Amphetamine Poisoning
Basics
Description
Description
- Increased release of norepinephrine, dopamine, and serotonin
- Decreased catecholamine reuptake
- Direct effect on α- and β-adrenergic receptors
Etiology
Etiology
- Prescription drugs:
- Amphetamine (Benzedrine)
- Dextroamphetamine (Dexedrine)
- Diethylpropion (Tenuate)
- Fenfluramine (Pondimin)
- Methamphetamine
- Methylphenidate (Ritalin)
- Phenmetrazine (Preludin)
- Phentermine
- “Designer drugs”:
- Variants of illegal parent drugs
- Often synthesized in underground labs
- “Crystal,” “Ice”:
- Crystalline methamphetamine hydrochloride
- Smoked, insufflated, or injected
- Rapid onset; duration several hours
- “Crank”
- “Ecstasy” (3,4-methylenedioxymethamphetamine, MDMA, XTC, E, Molly):
- Often used at dances and “rave” parties
- Dehydration can lead to hyperthermia, hyponatremia, fatality
- MDA (3,4-methylenedioxyamphetamine)
- Methcathinone (“cat,” “Jeff,” “mulka”):
- Derivative of cathinone, found in the evergreen tree Catha edulis
- Frequently synthesized in home labs
- Does not show up on urine toxicology screens
- Mephedrone
- May be contained in “bath salts”
Diagnosis
Signs and Symptoms
Signs and Symptoms
- CNS:
- Agitation
- Delirium
- Hyperactivity
- Tremors
- Dizziness
- Mydriasis
- Headache
- Choreoathetoid movements
- Hyperreflexia
- Cerebrovascular accident
- Seizures and status epilepticus
- Coma
- Psychiatric:
- Euphoria
- Increased aggressiveness
- Anxiety
- Hallucinations (visual, tactile)
- Compulsive repetitive actions
- Cardiovascular:
- Palpitations
- Hypertensive crisis
- Tachycardia or (reflex) bradycardia
- Dysrhythmias (usually tachydysrhythmias)
- Cardiovascular collapse
- Other:
- Rhabdomyolysis
- Myoglobinuria
- Acute renal failure
- Anorexia
- Diaphoresis
- Disseminated intravascular coagulation (DIC)
History
- Determine the type, amount, timing, and route of amphetamine exposure
- Assess for possible coingestions
- Evaluate for symptoms of end organ injury:
- Chest pain
- Shortness of breath
- Headache, confusion, and vomiting
Physical Exam
- Common findings include:
- Agitation
- Tachycardia
- Diaphoresis
- Mydriasis
- Severe intoxication characterized by:
- Tachycardia
- HTN
- Hyperthermia
- Agitated delirium
- Seizures
- Diaphoresis
- Hypotension and respiratory distress may precede cardiovascular collapse
- Evaluate for associated conditions:
- Cellulitis and soft tissue infections
- Diastolic cardiac murmurs or unequal pulses
- Examine carefully for trauma
- Pneumothorax from inhalation injury
- Focal neurological deficits
Essential Workup
Essential Workup
- Vital signs:
- Temperature >40°C:
- Core temperature recording essential
- Peripheral temperature may be cool
- Indication for urgent cooling
- Ominous prognostic sign
- BP:
- Severe hypertension can lead to cardiac and neurologic abnormalities.
