Medical Care
As with any toxic ingestion, proper attention first should be directed to the assessment and stabilization of the patient's airway, breathing, and circulation.
For any person presenting with hallucinations or psychosis, even if a hallucinogen is strongly suggested as the inciting agent, the basic approach to a patient with altered mental status should be followed. This includes administration of dextrose (or demonstration of a normal blood glucose level), thiamine, and naloxone. Other etiologies for the patient's symptoms should not be discounted.
Prehospital care providers should attempt to ascertain the type and amount of hallucinogen ingested and the presence of any other co-ingested drugs or psychoactive substances.
A basic principle in the care of persons who have ingested hallucinogens is calm reassurance. Patients presenting with an acute panic reaction should be placed in a quiet nonthreatening environment with minimal stimuli. Reassure patients that their anxiety is caused by the drug and that the effect will wear off in several hours. However, patients that are medically stable but 1) remain anxious or agitated, 2) have continued hallucinations 3) remain a danger to themselves or others, or 4) would not be able to care for themselves after several hours of observation, should be admitted to a psychiatric hospital.
Patients should be physically or chemically restrained if they are a danger to themselves or others. However, avoid prolonged or excessive physical restraint because this can contribute to hyperthermia, rhabdomyolysis, and acidosis, and it can exacerbate the patient's paranoia. Aggressive cooling measures (fans and mist) should be undertaken if significant hyperthermia is noted. In severe cases, paralyzation and endotracheal intubation should be undertaken. Rhabdomyolysis, if diagnosed, should be treated with fluid repletion and alkalinization of the urine.
Benzodiazepines are the cornerstone of treatment for anxious or agitated patients. They reduce anxiety and the sympathomimetic effects of hallucinogens.
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Phenothiazines should be avoided. They may reduce the seizure threshold, and their anticholinergic effects only serve to worsen the patient's hyperthermia and tachycardia.
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The role of butyrophenones, particularly droperidol and haloperidol, is less clear. Condemned by some as epileptogenic, they remain in wide use to chemically restrain violent and psychotic patients.
The hypertension and tachycardia associated with hallucinogens rarely require any treatment beyond a benzodiazepine. In the rare case of severe hypertension or tachycardia, treatment with nifedipine or nitroprusside may be indicated. Avoid beta-blockers because many of these drugs have both alpha- and beta-adrenergic effects. Isolated beta-blockade leads to unopposed alpha-adrenergic activity, worsening the hypertension and increasing mortality.
Consultations
Strongly consider consulting a toxicologist or the local poison control center in the following situations:
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Co-ingestion of potentially deadly substances
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Any ingestion causing severe and/or potentially life-threatening adverse effects
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Ingestion of a drug or plant not readily familiar to the treating physician (An unknown mushroom ingestion should prompt a call to not only the poison control center but also perhaps to a trained mycologist.)
A consultation or transfer to a mental health professional should be considered in the following circumstances:
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Any ingestion in the circumstance of a suicide attempt
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Any individual demonstrating psychotic symptoms after organic causes have been eliminated or after the psychoactive effects of the hallucinogen should have worn off
All individuals demonstrating signs and symptoms of substance abuse should be referred to the appropriate rehabilitation facility. Substance abuse professionals now have evidence that abusers become dependent.
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Hallucinogens. Claviceps purpurea.
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Hallucinogens. Morning glory (Ipomoea violacea).
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Hallucinogens. Bufo marinus.
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Hallucinogens. Psilocybe coprophilia.
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Hallucinogens. Amanita muscaria.
