Nature vs Narcotics - WMS

Nature vs NarcoticsOrganic and Synthetic Toxidrome Doppelgangers

Miguel Pineda, MDUCSD Wilderness Medicine Fellow 2020-2021

Introduction

• Many animal envenomation and toxic plant poisoning toxidromes can mimic those of synthetic drug ingestions

• Treatment for each may be vastly different with poor outcome if diagnosis is delayed

• Available History variable dependent on mental status, age, and family/friend visitation privileges

Learning Objectives

• Identify Organic and Synthetic Toxidrome mimics•Differentiate toxidromes based off of key presenting symptoms

• Identify different treatment modalities for each toxidrome

Disclosures

• None

• 2 year old Male• Agitation

• Inconsolable Crying• Ataxic Thrashing• Hypersalivation

• Abnormal Eye Movements• Tachycardia

• HTN

Scorpion Sting vs PCP Ingestion

Case 1: Tucson, AZ

• 2 year old Male• Agitation

• Inconsolable Crying• Ataxic Thrashing• Hypersalivation

• Abnormal Eye Movements• Tachycardia

• HTN

Scorpion Sting PCP Ingestion

• Neuro: Ataxia, Jerky Extremity Movements, Seizures

• CV: Tachycardia, HTN• Pulm: Tachypnea• HEENT: Nystagmus, Miosis, Dry Mucous

Membranes• Psych: Agitation, Psychosis, Delusions

(Invulnerable)

• Neuro: Pain, Paresthesias, Jerky Extremity Movements

• CV: Tachycardia, HTN• Pulm: Respiratory Failure• HEENT: Opsoclonus, Tongue Fasciculations• GI: Vomiting• Psych: Agitation





(Invulnerable)







(Invulnerable)




Toxin: Phencyclidine (NMDA Antagonist)Diagnosis• Urine Drug ScreenTreatment• Benzos• Behavioral Modifications (Enya)• IVF (Avoid Rhabdo)

Toxin: Neurotoxin MixtureDiagnosis• ClinicalTreatment• Anascorp (Grade 3-4 Severity)

• Fab2 Equine Antivenin• ~$10k/Vial (x3vials)• Regional Stocking Variable

• Intubation


• 20 year old male• Combative

• Red, sweaty skin• Mydriasis

• Tachycardia • HTN

Jimson Weed vs Methamphetamine

Case 2: Tulsa, OK

• 20 year old male• Combative

• Red, sweaty skin• Mydriasis

• Tachycardia • HTN

Jimson Weed MethamphetamineCase 2: Tulsa, OK

Jimson Weed Methamphetamine• Neuro: Agitation, Choreoathetotic

movements• HEENT: Mydriasis• CV: Tachycardia, HTN• Derm: Skin flushing, Diaphoresis• Psych: Paranoia, Increased Alertness,

Incessant Conversations

• Neuro: AMS, Hyperthermia, Seizures• HEENT: Mydriasis• CV: Tachycardia, HTN, QRS Prolongation, Cardiac

Dysrhythmias• GI: Decreased Bowel Sounds• GU: Urinary Retention• Derm: Skin Flushing, Xerodermia• Psych: Hallucinations, Mumbling, “Picking”, “Annoying”

Case 2: Tulsa, OK






Case 2: Tulsa, OK






Case 2: Tulsa, OK

Jimson Weed MethamphetamineToxin

• L-Methamphetamine (Peripheral)• D-Methamphetamine (Central)

Diagnosis• Urine Drug Screen

Treatment• Benzos, Antipsychotics, Supportive Care

Toxin• Belladonna Alkyloid (Atropine)

Diagnosis• Clincial

Treatment: • Benzos, Supportive care• Foley Catheter (Urinary Retention)• Bicarbonate Boluses (QRS Prolongation)

Case 2: Tulsa, OK

• 24 year old Female• Paranoia

• Responding to Visual Hallucinations• Mydriasis

• Diaphoresis• Tachycardia

• Grinding Teeth

Case 3: Santa Fe, NM

Peyote vs MDMA

• 24 year old Female• Paranoia

• Responding to Visual Hallucinations• Mydriasis

• Diaphoresis• Tachycardia

• Grinding Teeth

Peyote MDMACase 3: Santa Fe, NM

Peyote MDMA• Const: Hyperthermia

• Neuro: Ataxia, Poor Concentration, Seizures

• CV: Tachycardia, HTN, Dysrhythmias

• HEENT: Mydriasis

• GU: Hyponatremia, Rhabdo

• Derm: Diaphoresis

• Psych: Euphoria, Visual Hallucinations

• Pulm: Respiratory Depression


• GI: Nausea/Vomiting


• Psych: Depersonalization, Visual Hallucinations




























Peyote MDMAToxin:

• 3-Methylenedioxymethamphetamine

Diagnosis:

• Urine Drug Screen (Amphetamines, Possible False Negative)

