Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 38-18: Amphetamines & Cocaine Overdose + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ Laboratory Tests ++ Urine screening usually tests for amphetamines, cocaine metabolite benzoylecgonine Blood screening is generally not sensitive enough to detect these drugs + Treatment Download Section PDF Listen +++ +++ 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 alpha- and beta-adrenergic blocker (such as labetalol, 10–20 mg intravenously) Do not administer a pure beta-blocker, such as propranolol alone, because this may result in paradoxic worsening of the hypertension as a result of unopposed alpha-adrenergic effects Treat tachycardia or tachyarrhythmias with a short-acting beta-blocker such as esmolol, 25–100 mcg/kg/min by intravenous infusion Treat hyponatremia (see Hyponatremia) Treat hyperthermia (see Hyperthermia) + Outcome Download Section PDF Listen +++ +++ 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 effects Poor prognosis after severe hyperthermia (eg, temperature > 40°C) or intracranial hemorrhage +++ When to Admit ++ Persistent hypertension, tachycardia Hyperthermia Hyponatremia Multiple or prolonged seizures + References Download Section PDF Listen +++ + +Rahimi M et al. Predictive factors of mortality in acute amphetamine type stimulants poisoning; a review of 226 cases. Emerg (Tehran) 2018;6(1):e1. [PubMed: 29503826] + +Richards JR et al. Methamphetamine use and heart failure: prevalence, risk factors, and predictors. Am J Emerg Med. 2018 Aug;36(8):1423–8. [PubMed: 29307766] + +Stockings E et al. Mortality among people with regular or problematic use of amphetamines: a systematic review and meta-analysis. Addiction. 2019 Oct;114(10):1738–50. [PubMed: 31180607] + +White CM. The pharmacologic and clinical effects of illicit synthetic cannabinoids. J Clin Pharmacol. 2017 Mar;57(3):297–304. [PubMed: 27610597] + +Williams MV. Cannabinoids: emerging evidence in use and abuse. Emerg Med Pract. 2018 Aug;20(8):1–20. [PubMed: 30020736]