- Late in course, hypotension may supervene due to catecholamine depletion
- Temperature >40°C:
- ECG:
- Signs of cardiac ischemia
- Ventricular tachydysrhythmias
- Reflex bradycardia
Diagnostic Tests and Interpretation
LabDiagnostic Tests and Interpretation
- Urinalysis:
- Blood
- Myoglobin
- Electrolytes, BUN/creatinine, glucose:
- Hypoglycemia may contribute to altered mental status
- Acidosis may accompany severe toxicity
- Rhabdomyolysis may cause renal failure
- Hyperkalemia—life-threatening consequence of acute renal failure
- Coagulation profile to monitor for potential DIC:
- INR, PT, PTT, platelets
- Creatine phosphokinase (CPK):
- Markedly elevated in rhabdomyolysis
- Urine toxicology screen:
- For other toxins with similar effects (e.g., cocaine)
- Some amphetamine-like substances (e.g., methcathinone) may not be detected
- Aspirin and acetaminophen levels if suicide attempt is a possibility
- Arterial blood gas (ABG)
Imaging
- Chest radiograph:
- Adult respiratory distress syndrome
- Noncardiogenic pulmonary edema
- Head CT for:
- Significant headache
- Altered mental status
- Focal neurologic signs
- For subarachnoid hemorrhage, intracerebral bleed
Diagnostic Procedures/Other
Lumbar puncture for:
- Suspected meningitis (headache, altered mental status, hyperpyrexia)
- Suspected subarachnoid hemorrhage and CT normal
Differential Diagnosis
Differential Diagnosis
- Sepsis
- Thyroid storm
- Serotonin syndrome
- Neuroleptic malignant syndrome
- Pheochromocytoma
- Subarachnoid hemorrhage
- Drugs that cause delirium:
- Anticholinergics:
- Belladonna alkaloids
- Antihistamines
- Tricyclic antidepressants
- Cocaine
- Ethanol withdrawal
- Sedative/hypnotic withdrawal
- Hallucinogens
- Phencyclidine
- Anticholinergics:
- Drugs that cause HTN and tachycardia:
- Sympathomimetics
- Anticholinergics
- Ethanol withdrawal
- Phencyclidine
- Caffeine
- Phenylpropanolamine
- Ephedrine
- Monoamine oxidase inhibitors
- Theophylline
- Nicotine
- Drugs that cause seizures:
- Carbon monoxide
- Carbamazepine
- Cyanide
- Cocaine
- Cholinergics (organophosphate insecticides)
- Camphor
- Chlorinated hydrocarbons
- Ethanol withdrawal
- Sedative/hypnotic withdrawal
- Isoniazid
- Theophylline
- Hypoglycemics
- Lead
- Lithium
- Local anesthetics
- Anticholinergics
- Phencyclidine
- Phenothiazines
- Phenytoin
- Propoxyphene
- Salicylates
- Strychnine
Treatment
Pre Hospital
Pre Hospital
- Patient may be uncooperative or violent
- Secure IV access
- Protect from self-induced trauma
Initial Stabilization/Therapy
Initial Stabilization/Therapy
- ABCs
- Establish IV 0.9% NS access
- Cardiac monitor
- Naloxone, dextrose (or Accu-Chek), and thiamine if altered mental status
Ed Treatment/Procedures
Ed Treatment/Procedures
- Decontamination:
- Administration of activated charcoal
- Whole-bowel irrigation with polyethylene glycol solution for body packers
- Hypertensive crisis:
- Initially administer benzodiazepines if agitated
- α-Blocker (phentolamine) as second-line agent
- Nitroprusside for severe, unresponsive hypertension
- Avoid β-blockers, which may exacerbate hypertension
- Agitation, acute psychosis:
- Administer benzodiazepines
- Hyperthermia:
- Benzodiazepines if agitated
- Active cooling if temperature >40°C:
- Tepid water mist
- Evaporate with fan
- Paralysis:
- Indicated if muscle rigidity and hyperactivity contributing to persistent hyperthermia
- Nondepolarizing agent (e.g., vecuronium)
- Avoid succinylcholine
- Intubation; mechanical ventilation
- Apply cooling blankets
- Rhabdomyolysis:
- Administer benzodiazepines
- Hydrate with 0.9% NS
- Maintain urine output at 1–2 mL/min
- Hemodialysis (if acute renal failure and hyperkalemia occur)
- Seizures:
- Maintain airway
- Administer benzodiazepines
- Phenobarbital if unresponsive to benzodiazepines
- Phenytoin contraindicated
- Hypotension:
- May be late finding due to catecholamine depletion
