundation, hypothermia, bradycardia, hypotension, sz, respiratory depression, myoclonus, aspiration, rarely pulmonary edema & sz
Evaluation
• Serum/urine tox screen (rapidly metabolized → GHB levels not readily available)
Treatment
• Supportive, maintain airway, recovery w/i 2–4 h, resolution w/i 8 h
Disposition
• Home
OPIATES
Definition
• Opiate receptor agonist
History
• Witnessed or reported use of opiates (heroin, methadone, morphine, hydromorphone, fentanyl, oxycodone)
Physical Findings
• ↓ CNS, ↓ RR/BP, apnea, ± miosis, track marks, aspiration, noncardiogenic pulmonary edema
Evaluation
• Glucose, serum/urine tox screen (for coingestants), end-tidal CO2 monitor, Tele, pulse ox
Treatment
• Maintain airway
• Naloxone (titrate to effect) 0.2–0.4 mg IV → 1 mg IV → 2 mg IV → IV drip (duration 1–2 h)
• Activated charcoal (recent ingestion), whole bowel irrigation (long-acting opioid)
Disposition
• May require admission for long-acting opiates
Pearls
Pts die from untreated apnea, often in prehospital setting
• Pts w/ hypoxia/cyanosis have risk of aspiration/ARDS
• Pts w/ recurrent apnea after naloxone likely have longer-acting opiate
Opiate Withdrawal
Definition
• Cessation or rapid reduction of opiate use in a dependent individual
History
• Chronic opiate use, anxiety, nausea, vomiting, abdominal pain, diarrhea, myalgias
Physical Findings
• Yawning, rhinorrhea, mydriasis, piloerection, tachycardia
Treatment
• Clonidine 0.1 mg PO q30–60min (central α-agonist) → ↓ duration, methadone (not indicated in the ED)
Disposition
• Home or detox
Pearl
• Not life-threatening, do not require admission, may be precipitated by administration of naloxone & caution should be used before treating w/ additional opiate
COCAINE
Definition
• Snorting, injecting, smoking, ingesting (body packers) cocaine (peak 5–15 min, duration 1–4 h, releases norepinephrine/blocks reuptake)
History
• Cocaine use, anxiety, CP, focal weakness (CVA/ICH), sz, psychosis
Physical Findings
• ↑ HR, ↑ BP, hyperthermia, diaphoresis, agitation, nasal septal perforation
Evaluation
• Serum/urine tox screen, cardiac markers (if CP present), ECG (↑ QRS, ischemia), Cr (renal failure), CK (rhabdomyolysis), head CT (if ICH suspected), consider aortic dissection, intestinal infarction, stroke
Treatment
• Supportive care, BZD for anxiety/agitation/CP, treat hyperthermia (ice packs, cooling blankets, cooling mist), avoid βBs (unopposed α-adrenergic stimulation)
• Activated charcoal (recent ingestion), whole bowel irrigation (packers/stuffers)
Disposition
• Varies depending on existing cx of cocaine abuse
Pearl
• Cocaine wash-out syndrome: After cocaine binging, MS (lethargy, obtundation), lasts up to 24 h
METHAMPHETAMINE (“METH”)
Definition
• Norepinephrine release, dopaminergic (causes addiction)
History
• Ingestion, snorting, smoking, injection, rectal insertion of methamphetamines & derivatives (LSD, bath salts), ADHD, & narcolepsy medications
Physical Findings
• ↑ HR, ↑ BP, hyperthermia, diaphoresis, agitation, poor dentition (“meth mouth”), poor hygiene, compulsive scratching lesions (“meth mites”), tremors, sz
Evaluation
• Serum/urine tox screen, ECG, consider CT head (ICH), UA, CK (rhabdomyolysis), chemistries, cardiac enzymes (CP), Tele
Treatment
• Supportive care, BZD for anxiety/agitation/CP, cool hyperthermic pts (ice packs, cooling blankets, cooling mist)
• Activated charcoal (recent ingestion), whole bowel irrigation (packers/stuffers)
METHYLENEDIOXYMETHAMPHETAMINE (MDMA, “ECSTASY”), LYSERGIC ACID DIETHYLAMIDE (LSD)
Definition
• Serotonergic
History
• Ingestion MDMA, LSD, other hallucinogens
Physical Findings
• ↑ HR, ↑ BP, hyperthermia, anxiety, mydriasis, hallucinations, sz, diaphoresis, bruxism
Evaluation
• Serum/urine tox screen, chemistries (↓ Na due to excessive water ingestion), ECG, consider CT head (ICH), INR, UA, CK (rhabdomyolysis), cardiac enzymes (CP), Tele
Treatment
• Supportive care, BZD & haloperidol for agitation, cool hyperthermic pts (ice packs, cooling blankets, cooling mist)
• Activated charcoal (recent ingestion)