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Key Features

Essentials of Diagnosis

  • Agitation, paranoia, psychosis

  • Seizures, hyperthermia

  • Hypertension, tachycardia

  • Hyponatremia may occur with methylenedioxymethamphetamine (MDMA, "ecstasy")

General Considerations

  • Amphetamines and cocaine are widely abused for their euphorigenic and stimulant properties

  • Both drugs may be smoked, snorted, ingested, or injected

  • The toxic dose of each drug is highly variable and depends on the route of administration and individual tolerance

  • Amphetamine derivatives and related drugs include

    • Methamphetamine ("crystal meth," "crank")

    • MDMA

    • Ephedrine

    • Methcathinone ("cat" or "khat")

    • Methcathinone derivatives and related synthetic chemicals (eg, methylenedioxyprovalerone [MDPV] is often sold as purported "bath salts")

    • Amphetamine-like reactions have also been reported after use of synthetic cannabinoids (eg, "Spice" and "K2")

  • Nonprescription medications and nutritional supplements may contain stimulant or sympathomimetic drugs, such as

    • Ephedrine

    • Yohimbine

    • Caffeine

Clinical Findings

Symptoms and Signs

  • CNS stimulation and a generalized increase in central and peripheral sympathetic activity

  • The onset of effects is most rapid after intravenous injection or smoking

  • Anxiety

  • Tremulousness

  • Tachycardia

  • Hypertension

  • Diaphoresis

  • Dilated pupils

  • Agitation

  • Muscular hyperactivity

  • Psychosis

  • In severe intoxication, seizures and hyperthermia may occur

  • Prolonged use may cause cardiomyopathy

  • Hyponatremia has been reported after MDMA use

Differential Diagnosis

  • Pseudoephedrine, caffeine

  • Anticholinergic poisoning

  • Psychosis

  • Heat stroke

  • Alcohol or sedative-hypnotic withdrawal

  • Serotonin syndrome

Diagnosis

Laboratory Tests

  • Urine screening usually tests for amphetamines, cocaine metabolite benzoylecgonine

  • Blood screening is generally not sensitive enough to detect these drugs

Treatment

Emergency and supportive measures

  • Maintain patent airway and assist ventilation, if necessary

  • Rapidly lower the body temperature (see Hyperthermia) in patients who are hyperthermic (39–40°C)

  • Give intravenous fluids to prevent myoglobinuric kidney injury in patients who have rhabdomyolysis

Medications

  • Treat agitation, psychosis, or seizures with a sedating benzodiazepine such as diazepam, 5–10 mg, or lorazepam, 2–3 mg intravenously

  • Add phenobarbital (15 mg/kg intravenously) for persistent seizures

  • Treat hypertension with a vasodilator drug, such as phentolamine (1–5 mg intravenously), or nitroprusside, or a combined α- and β-adrenergic blocker (such as labetalol, 10–20 mg intravenously)

    • Do not administer a pure β-blocker, such as propranolol alone, because this may result in paradoxic worsening of the hypertension as a result of unopposed α-adrenergic effects

  • Treat tachycardia or tachyarrhythmias with a short-acting β-blocker such as esmolol, 25–100 mcg/kg/min by intravenous infusion

  • Treat hyponatremia (see Hyponatremia)

  • Treat hyperthermia (see Hyperthermia)

Outcome

Complications

  • Sustained or severe hypertension may result in

    • Intracranial hemorrhage

    • Aortic dissection

    • Myocardial infarction

  • Hyperthermia may cause

    • Multiorgan failure

    • Permanent brain damage

  • Muscle hyperactivity may lead to metabolic acidosis and rhabdomyolysis

Prognosis

  • Good prognosis if only a single brief seizure or if only mild-moderate agitation or if only cardiovascular ...

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