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Toxicity, Phencyclidine: Differential Diagnoses & Workup

Author: Patrick L West, MD, Clinical Instructor, Medical Toxicology Fellow, Department of Emergency Medicine, Oregon Health and Sciences University; Staff Physician, Department of Emergency Medicine, Portland Veterans Affairs Medical Center
Coauthor(s): Nathanael J McKeown, DO, Assistant Professor, Oregon Health and Science University; Medical Toxicologist, Oregon Poison Center; Attending Physician, Emergency Medicine, Portland Veteran Affairs Medical Center, Oregon Health and Science University
Contributor Information and Disclosures

Updated: Jan 21, 2009

Differential Diagnoses

Alcohol and Substance Abuse Evaluation
Panic Disorders
Anxiety
Personality Disorders
Delirium Tremens
Plant Poisoning, Herbs
Depression and Suicide
Plant Poisoning, Hypoglycemics
Encephalitis
Schizophrenia
Epidural and Subdural Infections
Toxicity, Cocaine
Epidural Hematoma
Toxicity, Hallucinogen
Herpes Simplex
Toxicity, MDMA
Herpes Simplex Encephalitis
Toxicity, Medication-Induced Dystonic Reactions
Hypertensive Emergencies
Toxicity, Methamphetamine
Hyperventilation Syndrome
Toxicity, Mushroom - Hallucinogens
Hypoglycemia
Toxicity, Selective Serotonin Reuptake Inhibitor
Hyponatremia
Toxicity, Sympathomimetic
Meningitis
Withdrawal Syndromes
Neoplasms, Brain
Neuroleptic Malignant Syndrome

Other Problems to Be Considered

Lysergic acid diethylamide toxicity
Plant poisoning, mescaline
Malignant hyperthermia
Serotonin syndrome

Workup

Laboratory Studies

  • The diagnosis of PCP intoxication is a difficult one to make without some sort of history of drug use from the patient. It should be considered in patients with bizarre behavior, hypertension, and nystagmus, or coma unresponsive to naloxone in a substance abuse case.
  • Exposure to PCP can be confirmed by qualitative urine toxicology screening. Serum screening for PCP is not useful clinically because the test is not readily available. In addition, quantitative serum PCP level does not correlate with the symptoms.
  • A fingerstick should be performed in all patients with altered mental status, as hypoglycemia can cause symptoms consistent with PCP intoxication. In addition, McCarron et al found that 20% of patients with acute PCP intoxication were hypoglycemic on presentation.7
  • No laboratory tests are specific for PCP intoxication, but, in addition to hypoglycemia, elevations in WBC count and BUN and creatinine levels may be seen.
  • Serum creatine phosphokinase and urine myoglobin levels should also be measured to rule out rhabdomyolysis, especially in the patients with severe agitation.
  • Consider an arterial blood gas (ABG) measurement to assess for hypoxemia and metabolic acidosis in unresponsive patients.
  • Urine pregnancy tests are indicated for female patients of childbearing age.
  • False-positive results on a quantitative drug screen for PCP vary based on the actual test used. (Consult the laboratory for a list of confounders. Reported confounders include dextromethorphan, diphenhydramine, methadone, ibuprofen, metamizol, chlorpromazine, and venlafaxine.) If contaminants are a concern gas chromatography–mass spectroscopy (GC-MS) confirmatory test can be ordered.

Imaging Studies

  • No imaging studies are necessary for the evaluation of acute PCP intoxication.
  • Consider a CT scan of the head to rule out an intracranial cause for altered mental status.
  • Consider specific imaging to evaluate traumatic injuries associated with PCP intoxication.

Procedures

  • For patients who are unable to protect their airway or have evidence of respiratory compromise, endotracheal intubation and mechanical ventilation may be needed.
  • Consider lumbar puncture in patients with altered mental status and fever in whom the diagnosis is unclear.

More on Toxicity, Phencyclidine

Overview: Toxicity, Phencyclidine
Differential Diagnoses & Workup: Toxicity, Phencyclidine
Treatment & Medication: Toxicity, Phencyclidine
Follow-up: Toxicity, Phencyclidine
References
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References

  1. Marx JA, Hockberger RS, Walls RM. Phencyclidine. In: Rosen's Emergency Medicine Concepts and Clinical Practice. 5th ed. St Louis: Mosby Inc; 2002:2146-8.

  2. Poisindex Editorial Staff. Phencyclidine (Acute Toxicity). In: Klasco RK, ed. POISINDEX System. Thomson Micromedex: Greenwood Village, CO; 2005.

  3. OAS Home of Alcohol, Tobacco, and Drug Abuse Statistics. 2006 National Survey on Drug Use and Health (NSDUH). [Full Text].