Treatment

• Benzos

• IVF Rehydration (CK, Na+ Trend)

• Cardiac Monitoring

Toxin:

• Mescaline

Diagnosis:

• Clinical

Treatment

• Benzos, Supportive Care


• 19 year old male• Fearful Agitation

• Tachycardia• Watching Invisible Objects in room

• Grabbing at air with poor coordination• Infrequent Vomiting

• Progressive Somnolence

Case 4: Seattle, WA

Psilocybin vs Dextromethorphan

• 19 year old male• Fearful Agitation

• Tachycardia• Watching Invisible Objects in room

• Grabbing at air with poor coordination• Infrequent Vomiting

• Progressive Somnolence

Case 4: Seattle, WAPsilocybin Dextromethorphan


• Neuro: Ataxia, Hyperkinesis, Tremor, Seizures• CV: Tachycardia, Cardiac Arrest• HEENT: Mydriasis• GI: Nausea/Vomiting• Psych: Visual Hallucinations, Anxiety, LH,

Agitation

• Neuro: CNS Depression, Dystonia, Ataxia• CV: Tachycardia• Pulm: Respiratory depression• HEENT: Nystagmus• GI: Nausea/Vomiting• Derm: Diaphoresis• Psych: Visual Hallucinations/Euphoria, Agitation,

Psychosis• Const: Hyperthermia



Agitation

• Neuro: CNS Depression, Dystonia, Ataxia• CV: Tachycardia• Pulm: Respiratory depression• HEENT: Nystagmus• GI: Nausea/Vomiting• Derm: Diaphoresis• Psych: Visual Hallucinations/Euphoria, Agitation,

Psychosis• Const: Hyperthermia



Agitation

• Neuro: CNS Depression, Dystonia, Ataxia, Hyerreflexia• CV: Tachycardia• Pulm: Respiratory depression• HEENT: Nystagmus• GI: Nausea/Vomiting• Derm: Diaphoresis• Psych: Visual Hallucinations/Euphoria, Agitation,

Psychosis


• Toxin: • Indolealkylamine

• Diagnosis:• Clinical

• Treatment:• Benzos, Supportive Care• Cardiac Monitoring

• Toxin:• Dextromethorphan

• Diagnosis:• Urine Drug Screen (PCP Positive)

• Treatment• Benzos, Supportive Care• Naloxone (CNS/Respiratory Depression)• Test for Syrup Co-Ingestion

• Acetaminophen, Antihistamine, Antimuscarinic

• 4 year old female• Flaccid weakness

• Decreased Reflexes• Increased Work of Breathing

• Alert• Afebrile

Tick Paralysis vs Marijuana

Case 5: Denver, CO

• 4 year old female• Flaccid weakness

• Decreased Reflexes• Increased Work of

Breathing• Alert

• Afebrile

Tick Paralysis MarijuanaCase 5: Denver, CO

• Neuro: Somnolence, Ataxia, Hypotonia, Seizures (Peds)

• HEENT: Mydriasis, Nystagmus• CV: Tachycardia (Peds)• GI: Nausea/Vomiting• Pulm: Respiratory Depression (Central)• Psych: Relaxation, Decreased

Concentration

• Neuro: Ascending Paralysis, Hyporeflexia, Intact Sensation

• HEENT: Opthalmoplegia, Bulbar Palsy• Pulm: Respiratory Failure (Diaphragm)




Concentration






Concentration




Toxin• Tetrahydrocannabinol (THC)

Diagnosis: • Urine Drug Screen

Treatment: • Supportive Care

Toxin• Ixobotoxin (2-6days)

Diagnosis: • Tick Identification (Hair)

Treatment: • Tick Removal

Tick Paralysis Marijuana

Case 5: Denver, CO

Conclusions

• Always keep organic poisoning/envenomation on the differential for toxidrome presentations

• Key treatments can vary depending on causative agent• Poison Control services are available 24/7

• 1-800-222-1222• www.poison.org

References

• Goldfrank's Toxicologic Emergencies, 11e | AccessEmergency Medicine | McGraw-Hill Medical

• Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e | AccessEmergency Medicine | McGraw-Hill Medical

• Atlas of Pediatric Emergency Medicine, 3e | AccessEmergency Medicine | McGraw-Hill Medical

• Amphetamine Toxicity | The Atlas of Emergency Medicine, 5e | AccessEmergency Medicine | McGraw-Hill Medical

• “When the Scorpion Stings” The University of Arizona. https://www.youtube.com/watch?v=DE60ig0CIZc

• “See What Happens When 3-Year-Old Was Paralyzed by Tick Bite” Inside Edition. May 25, 2017. https://www.youtube.com/watch?v=DUP6EjMbgfE

https://www.youtube.com/watch?v=DE60ig0CIZc

https://www.youtube.com/watch?v=DUP6EjMbgfE

Questions?

Documents

Nature vs Narcotics - WMS