Assessment and management of a patient presenting with acute psychostimulant toxicity can be a demanding and potentially dangerous activity. They may crash into a critical condition without warning…or…they may become extremely agitated and violent, displaying erratic and unpredictable behaviour. A definite professional and personal challenge for all staff working in our emergency departments.

Some examples of recreational stimulants in common usage include:

• Cocaine (benzoylmethyl ecgonine). A psychoactive alkaloid obtained from the Coca plant. It is snorted or injected in its powder form, but may be chemically altered into an alkoloidal state (freebase, crack) that can be smoked.
• Amphetamines. (speed, crank)
• Methamphetamines. Including methamphetamine tablets, powder and Crystal Methamphetamine (Ice, Crystal Meth).
• MDMA. Methelynedioxymethamphetamine. Also known as: Ecstasy, E, XTC, Eckie, Eggs, Elizabeth,Adam, pink studs, big brown ones, burgers, disco biscuits, grey biscuits, doves (love doves, pink
  doves, white doves), hug drug, New Yorkers, fantasia, orbit, whizz bombs, yellow dallies.

All these psychostimulants act to increase the activity of certain neurotransmitters (predominantly: noradrenaline, dopamine and serotonin) in the synapse between neurons. These neurotransmitters normally control a vast range of physiological functions, but with a little chemical assistance users hope to synthesize feelings of euphoria, increased well-being, energy and alertness. Users of MDMA commonly report feelings of increased closeness or compassion toward others.
Pretty much what we are all searching for really.

Unfortunately the toxic effects that bring them to the ED include various cerebrovascular, metabolic, psychiatric, cardiovascular or neurological catastrophes. Patients may experience panic attacks, delirium, irritability, increased aggression, as well as, confusion, tactile, auditory and visual hallucinations.

Psychostimulants are often taken in combination with other drugs including anti-depressants, alcohol, and cannabis.

Assessment

Signs of recent psychostimulant drug usage may include:

• Dilated (mydriatic) pupils reacting sluggishly to light.
• Clenched jaw or muscle rigidity.
• Agitation, pacing, with rapid speech and repetitive movements.
• Tachycardia
• Sweaty palms, flushed / diaphoretic skin.
• Hyper vigilance, paranoia.
• Long term users may display signs of poor nutrition, have sores on their face arms or legs, or have needle marks or thrombophlebitis.
• Patients may become acutely hyperthermic with temperatures above 39.5C.

Obtaining a good history and establishing a basic level of trust with the patient is very important.
Make sure you use the most powerful word in your professional vocabulary. The patients name.
Give them some space. Both physical and narrative. Give them some time to tell you what they want and why before launching into your rote assessment questions. And actively listen during this time.
Use ample open ended questions to assess the psychosocial terrain.
Set firm boundaries with respect to aggressive or counter-productive behaviour. Try to give positive information on what you will do to help the patient.
Here are some more guidelines on opening up some deep communication.

violent behavioural disturbances.

Never forget the bottom line. The bottom line is: Stay safe.
Zero tolerance for aggressive or violent behaviour, period. Involve security and or police if the situation looks like escalating. Our Triage nurses wear a personal remote alarm to summon help. Always make sure at least one other staff member is keeping an eye on your interactions.
Often times it is difficult to tell if the patient has acute drug intoxication, psychosis or is just a total wanker (Aussie slang: jerk). Initial management for behavioural disturbances is the same for all.
Never let your patient come between you and a clear path of egress to safety. Switch on whenever the patient gets within arms reach, which should only happen when absolutely necessary.
Talk in a calm, even, clear voice. Make any instructions short and unambiguous. Avoid prolonged eye contact if patient is agitated or paranoid.
When interacting with a potentially volatile patient it may be helpful to try and see your self as an observer of the scene. Imagine yourself stepping *outside* the situation looking on dispassionately. Watch how the relationship between the other you and the patient is evolving. Remember all this anger is not yours unless you choose to react to it.
Its not easy but, using this technique may help you from getting caught in the emotional wash from an abusive patient and feeding the escalation with your own reactions.
It should be part of your ongoing professional development to establish a set of skills and strategies for dealing with these sort of situations. In reality, there should be no difference helping a patient manage their emotional problems and helping them manage their physical problems. Apart from the fact that most of us are not so confident at the former.

tie them up. bring them down.

Physical and chemical restraints may be necessary to ensure both safety to the staff and the patient, and to control the situation so that physical assessment and interventions can be undertaken. ( Physical restraint alone is not recommended and may be linked to cases of sudden death.) Using such restraints is a specialized situation. Clear protocols should be developed and staff should be trained appropriately.
They should not be used unless de-escalation and other non-drug interventions have failed and the patient is at imminent or perceived risk to themselves or others. Both adequate manpower as well as advanced airway management and monitoring equipment should be on scene.

Benzodiazepines have been recommended as the agent of choice for sedating the patient with severe behavioural disturbances. Diazepam (oral or IV) is considered most appropriate.
[ Management of Patients with Psychostimulant Toxicity. pdf file.]

Management.

• Serotonin Syndrome:
  May develop in patients using psychostimulants, particularly MDMA.
  Excess build up of serotonin in the synaptic cleft may produce such potentially life threatening symptoms as extreme hyperthermia, muscle rigidity, hyper or hypotension, seizures, and coma.
  The patient may develop hyperkalaemia, acidosis, rhabdomyalysis and renal failure.
  Hyperthermia above 39.5 C will require rapid cooling.
  IV volume resuscitation to correct dehydration and hypotension. Strict fluid balance aiming for urine output = 1.5-2 mls/kg/hr.
• Cardiovascular:
  Patients using Cocaine or to a lesser extent amphetamines may develop ischaemic chest pain due to myocardial vasoconstriction. Treatment is as per chest pain protocol (including Oxygen and sublingual nitroglycerine to relieve vasoconstriction) EXCEPT: aspirin should be avoided if the patient has prolonged hypertension due to increased risk of intercerebral haemorrhage and Beta-blockers should be avoided as they may exacerbate adverse effects.
  Benzodiazepines should be considered to manage anxiety and prolonged hypertension as they reduce myocardial oxygen demand, blood pressure and heart rate.
• Cerebrovascular:
  Cocaine or amphetamine usage increases the risk of stroke and cerebral haemorrhage.
  Management includes ABC’s, supportive care and early head CT if deterioration in neurological status. Seizures should be treated with benzodiazepines. Aspirin should be avoided as above.
• Hyponatremia:
  May occur as a result of excessive fluid intake (as the person attempts to prevent dehydration at rave parties) or from drug effect of MDMA and is a potentially life threatening condition. Patient may become confused and have seizures.
  May be treated with fluid restriction or in severe cases with IV hypertonic saline. Careful monitoring of fluid balance and electrolytes is essential.
• Psychosocial problems:
  Long term drug users may have a complex mosaic of other medical, psychiatric and social problems that will also need to be addressed once they are stabilized.
  They should be offered contact with specialist drug and alcohol services, social worker and crisis management teams.

Further reading:

As usual, this article is not intended as reference material, but rather a few words to get your interest so you might investigate the subject a little further. For more comprehensive information , I recommend you download and browse: Models of intervention and care for psychstimulant users. (pdf) published by the Australian Government department of health and aging.