  4. National Institute on Drug Abuse. 2007 Monitoring the Future (MTF) Survey, funded by the National Institute on Drug Abuse, National Institutes of Health, DHHS, and conducted by the University of Michigan's Institute for Social Research. [Full Text].

  5. Bronstein AC, Spyker DA, Cantilena LR Jr, Green J, Rumack BH, Heard SE. 2006 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS). Clin Toxicol (Phila). Dec 2007;45(8):815-917. [Medline].

  6. Drug Abuse Warning Network. Trends in PCP-Related Emergency Department Visits. January 2004. The Drug Abuse Warning Network Report. Available at www.dawninfo.samhsa.gov.

  7. McCarron MM, Schulze BW, Thompson GA, Conder MC, Goetz WA. Acute phencyclidine intoxication: clinical patterns, complications, and treatment. Ann Emerg Med. Jun 1981;10(6):290-7. [Medline].

  8. Babu K, Boyer E, et al. Emerging drugs of abuse. Clin Pediatr Emerg Med. Jun 2005;6(2):81-4.

  9. Bryson P. Phencyclidine. In: Comprehensive Review in Toxicology for Emergency Clinicians. 3rd ed. Taylor & Francis; 1996:509-16.

  10. Budai B, Iskandar H. Dextromethorphan can produce false positive phencyclidine testing with HPLC. Am J Emerg Med. Jan 2002;20(1):61-2. [Medline].

  11. Goldfrank LR, et al. Phencyclidine and Ketamine. In: Goldfrank's Toxicologic Emergencies. 7th ed. New York: McGraw-Hill; 2002:chap 69.

  12. Greydanus DE, Patel DR. Substance abuse in adolescents: a complex conundrum for the clinician. Pediatr Clin North Am. Oct 2003;50(5):1179-223. [Medline].

  13. Haroz R, Greenberg MI. Emerging drugs of abuse. Med Clin North Am. Nov 2005;89(6):1259-76. [Medline].

  14. Leshner A. Hallucinogens and Dissociative Drugs Including LSD, PCP, Ketamine, Dextromethorphan. National Institute on Drug Abuse Research Report Series. Mar 2001;NIH Pub. No. 01-4209.

  15. Marchei E, Pellegrini M, Pichini S, Martin I, Garcia-Algar O, Vall O. Are false-positive phencyclidine immunoassay instant-view multi-test results caused by overdose concentrations of Ibuprofen, metamizol, and dextromethorphan?. Ther Drug Monit. Oct 2007;29(5):671-3. [Medline].

  16. Mokhlesi B, Leikin JB, Murray P, Corbridge TC. Adult toxicology in critical care: Part II: specific poisonings. Chest. Mar 2003;123(3):897-922. [Medline].

  17. Morocco AP, Osterhoudt KC. Getting "wet" from recreational use of embalming fluid. Pediatr Case Rev. Apr 2003;3(2):111-3. [Medline].

  18. Morris BJ, Cochran SM, Pratt JA. PCP: from pharmacology to modelling schizophrenia. Curr Opin Pharmacol. Feb 2005;5(1):101-6. [Medline].

  19. Rimsza ME, Moses KS. Substance abuse on the college campus. Pediatr Clin North Am. Feb 2005;52(1):307-19, xii. [Medline].

  20. Sena S, Kazimia S, et al. False positive phencyclidine results caused by venlafaxine. Am J Psychiatry. Feb 2007;164(2):349.

  21. Wills B, Erickson T. Drug- and toxin-associated seizures. Med Clin North Am. Nov 2005;89(6):1297-321. [Medline].

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Further Reading

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Keywords

phencyclidine toxicity, PCP, PCP overdose, phencyclidine overdose, angel dust, peace pill, crystal joint, supergrass, wack, rocket fuel, KJ, illy, elephant tranquilizer, embalming fluid

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Contributor Information and Disclosures

Author

Patrick L West, MD, Clinical Instructor, Medical Toxicology Fellow, Department of Emergency Medicine, Oregon Health and Sciences University; Staff Physician, Department of Emergency Medicine, Portland Veterans Affairs Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Nathanael J McKeown, DO, Assistant Professor, Oregon Health and Science University; Medical Toxicologist, Oregon Poison Center; Attending Physician, Emergency Medicine, Portland Veteran Affairs Medical Center, Oregon Health and Science University
Nathanael J McKeown, DO is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Lance W Kreplick, MD, MMM, FAAEM, FACEP, Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC
Lance W Kreplick, MD, MMM, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Director of Pharmacy, Sacred Heart Hospital
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Fred Harchelroad, MD, FACMT, Chair, Department of Emergency Medicine, Director of Medical Toxicology, Department of Emergency Medicine, Associate Professor, Allegheny General Hospital
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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