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LSD Toxicity Treatment & Management

  • Author: Paul P Rega, MD, FACEP; Chief Editor: Timothy E Corden, MD  more...
 
Updated: Dec 29, 2015
 

Approach Considerations

Prior to patient management considerations, the clinician must first assess the entire situation in terms of scene safety. Is there an actual or potential threat of violence not only to himself or herself but also to the healthcare team? If the answer to that question is in the affirmative, then it is incumbent upon the team to approach the patient in an expeditious manner while limiting harmful exposure to the team. Developing guidelines, teaching those guidelines, and table-topping or exercising those guidelines helps to ensure that this type of patient is addressed in a calm, measured, and safe fashion—safe not only for the patient but also for the staff.[32, 33]

Otherwise, the basic tenet of caring for patients who have ingested hallucinogens such as lysergic acid diethylamide (LSD) is supportive reassurance in a calm, stress-free environment (“talking down”).[4] Rarely, as mentioned above, patients need to be either sedated or physically restrained. Benzodiazepines can safely be given to treat agitation, but neuroleptic medications, such as haloperidol (Haldol), may have adverse psychomimetic effects and thus are not indicated in LSD intoxication.

Excessive physical restraint should be avoided because of potential complications of LSD intoxication, such as hyperthermia and/or rhabdomyolysis.

Guidelines for detoxification and substance abuse treatment, including as they apply to LSD and other hallucinogens, have been established by the Substance Abuse and Mental Health Services Administration.[34]

Gastrointestinal decontamination (eg, activated charcoal) is rarely required, with the possible exception of ingesting huge amounts in a matter of 30-60 minutes prior to presentation. Enhanced elimination measure, likewise, may be counter-productive.[1]

Supportive care

Massive ingestions of LSD should be treated with supportive care, including respiratory support and endotracheal intubation if needed. Hypertension, tachycardia, and hyperthermia should be treated symptomatically. Hypotension should be treated initially with fluids and subsequently with pressors if required.

Ergotism therapy

Ergotism is treated with discontinuation of any inciting drugs and supportive care. Intravenous administration of anticoagulants, vasodilators, and sympatholytics may be useful. The use of balloon percutaneous transluminal angioplasty in severe cases has been reported.[26]

Consultations

Simple hallucinogen intoxication can usually be managed without consultation. Patients with a history of substance abuse should be referred for drug treatment, while patients who require admission should have consultation with a medical toxicologist or regional poison control center.

Transfer

Because most patients only require a period of observation, transfer rarely is necessary. However, transfer may be justified in situations involving serious complications or comorbidity or when management of behavioral symptoms exceeds the capability of the facility.

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Prehospital and Emergency Department Care

Prehospital care

Prehospital care for LSD toxicity should be directed toward supporting the patient’s vital signs. Obtaining vascular access, administering oxygen, and monitoring cardiac function may be appropriate in severely intoxicated patients. Make an attempt to provide a quiet environment. Prehospital providers should obtain as thorough a history as possible and examine the patient for signs of coingestion.

Emergency department care

Most patients evaluated by medical personnel for LSD use are experiencing a "bad trip." Patients who have only minor agitation can usually be treated safely in the emergency department with observation and supportive care until symptoms have resolved.

Management priorities include searching for other causes of altered mental status, attending to the patient's safety, and achieving adequate sedation to prevent complications such as rhabdomyolysis or hyperthermia.[27] Patients with a history of psychedelic ingestion may have coingested other substances, so the care provider must be aware of other toxidromes.

Because LSD is rapidly absorbed through the GI tract, activated charcoal administration and gastric emptying are of little clinical value by the time a patient presents to the emergency department. These procedures may even cause the patient to become more frightened and agitated and can increase the risk of vomiting with aspiration. Activated charcoal may be indicated, however, to treat coingestants.

The patient should be placed in a quiet room to minimize sensory input. In many cases, establishing verbal rapport with patients makes it possible to "talk them down," eliminating the need for pharmacologic intervention. The clinician should attempt to define reality for the patient, making it clear that the patient's hallucinations are from the drug and are not real.

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Inpatient Care

Admission should be considered if the etiology for the patient's abnormal behavior is unclear or if toxic coingestions are suspected. Patients with persistent or unexplained psychotic symptoms should have a psychiatric evaluation.

Admission is also warranted if the patient is severely intoxicated, requires prolonged observation, or is suicidal.

Admitted patients may warrant continued administration of anxiolytics or other medications directed at specific symptoms. Outpatient medications rarely are necessary.

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Contributor Information and Disclosures
Author

Paul P Rega, MD, FACEP Assistant Professor, Department of Public Health and Preventive Medicine, Assistant Professor, Emergency Medicine Residency Program, Department of Emergency Medicine, The University of Toledo College of Medicine; Director of Emergency Medicine Education and Disaster Management, OMNI Health Services

Paul P Rega, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Stephan Brenner, MD, MPH Resident Physician, Department of Emergency Medicine, Washington University in St Louis School of Medicine

Disclosure: Nothing to disclose.

Robert G Darling, MD, FACEP Adjunct Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine

Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Telemedicine Association, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

William H Dribben, MD Assistant Professor, Division of Emergency Medicine, Washington University in St Louis School of Medicine

William H Dribben, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Alan H Hall, MD, FACEP Assistant Professor of Emergency Medicine, Division of Toxicology, Texas Tech University Health Sciences Center at El Paso; President, Chief Medical Toxicologist, Toxicology Consulting and Medical Translating Services, Inc

Disclosure: Nothing to disclose.

Halim Hennes, MD, MS Division Director, Pediatric Emergency Medicine, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Director of Emergency Services, Children's Medical Center

Halim Hennes, MD, MS is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

C Crawford Mechem, MD, MS, FACEP Professor, Department of Emergency Medicine, University of Pennsylvania School of Medicine; Emergency Medical Services Medical Director, Philadelphia Fire Department

C Crawford Mechem, MD, MS, FACEP is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jeffrey R Tucker, MD Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut School of Medicine, Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

Suzanne White, MD Medical Director, Regional Poison Control Center at Children's Hospital, Program Director of Medical Toxicology, Associate Professor, Departments of Emergency Medicine and Pediatrics, Wayne State University School of Medicine

Suzanne White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Clinical Toxicology, American College of Epidemiology, American College of Medical Toxicology, American Medical Association, and Michigan State Medical Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Amanda Wood, MD Resident Physician, Emergency Medicine Resident, Division of Emergency Medicine, Barnes Jewish and St Louis Children's Hospitals

Disclosure: Nothing to disclose.

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Assorted lysergic acid diethylamide (LSD) blotter papers.
Lysergic acid diethylamide (LSD) in assorted pill forms.
 
 
 
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