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A variety of substances—ranging from naturally occurring plants and mushrooms to synthetic substances such as phencyclidine (PCP), toluene and other solvents, dextromethorphan, and lysergic acid diethylamide (LSD)—are abused for their hallucinogenic properties. The mechanism of toxicity and the clinical effects vary for each substance.

Many hallucinogenic plants and mushrooms produce anticholinergic delirium, characterized by flushed skin, dry mucous membranes, dilated pupils, tachycardia, and urinary retention. Other plants and mushrooms may contain hallucinogenic indoles such as mescaline and LSD, which typically cause marked visual hallucinations and perceptual distortion, widely dilated pupils, and mild tachycardia. PCP, a dissociative anesthetic agent similar to ketamine, can produce fluctuating delirium and coma, often associated with vertical and horizontal nystagmus. Toluene and other hydrocarbon solvents (butane, trichloroethylene, “chemo,” etc) cause euphoria and delirium and may sensitize the myocardium to the effects of catecholamines, leading to fatal dysrhythmias. Other drugs used for their psychostimulant effects include synthetic cannabinoid receptor agonists, Salvia divinorum, synthetic tryptamines, and phenylethylamines, and mephedrone and related cathinone derivatives. See https://www.erowid.org/psychoactives/psychoactives.shtml for descriptions of various hallucinogenic substances.

TREATMENT

A. Emergency and Supportive Measures

Maintain a patent airway and assist respirations if necessary. Treat coma, hyperthermia, hypertension, and seizures as outlined at the beginning of this chapter. For recent large ingestions, consider giving activated charcoal orally or by gastric tube.

B. Specific Treatment

Patients with anticholinergic delirium may benefit from a dose of physostigmine, 0.5–1 mg intravenously, not to exceed 1 mg/min. Dysphoria, agitation, and psychosis associated with LSD or mescaline intoxication may respond to benzodiazepines (eg, lorazepam, 1–2 mg orally or intravenously) or haloperidol (2–5 mg intramuscularly or intravenously) or another antipsychotic drug (eg, olanzapine or ziprasidone). Monitor patients who have sniffed solvents for cardiac dysrhythmias (most commonly premature ventricular contractions, ventricular tachycardia, ventricular fibrillation); treatment with beta-blockers such as propranolol (1–5 mg intravenously) or esmolol (250–500 mcg/kg intravenously, then 50 mcg/kg/min by infusion) may be more effective than lidocaine or amiodarone.

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Araújo  AM  et al. The hallucinogenic world of tryptamines: an updated review. Arch Toxicol. 2015 Aug;89(8):1151–73.
[PubMed: 25877327]
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Caffrey  CR  et al. When good times go bad: managing ‘legal high’ complications in the emergency department. Open Access Emerg Med. 2017 Dec 20;10:9–23.
[PubMed: 29302196]

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