nps health responses: insights from the emergency department … · control ecg changes...
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NPS Health Responses:
insights from the Emergency Department (ED)
Dr Christopher Yates
Emergency Department/Clinical Toxicology Unit
Hospital Universitari Son Espases
Palma de Mallorca, Spain
Disclosures
• Work presented here also from the Euro-DEN
project
• With financial support from the DPIP/ISEC
Programme of the European Union
• No other disclosures
Introduction
Why the ED?
• Front row seat to acute harm
Experience in ED
• Agitated delirium, heart rate (174 lpm).
04:10 A.M.: Picked up by ambulance and police
• Persistent agitation and tachycardia (160), requires large
doses of benzodiazepines.• An extensive toxicological screening (GCMS) is requested
06:00 A.M.: Admitted to ED.
� 19 year old male
� Admitted taking MDMA (at an unknown time) and
alcohol
• Agitation and psychosis persists
• Friends and family deny psychiatric history
• Heart rate 110.
6h after admission
• Hyperthermia (38ºC) requires physical coolingmeasures
8h after admission
• Stable vital signs
• Now recognises friends
26h after admission
48h after admission: Discharge
Definitely an NPS?
• The patient tested negative for classical drugs
of abuse screened (cocaine, amphetamine,
cannabis, MDMA)
– positive for alfa-PVP
• However…
– A patient on the stretcher next to him with a
similar pattern of symptoms (though only lasting
4-5 hours) had taken cocaine and alcohol
Toxicity of “classical drugs”
Stimulants
Cocaine
Ecstasy (MDMA)
Amphetamines
Hallucinogens
LSD
Ketamine
Psilocybin
Depressants
Heroin/metha
done
GHB
Toxicity of “novel drugs”
Stimulants
Piperazines
Cathinones
Synthetic Cocaine
Pipradols
Hallucinogens
Tryptamine
Glaucine
“Spice”
Salvia
Methoxetamine
Depressants
GBL/ 1,4
butanediol
Novel opioids
Stimulant toxicity treatment
AgitationBenzodiazepines
HypertensionControl agitationPhentolamine, nitroglycerin
HyperthemiaControl agitationAggressive physical cooling
ConfusionBenzodiazepinesCaveat antipsychotics
SeizuresBenzodiazepinesBarbituatesPropofol
OtherControl ECG changesRhabdomyolisis/AKIHypoglycemia
NPS challenges for ED staff
Common to other drugs Specific challenges
Difficult clinical scenario
(agitation etc.)
Often come late at night
Unclear what substances are
consumed
Unknown effects, specific
toxicities
Technical difficulties identifying
substances
Unclear what substances are
consumed
The European Drug Emergencies Network (Euro-DEN)
D. M. WOOD,1,2 F. HEYERDAHL,3 C. B. YATES,4 A. M. DINES,1 I. GIRAUDON,5 K. E. HOVDA,3 and P. I. DARGAN1,2
1Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK2King’s College London, London, UK3Department of Acute Medicine, The National NBC Centre, Oslo University Hospital, Ullevaal, Oslo, Norway4Emergency Department and Clinical Toxicology Unit, Hospital Universitari Son Espases, Palma de Mallorca, Spain5Action on New Drugs and Epidemiology Units, European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
Fig. 2. Predominant stimulant drug by last year prevalence among 15 to 34 year olds across Europe.1 (colour version of this gure can be found in the online version at www.informahealthcare.com/ctx)
Fig. 1. European Drug Emergencies Network (Euro-DEN) Centres
Clinical Toxicology (2014), 52, 239–241Copyright © 2014 Informa Healthcare USA
Experience from Euro-DEN
• 1 year experience, ED presentations
64.6%
26.5%
5.6%
2.8% 0.5%
Classical recreational drugs
Prescription and OTC
medicines
New psychoactive
substances
Unknown agents
Other agents
Top-20 drugs in ED visits
1345
957904
711
593
467
315259 248 245 245 220
186147 140 136 128 112 92 87
0
200
400
600
800
1000
1200
1400
1600
Co
un
t o
f d
rug
NPS
0.5% 0.9% 1.6%0%
11.4%
30.6%
22.1%
14.7%
2.8%
15.9%
0.6% 0.5% 0.4% 0%
17.8%
0%0%
5%
10%
15%
20%
25%
30%
35%
pe
rce
nta
ga
e o
f p
rese
nta
tio
ns
at
cen
tre
245
92
22
6 4 3 3 1 1 10
50
100
150
200
250
Co
un
t 0
f d
rug
Summary
• Rapidly evolving panorama of NPS
• Limited robust data
• Acute toxicity:
– Similar to classical drugs
– ED management based on supportive care of signs
and symptoms
• Important role for Emergency Departments in
identifying emerging trends
