nature vs narcotics - wms
TRANSCRIPT
Nature vs NarcoticsOrganic and Synthetic Toxidrome Doppelgangers
Miguel Pineda, MDUCSD Wilderness Medicine Fellow 2020-2021
Introduction
• Many animal envenomation and toxic plant poisoning toxidromes can mimic those of synthetic drug ingestions
• Treatment for each may be vastly different with poor outcome if diagnosis is delayed
• Available History variable dependent on mental status, age, and family/friend visitation privileges
Learning Objectives
• Identify Organic and Synthetic Toxidrome mimics•Differentiate toxidromes based off of key presenting symptoms
• Identify different treatment modalities for each toxidrome
Disclosures
• None
• 2 year old Male• Agitation
• Inconsolable Crying• Ataxic Thrashing• Hypersalivation
• Abnormal Eye Movements• Tachycardia
• HTN
Scorpion Sting vs PCP Ingestion
Case 1: Tucson, AZ
• 2 year old Male• Agitation
• Inconsolable Crying• Ataxic Thrashing• Hypersalivation
• Abnormal Eye Movements• Tachycardia
• HTN
Scorpion Sting PCP Ingestion
• Neuro: Ataxia, Jerky Extremity Movements, Seizures
• CV: Tachycardia, HTN• Pulm: Tachypnea• HEENT: Nystagmus, Miosis, Dry Mucous
Membranes• Psych: Agitation, Psychosis, Delusions
(Invulnerable)
• Neuro: Pain, Paresthesias, Jerky Extremity Movements
• CV: Tachycardia, HTN• Pulm: Respiratory Failure• HEENT: Opsoclonus, Tongue Fasciculations• GI: Vomiting• Psych: Agitation
Scorpion Sting PCP Ingestion
• Neuro: Ataxia, Jerky Extremity Movements, Seizures
• CV: Tachycardia, HTN• Pulm: Tachypnea• HEENT: Nystagmus, Miosis, Dry Mucous
Membranes• Psych: Agitation, Psychosis, Delusions
(Invulnerable)
• Neuro: Pain, Paresthesias, Jerky Extremity Movements
• CV: Tachycardia, HTN• Pulm: Respiratory Failure• HEENT: Opsoclonus, Tongue Fasciculations• GI: Vomiting• Psych: Agitation
Scorpion Sting PCP Ingestion
• Neuro: Ataxia, Jerky Extremity Movements, Seizures
• CV: Tachycardia, HTN• Pulm: Tachypnea• HEENT: Nystagmus, Miosis, Dry Mucous
Membranes• Psych: Agitation, Psychosis, Delusions
(Invulnerable)
• Neuro: Pain, Paresthesias, Jerky Extremity Movements
• CV: Tachycardia, HTN• Pulm: Respiratory Failure• HEENT: Opsoclonus, Tongue Fasciculations• GI: Vomiting• Psych: Agitation
Scorpion Sting PCP Ingestion
Toxin: Phencyclidine (NMDA Antagonist)Diagnosis• Urine Drug ScreenTreatment• Benzos• Behavioral Modifications (Enya)• IVF (Avoid Rhabdo)
Toxin: Neurotoxin MixtureDiagnosis• ClinicalTreatment• Anascorp (Grade 3-4 Severity)
• Fab2 Equine Antivenin• ~$10k/Vial (x3vials)• Regional Stocking Variable
• Intubation
Scorpion Sting PCP Ingestion
• 20 year old male• Combative
• Red, sweaty skin• Mydriasis
• Tachycardia • HTN
Jimson Weed vs Methamphetamine
Case 2: Tulsa, OK
• 20 year old male• Combative
• Red, sweaty skin• Mydriasis
• Tachycardia • HTN
Jimson Weed MethamphetamineCase 2: Tulsa, OK
Jimson Weed Methamphetamine• Neuro: Agitation, Choreoathetotic
movements• HEENT: Mydriasis• CV: Tachycardia, HTN• Derm: Skin flushing, Diaphoresis• Psych: Paranoia, Increased Alertness,
Incessant Conversations
• Neuro: AMS, Hyperthermia, Seizures• HEENT: Mydriasis• CV: Tachycardia, HTN, QRS Prolongation, Cardiac
Dysrhythmias• GI: Decreased Bowel Sounds• GU: Urinary Retention• Derm: Skin Flushing, Xerodermia• Psych: Hallucinations, Mumbling, “Picking”, “Annoying”
Case 2: Tulsa, OK
Jimson Weed Methamphetamine• Neuro: Agitation, Choreoathetotic
movements• HEENT: Mydriasis• CV: Tachycardia, HTN• Derm: Skin flushing, Diaphoresis• Psych: Paranoia, Increased Alertness,
Incessant Conversations
• Neuro: AMS, Hyperthermia, Seizures• HEENT: Mydriasis• CV: Tachycardia, HTN, QRS Prolongation, Cardiac
Dysrhythmias• GI: Decreased Bowel Sounds• GU: Urinary Retention• Derm: Skin Flushing, Xerodermia• Psych: Hallucinations, Mumbling, “Picking”, “Annoying”
