Methamphetamine Toxicity Treatment & Management

  • Author: John R Richards, MD, FAAEM; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Aug 18, 2011
 

Prehospital Care

Patients with acute methamphetamine intoxication may be highly agitated and present a serious safety risk to themselves and prehospital personnel. Seek additional help from police or other EMS providers before the patient is transported, if possible. The patient's mental function may be sufficiently impaired, precluding the patient from making an informed decision to refuse treatment and transport. Prehospital intravenous access is warranted with or without patient consent, allowing for treatment of seizures and agitation using intravenous sedatives according to medical direction or protocol.

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Emergency Department Care

Most cases of methamphetamine toxicity can be managed supportively. In the case of a severe overdose, immediate supportive care, including airway control, oxygenation and ventilation support, and appropriate monitoring is required. Specific treatments for heavy metal toxicity caused by contaminants in some methamphetamine preparations may be needed. Animal studies suggest orally ingested amphetamine-like compounds can be decontaminated with oral activated charcoal.[50] In severe overdoses, termination of methamphetamine-induced seizure activity and arrhythmias are of immediate importance. Correction of hypertension, hypotension, hyperthermia, metabolic and electrolyte abnormalities, and control of severe psychiatric agitation are indicated. Consider health maintenance activities, such as testing for viral hepatitis and HIV disease and rehabilitation follow-up.

  • Agitation
    • Because of the ability of methamphetamine to cause significant CNS and psychiatric activation, patients who present to EDs for acute intoxication often require physical restraint and pharmacologic intervention.
    • Treat hyperactive or agitated patients with droperidol or haloperidol, butyrophenones which antagonize CNS dopamine receptors and mitigate the excess dopamine produced from methamphetamine toxicity. Multiple human and animal studies attest to the efficacy of droperidol and haloperidol in acute methamphetamine toxicity.[51, 52, 39] However, droperidol has been subject to a Black Box warning by the US Food and Drug Administration (FDA), and, as a result, some institutions restrict its use. The doses of these medications should be titrated to the symptoms and should be administered intravenously (see Medication).
    • Benzodiazepines enhance GABA neurotransmission and sedation, diminishing methamphetamine-induced behavioral and psychiatric intoxication. This class of drug is also used to terminate methamphetamine-induced seizures.[51, 53]
    • In a study of 146 patients presenting to the ED agitated, violent, or psychotic from methamphetamine, droperidol produced more rapid and profound sedation than lorazepam. Droperidol and lorazepam produced clinically significant reductions in pulse, systolic blood pressure, respiration rate, and temperature over a 60-minute period.[39]
    • More recent antipsychotics such as olanzapine and risperidone have been used to treat amphetamine psychosis.[54, 55, 56] A study of 58 patients comparing haloperidol to olanzapine demonstrated both were effective, but olanzapine had fewer adverse side effects such as extrapyramidal symptoms.[54] To date, no large studies in the setting of the ED have been performed.
    • If physical and chemical restraint is unsuccessful, rapid sequence induction, paralysis, and intubation may be required in extreme cases.
    • After chemical restraint has been successfully implemented, physical restraints should be loosened or removed altogether.
  • Hypertension and tachycardia
    • If sedation fails to reduce blood pressure, antihypertensive agents such as beta-blockers and vasodilators, are effective in reversing methamphetamine-induced hypertension.
    • With regard to choice of beta-blockers, labetalol is preferred because of combined anti–alpha-adrenergic and anti–beta-adrenergic effects. Esmolol is advantageous because of its short half-life but must be administered via IV drip. Metoprolol has excellent CNS penetration characteristics and may also ameliorate agitation. These drugs should be given IV in smaller than usual doses and titrated to effect.
    • In rare instances, afterload reduction with agents such as hydralazine, nitroprusside, or fenoldopam may be necessary.
    • Patients with chest pain and suspected ACS should also receive sublingual nitroglycerin if their blood pressure is normal or elevated.
  • Myocardial infarction
    • The approach to the patient with methamphetamine-induced cardiac ischemia should be no different than standard of care ACS treatment. Nitrates, beta-blockers, aspirin, heparin, and morphine should be administered if indicated. Patients with ST-segment elevation detected on their ECG should be triaged to thrombolytic treatment and/or catheterization with cardiology consultation.
  • Seizures
    • Treat methamphetamine-induced seizures like other seizures of unknown etiology.
    • Administer benzodiazepines IV (see Medication).
    • In those patients who do not have IV access, an agent with IM absorption can be used (eg, lorazepam, midazolam).
    • After control of the acute episode, longer-acting agents such as phenobarbital, may be necessary.
    • Patients with methamphetamine-induced seizures are at high risk for intracranial hemorrhage and should undergo CT imaging as soon as possible.
  • Rhabdomyolysis
    • Suspect rhabdomyolysis and follow CK levels in patients who present to the ED with severe agitation from methamphetamine or have had prolonged periods of immobilization.
    • Aggressively treat patients with rhabdomyolysis with IV crystalloid and admit them to the hospital after obtaining nephrology consultation.
    • Closely monitor renal function, vital signs, and fluid input and output. By preventing acidic urine pH, the addition of sodium bicarbonate prevents precipitation of myoglobin in renal tubules.
    • Early and aggressive fluid and electrolyte treatment of potential rhabdomyolysis can improve the clinical outcome and decrease potential nephrotoxicity. However, hemodialysis may be necessary in certain severe cases.
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Consultations

Consult with a regional poison control center or a local medical toxicologist (certified through the American Board of Medical Toxicology and/or the American Board of Emergency Medicine) to obtain additional information and patient care recommendations. Cardiology, nephrology, and psychiatry consultation may be indicated in certain cases.

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Contributor Information and Disclosures
Author

John R Richards, MD, FAAEM  Professor of Emergency Medicine, University of California at Davis School of Medicine

John R Richards, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Robert W Derlet, MD  Professor of Emergency Medicine, University of California at Davis School of Medicine; Chief Emeritus, Emergency Department, University of California at Davis Health System

Robert W Derlet, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Association for the Advancement of Science, Infectious Diseases Society of America, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Timothy E Albertson, MD, MPH, PhD  Professor of Pharmacology and Toxicology, Division Chief and Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Vice-Chair, Department of Internal Medicine, University of California, Davis, School of Medicine; Professor of Anesthesiology, Associate Dean, Academic Clinical Programs, University of California, Davis Health System; Professor of Emergency Medicine and Clinical Toxicology, Davis Medical Center; Chief of Pulmonary and Critical Care, Veterans Affairs, Northern California Health Care System; Medical Director of Poison Control System, University of California at San Francisco, School of Pharmacy.

Timothy E Albertson, MD, MPH, PhD is a member of the following medical societies: American College of Chest Physicians and Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Edward A Michelson, MD  Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland

Edward A Michelson, MD 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.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP  Director of Medical Toxicology, Allegheny General Hospital

Disclosure: Nothing to disclose.

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, Director, Medical Toxicology, Department 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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