Evidence-Based Emergency Department Management of Methamphetamine Toxicity (Pharmacology CME)

Table of Contents

 

About This Issue

When a patient presents to the ED exhibiting symptoms of sympathomimetic toxidrome, including agitation, prompt management will not only treat the patient’s dangerous complications, but can assist in ED management of patients who can be resource-intensive. In this issue you will learn:

The symptoms of the sympathomimetic toxidrome, and how to distinguish it from other toxidromes.

How to manage the most dangerous complications of methamphetamine toxicity: rhabdomyolysis, acute kidney injury, and cardiovascular/cerebrovascular complications.

The symptoms of methamphetamine withdrawal and how to distinguish it from withdrawal from other substances.

Why hyperthermia is an urgent concern in these patients, and how to best treat it.

Benzodiazepines and antipsychotics: when to use each (or both).

The must-do laboratory tests for all patients and the symptoms that call for further testing.

Whether to use antihypertensives.

The circumstances when toxicology screening should be performed.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology And Pathophysiology
   1. Dangerous Complications of Methamphetamine Use
      1. Rhabdomyolysis and Acute Kidney Injury
      2. Cardiovascular and Cerebrovascular Complications
   2. Methamphetamine Withdrawal
7. Differential Diagnosis
8. Prehospital Care
   1. Medications
   2. Restraints
   3. Gathering On-Scene Information
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Electrocardiogram
    2. Urine Drug Screen
    3. Additional Laboratory Studies
    4. Imaging Studies
11. Treatment
    1. Treatment of Acute Agitation and Psychosis
       1. Benzodiazepines and Antipsychotic Agents
       2. Adjunct Medications
       3. Airway Manaagement
    2. Treatment of Vital Sign Abnormalities
       1. Antihypertensives
       2. Antipyretics
    3. Treatment of Withdrawal
12. Special Populations
    1. Elderly Patients
    2. Pediatric Patients
    3. Pregnant Patients
13. Controversies and Cutting Edge
14. Disposition
15. 5 Things That Will Change Your Practice
16. Risk Management Pitfalls for Emergency Department Patients With Methamphetamine Intoxication
17. Summary
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathway for Management of Emergency Department Patients With Methamphetamine Intoxication
21. Tables and Figures
22. References

Abstract

Management of patients who are acutely intoxicated with methamphetamine (a member of the substituted amphetamine class of drugs) can be resource-intensive for most emergency departments. Clinical presentations of the methamphetamine sympathomimetic toxidrome range from mild agitation to rhabdomyolysis, acute kidney injury, seizures, and intracranial hemorrhage. High-quality evidence on how to best manage these patients is lacking, and most research focuses on symptomatic interventions to control patients‘ agitation and hemodynamics. This review analyzes the best available evidence on the diagnosis and management of emergency department patients with substituted amphetamine toxicity and offers best-practice recommendations on treatment and disposition.

Case Presentations

The triage nurse asks you for assistance with an agitated patient who is pacing the floor…

• When you approach the patient, you find an 18-year-old woman who gives you her name but does not respond appropriately to orienting questions. She is cooperative at first, but then starts to become increasingly agitated when you try to obtain further history.
• Her vital signs are: temperature, 37°C; blood pressure, 170/99 mm Hg; heart rate, 120 beats/min; and respiratory rate, 16 breaths/min. She is diaphoretic, but neurologically intact and without any evidence of trauma.
• She becomes uncooperative and starts to threaten the staff. Your attempts at de-escalation with redirection and relocation fail, and you wonder what the best pharmacologic intervention would be...

A 22-year-old man presents after developing chest pain while dancing at a club....

• He admits to taking an “upper,” but says that he is unsure of the specific substance.
• His vital signs are: temperature, 36.6°C; blood pressure, 170/110 mm Hg; heart rate, 115 beats/min; and respiratory rate, 14 breaths/min. His electrocardiogram is negative for ischemic changes.
• He denies any cardiac history or risk factors for pulmonary embolism. You wonder whether this young man needs to have a cardiac workup . . .

A 25-year-old woman arrives via emergency medical services, after having had a seizure…

• The EMTs report that the patient is otherwise healthy and had a witnessed seizure in front of family. Her family denies any prior history of seizure.
• Upon arrival, the patient is disoriented and unable to provide further history. Her vital signs are: temperature, 37.1°C; blood pressure, 190/120 mm Hg; heart rate, 116 beats/min; and respiratory rate, 12 breaths/min.
• You wonder whether her depressed consciousness is due to the seizure or if something else could be going on . . .

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Clinical Pathway for Management of Emergency Department Patients With Methamphetamine Intoxication

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

4. * Schep LJ, Slaughter RJ, Beasley DM. The clinical toxicology of metamfetamine. Clin Toxicol (Phila). 2010;48(7):675-694. (Review) DOI: 10.3109/15563650.2010.516752

7. * Prosser JM, Nelson LS. The toxicology of bath salts: a review of synthetic cathinones. J Med Toxicol. 2012;8(1):33-42. (Review) DOI: 10.1007/s13181-011-0193-z

24. * Richards JR, Hawkins JA, Acevedo EW, et al. The care of patients using methamphetamine in the emergency department: perception of nurses, residents, and faculty. Subst Abus. 2019;40(1):95-101. (Survey) DOI: 10.1080/08897077.2018.1449170

26. * Banks ML, Worst TJ, Rusyniak DE, et al. Synthetic cathinones (“bath salts”). J Emerg Med. 2014;46(5):632-642. (Review) DOI: 10.1016/j.jemermed.2013.11.104

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Keywords: methamphetamine, substituted amphetamine, cathinone, sympathomimetic, tachycardia, hyperthermia, diaphoresis, seizure, agitation, psychosis, rhabdomyolysis, acute kidney injury, benzodiazepine, antipsychotic, myoclonus