Case 2: Tulsa, OK
Jimson Weed Methamphetamine• Neuro: Agitation, Choreoathetotic
movements• HEENT: Mydriasis• CV: Tachycardia, HTN• Derm: Skin flushing, Diaphoresis• Psych: Paranoia, Increased Alertness,
Incessant Conversations
• Neuro: AMS, Hyperthermia, Seizures• HEENT: Mydriasis• CV: Tachycardia, HTN, QRS Prolongation, Cardiac
Dysrhythmias• GI: Decreased Bowel Sounds• GU: Urinary Retention• Derm: Skin Flushing, Xerodermia• Psych: Hallucinations, Mumbling, “Picking”, “Annoying”
Case 2: Tulsa, OK
Jimson Weed MethamphetamineToxin
• L-Methamphetamine (Peripheral)• D-Methamphetamine (Central)
Diagnosis• Urine Drug Screen
Treatment• Benzos, Antipsychotics, Supportive Care
Toxin• Belladonna Alkyloid (Atropine)
Diagnosis• Clincial
Treatment: • Benzos, Supportive care• Foley Catheter (Urinary Retention)• Bicarbonate Boluses (QRS Prolongation)
Case 2: Tulsa, OK
• 24 year old Female• Paranoia
• Responding to Visual Hallucinations• Mydriasis
• Diaphoresis• Tachycardia
• Grinding Teeth
Case 3: Santa Fe, NM
Peyote vs MDMA
• 24 year old Female• Paranoia
• Responding to Visual Hallucinations• Mydriasis
• Diaphoresis• Tachycardia
• Grinding Teeth
Peyote MDMACase 3: Santa Fe, NM
Peyote MDMA• Const: Hyperthermia
• Neuro: Ataxia, Poor Concentration, Seizures
• CV: Tachycardia, HTN, Dysrhythmias
• HEENT: Mydriasis
• GU: Hyponatremia, Rhabdo
• Derm: Diaphoresis
• Psych: Euphoria, Visual Hallucinations
• Pulm: Respiratory Depression
• HEENT: Mydriasis
• GI: Nausea/Vomiting
• Derm: Diaphoresis
• Psych: Depersonalization, Visual Hallucinations
Case 3: Santa Fe, NM
Peyote MDMA• Const: Hyperthermia
• Neuro: Ataxia, Poor Concentration, Seizures
• CV: Tachycardia, HTN, Dysrhythmias
• HEENT: Mydriasis
• GU: Hyponatremia, Rhabdo
• Derm: Diaphoresis
• Psych: Euphoria, Visual Hallucinations
• Pulm: Respiratory Depression
• HEENT: Mydriasis
• GI: Nausea/Vomiting
• Derm: Diaphoresis
• Psych: Depersonalization, Visual Hallucinations
Case 3: Santa Fe, NM
Peyote MDMA• Const: Hyperthermia
• Neuro: Ataxia, Poor Concentration, Seizures
• CV: Tachycardia, HTN, Dysrhythmias
• HEENT: Mydriasis
• GU: Hyponatremia, Rhabdo
• Derm: Diaphoresis
• Psych: Euphoria, Visual Hallucinations
• Pulm: Respiratory Depression
• HEENT: Mydriasis
• GI: Nausea/Vomiting
• Derm: Diaphoresis
• Psych: Depersonalization, Visual Hallucinations
Case 3: Santa Fe, NM
Peyote MDMAToxin:
• 3-Methylenedioxymethamphetamine
Diagnosis:
• Urine Drug Screen (Amphetamines, Possible False Negative)
Treatment
• Benzos
• IVF Rehydration (CK, Na+ Trend)
• Cardiac Monitoring
Toxin:
• Mescaline
Diagnosis:
• Clinical
Treatment
• Benzos, Supportive Care
Case 3: Santa Fe, NM
• 19 year old male• Fearful Agitation
• Tachycardia• Watching Invisible Objects in room
• Grabbing at air with poor coordination• Infrequent Vomiting
• Progressive Somnolence
Case 4: Seattle, WA
Psilocybin vs Dextromethorphan
• 19 year old male• Fearful Agitation
• Tachycardia• Watching Invisible Objects in room
• Grabbing at air with poor coordination• Infrequent Vomiting
• Progressive Somnolence
Case 4: Seattle, WAPsilocybin Dextromethorphan
Case 4: Seattle, WAPsilocybin Dextromethorphan
• Neuro: Ataxia, Hyperkinesis, Tremor, Seizures• CV: Tachycardia, Cardiac Arrest• HEENT: Mydriasis• GI: Nausea/Vomiting• Psych: Visual Hallucinations, Anxiety, LH,
Agitation
• Neuro: CNS Depression, Dystonia, Ataxia• CV: Tachycardia• Pulm: Respiratory depression• HEENT: Nystagmus• GI: Nausea/Vomiting• Derm: Diaphoresis• Psych: Visual Hallucinations/Euphoria, Agitation,
Psychosis• Const: Hyperthermia
Case 4: Seattle, WAPsilocybin Dextromethorphan
• Neuro: Ataxia, Hyperkinesis, Tremor, Seizures• CV: Tachycardia, Cardiac Arrest• HEENT: Mydriasis• GI: Nausea/Vomiting• Psych: Visual Hallucinations, Anxiety, LH,