- Initially bolus with isotonic crystalloid solution
- If no response, administer norepinephrine
- Dopamine may not be effective
Medication
Medication
- Activated charcoal: 1–2 g/kg up to 100 g PO
- Dextrose: D50W 1 amp: 50 mL or 25 g (peds: D25W 2–4 mL/kg) IV
- Diazepam (benzodiazepine): 5–10 mg (peds: 0.2–0.5 mg/kg) IV
- Lorazepam (benzodiazepine): 2–6 mg (peds: 0.03–0.05 mg/kg) IV
- Nitroprusside: 1–8 mcg/kg/min IV (titrated to BP)
- Phenobarbital: 15–20 mg/kg IV at 25–50 mg/min until cessation of seizure activity
- Phentolamine: 1–5 mg IV over 5 min (titrated to BP)
- Vecuronium: 0.1 mg/kg IVP
Ongoing Care
Disposition
Admission CriteriaDisposition
- Hyperthermia
- Persistent altered mental status
- Hypertensive crisis
- Seizures
- Rhabdomyolysis
- Persistent tachycardia
Discharge Criteria
- Asymptomatic after 6-hr observation
- Absence of the above admission criteria
Follow-Up Recommendations
Follow-Up Recommendations
Patients may need referral for chemical dependency rehab and detoxification
Pearls and Pitfalls
- Admit patients with severe or persistent symptoms
- Monitor core temperature:
- Hyperthermia >40°C may be life threatening
- Treat with aggressive sedation and active cooling
- Recognize rhabdomyolysis and hyperkalemia
- Avoid physical restraints in agitated patients if possible
- Consider associated emergency conditions:
- Patients with chest pain should be evaluated for acute coronary syndromes and treated accordingly
- Consider infection in altered patients with fever and history of IV drug use
- Methamphetamine abuse frequently associated with traumatic injury
- Benzodiazepines are first-line therapy in symptomatic methamphetamine intoxication
- Some newer stimulant drugs-of-abuse are chemically similar to amphetamines
Additional Reading
- Carvalho M, Carmo H, Costa VM, et al. Toxicity of amphetamines: An update. Arch Toxicol. 2012;86:1167–1231.
- Courtney KE, Ray LA. Clinical neuroscience of amphetamine-type stimulants: From basic science to treatment development. Prog Brain Res. 2016;223:295–310.
- Gray SD, Fatovich DM, McCoubrie DL, et al. Amphetamine-related presentations to and inner-city tertiary emergency department: A prospective evaluation. Med J Aust. 2007;186:336.
- Prosser JM, Nelson LS. The toxicology of bath salts: a review of synthetic cathinones. J Med Toxicol. 2012;8:33–42.
See Also
See Also
Authors
James W. Rhee
© Wolters Kluwer Health Lippincott Williams & Wilkins
Citation
Schaider, Jeffrey J., et al., editors. "Amphetamine Poisoning." 5-Minute Emergency Consult, 6th ed., Lippincott Williams & Wilkins, 2020. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307063/1.2/Amphetamine_Poisoning.
Amphetamine Poisoning. In: Schaider JJJ, Barkin RMR, Hayden SRS, et al, eds. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307063/1.2/Amphetamine_Poisoning. Accessed October 15, 2024.
Amphetamine Poisoning. (2020). In Schaider, J. J., Barkin, R. M., Hayden, S. R., Wolfe, R. E., Barkin, A. Z., Shayne, P., & Rosen, P. (Eds.), 5-Minute Emergency Consult (6th ed.). Lippincott Williams & Wilkins. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307063/1.2/Amphetamine_Poisoning
Amphetamine Poisoning [Internet]. In: Schaider JJJ, Barkin RMR, Hayden SRS, Wolfe RER, Barkin AZA, Shayne PP, Rosen PP, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. [cited 2024 October 15]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307063/1.2/Amphetamine_Poisoning.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC
T1 - Amphetamine Poisoning
ID - 307063
ED - Barkin,Adam Z,
ED - Shayne,Philip,
ED - Rosen,Peter,
ED - Schaider,Jeffrey J,
ED - Barkin,Roger M,
ED - Hayden,Stephen R,
ED - Wolfe,Richard E,
BT - 5-Minute Emergency Consult
UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307063/1.2/Amphetamine_Poisoning
PB - Lippincott Williams & Wilkins
ET - 6
DB - Emergency Central
DP - Unbound Medicine
ER -