LSD Toxicity Treatment & Management
- Author: Paul P Rega, MD, FACEP; Chief Editor: Timothy E Corden, MD more...
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”). 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.
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.
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 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.
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.
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.
Prehospital and Emergency Department 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. 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.
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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