Agitation
• Neuro: CNS Depression, Dystonia, Ataxia• CV: Tachycardia• Pulm: Respiratory depression• HEENT: Nystagmus• GI: Nausea/Vomiting• Derm: Diaphoresis• Psych: Visual Hallucinations/Euphoria, Agitation,
Psychosis• Const: Hyperthermia
Case 4: Seattle, WAPsilocybin Dextromethorphan
• Neuro: Ataxia, Hyperkinesis, Tremor, Seizures• CV: Tachycardia, Cardiac Arrest• HEENT: Mydriasis• GI: Nausea/Vomiting• Psych: Visual Hallucinations, Anxiety, LH,
Agitation
• Neuro: CNS Depression, Dystonia, Ataxia, Hyerreflexia• CV: Tachycardia• Pulm: Respiratory depression• HEENT: Nystagmus• GI: Nausea/Vomiting• Derm: Diaphoresis• Psych: Visual Hallucinations/Euphoria, Agitation,
Psychosis
Case 4: Seattle, WAPsilocybin Dextromethorphan
• Toxin: • Indolealkylamine
• Diagnosis:• Clinical
• Treatment:• Benzos, Supportive Care• Cardiac Monitoring
• Toxin:• Dextromethorphan
• Diagnosis:• Urine Drug Screen (PCP Positive)
• Treatment• Benzos, Supportive Care• Naloxone (CNS/Respiratory Depression)• Test for Syrup Co-Ingestion
• Acetaminophen, Antihistamine, Antimuscarinic
• 4 year old female• Flaccid weakness
• Decreased Reflexes• Increased Work of Breathing
• Alert• Afebrile
Tick Paralysis vs Marijuana
Case 5: Denver, CO
• 4 year old female• Flaccid weakness
• Decreased Reflexes• Increased Work of
Breathing• Alert
• Afebrile
Tick Paralysis MarijuanaCase 5: Denver, CO
• Neuro: Somnolence, Ataxia, Hypotonia, Seizures (Peds)
• HEENT: Mydriasis, Nystagmus• CV: Tachycardia (Peds)• GI: Nausea/Vomiting• Pulm: Respiratory Depression (Central)• Psych: Relaxation, Decreased
Concentration
• Neuro: Ascending Paralysis, Hyporeflexia, Intact Sensation
• HEENT: Opthalmoplegia, Bulbar Palsy• Pulm: Respiratory Failure (Diaphragm)
Tick Paralysis MarijuanaCase 5: Denver, CO
• Neuro: Somnolence, Ataxia, Hypotonia, Seizures (Peds)
• HEENT: Mydriasis, Nystagmus• CV: Tachycardia (Peds)• GI: Nausea/Vomiting• Pulm: Respiratory Depression (Central)• Psych: Relaxation, Decreased
Concentration
• Neuro: Ascending Paralysis, Hyporeflexia, Intact Sensation
• HEENT: Opthalmoplegia, Bulbar Palsy• Pulm: Respiratory Failure (Diaphragm)
Tick Paralysis MarijuanaCase 5: Denver, CO
• Neuro: Somnolence, Ataxia, Hypotonia, Seizures (Peds)
• HEENT: Mydriasis, Nystagmus• CV: Tachycardia (Peds)• GI: Nausea/Vomiting• Pulm: Respiratory Depression (Central)• Psych: Relaxation, Decreased
Concentration
• Neuro: Ascending Paralysis, Hyporeflexia, Intact Sensation
• HEENT: Opthalmoplegia, Bulbar Palsy• Pulm: Respiratory Failure (Diaphragm)
Tick Paralysis MarijuanaCase 5: Denver, CO
Toxin• Tetrahydrocannabinol (THC)
Diagnosis: • Urine Drug Screen
Treatment: • Supportive Care
Toxin• Ixobotoxin (2-6days)
Diagnosis: • Tick Identification (Hair)
Treatment: • Tick Removal
Tick Paralysis Marijuana
Case 5: Denver, CO
Conclusions
• Always keep organic poisoning/envenomation on the differential for toxidrome presentations
• Key treatments can vary depending on causative agent• Poison Control services are available 24/7
• 1-800-222-1222• www.poison.org
References
• Goldfrank's Toxicologic Emergencies, 11e | AccessEmergency Medicine | McGraw-Hill Medical
• Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e | AccessEmergency Medicine | McGraw-Hill Medical
• Atlas of Pediatric Emergency Medicine, 3e | AccessEmergency Medicine | McGraw-Hill Medical
• Amphetamine Toxicity | The Atlas of Emergency Medicine, 5e | AccessEmergency Medicine | McGraw-Hill Medical
• “When the Scorpion Stings” The University of Arizona. https://www.youtube.com/watch?v=DE60ig0CIZc
• “See What Happens When 3-Year-Old Was Paralyzed by Tick Bite” Inside Edition. May 25, 2017. https://www.youtube.com/watch?v=DUP6EjMbgfE
Questions?