Neurology Book

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Sympathomimetic Toxicity

Aka: Sympathomimetic Toxicity, Adrenergic Overdose, Sympathomimetic Overdose, Sympathomimetic Adverse Reaction
  1. See Also
    1. Sympathomimetic
    2. Adrenergic Receptor
    3. Alpha Adrenergic Receptor
    4. Beta Adrenergic Receptor
    5. Sympathetic Nervous System
  2. Causes: Illicit
    1. Cocaine
    2. Amphetamines (MDMA or Ecstasy, Methamphetamine)
    3. Synthetic Cathinones (Psychoactive Bath Salts)
  3. Symptoms
    1. Anxiety
    2. Agitation
    3. Euphoria
    4. Increased alertness
    5. Increased vigilance
  4. Associated Conditions
    1. Serotonin Syndrome
    2. Rhabdomyolysis
  5. Signs (Mnemonic: Aspirin)
    1. Altered Level of Consciousness
    2. Sweaty
    3. Pulmonary edema
    4. Irritability
    5. Ringing in the ears
    6. Increased Respiratory Rate
    7. Nausea or Vomiting
  6. Signs: Systemic Sympathomimetic Effect
    1. Cardiovascular
      1. Arrhythmia
        1. Sinus Tachycardia
        2. Supraventricular Tachycardia
        3. Ventricular Tachycardia
        4. Widened QRS wave duration
        5. Asymptomatic ST Elevation
      2. Severe Hypertension
        1. Aortic Dissection
        2. Cerebral bleeding
      3. Myocardial Infarction
        1. Risk from Coronary Artery constriction
        2. Self limited Chest Pain without EKG change
    2. Peripheral Vasoconstriction
      1. Ischemia at fingers at toes
      2. Ischemia at Kidneys, gut, and spinal cord
    3. Pulmonary
      1. Crack Intravenous
        1. Pulmonary edema
        2. Pulmonary Hemorrhage
      2. Crack
        1. Interstitial pneumonitis
        2. Pneumothorax or Pneumomediastinum (with Valsalva)
    4. Central Nervous System
      1. Anxiety or agitation
      2. Paranoia
      3. Delirium
      4. Seizures
      5. Cerebral Vasculitis
      6. Thrombotic or Hemorrhagic Cerebrovascular Accident
      7. Hyperthermia
      8. Mydriasis
    5. Muscle
      1. Acute Rhabdomyolysis
    6. Hepatic
      1. Acute Toxic Hepatitis (similar to Tylenol)
    7. Maternal
      1. Placental Abruption
    8. Newborn
      1. Ventricular Tachycardia
      2. Cerebral Infarction
  7. Labs
    1. See Unknown Ingestion
    2. Comprehensive metabolic panel
    3. Serum Lactic Acid
    4. Venous Blood Gas
    5. Creatinine phosphokinase
  8. Management: Toxicity
    1. General
      1. See Unknown Ingestion
      2. See Altered Level of Consciousness
      3. See specific agents: Cocaine, MDMA, Methamphetamine, Psychoactive Bath Salts
      4. Gastric Decontamination
        1. Indicated for <60 minutes from ingestion
    2. Anxiety, Agitation, or Seizures
      1. See Agitated Delirium
      2. Benzodiazepines IV (repeat every 10 min as needed)
        1. Diazepam 5-10 mg IV
        2. Lorazepam 4 mg IV
      3. Antispychotics (consider, but risk of QTc Prolongation and provocation of hyperthermia)
    3. Rapid Sequence Intubation
      1. Rocuronium
      2. Avoid Succinylcholine (due to potential for Hyperkalemia in Sympathomimetic Overdose)
    4. Hyperthermia
      1. Rapid cooling
      2. Benzodiazepines IV
      3. RSI, Endotracheal Intubation with Sedation (and consider continuing paralysis)
      4. Avoid Antipyretics (e.g. NSAIDs, Acetaminophen)
        1. Ineffective in Sympathomimetic Overdose
    5. Hypertension
      1. See Hypertensive Crisis
      2. First-line
        1. Benzodiazepines IV
      3. Refractory Hypertension
        1. Nitroprusside
        2. Phentolamine
      4. Precautions
        1. Avoid Beta Blockers (risk of unopposed alpha-adrenergic effects and coronary risk)
    6. Arrhythmias
      1. Avoid Lidocaine if possible (may cause Seizures)
      2. Tachyarrhythmias
        1. Benzodiazepines IV
      3. Prolonged QRS wave duration
        1. Hypertonic Sodium Bicarbonate 1-2 meq/kg
        2. Typically requires repeat dosing with goal QRS width normalization
        3. See Tricyclic Antidepressant Overdose for example protocol
    7. Myocardial Ischemia
      1. Indicated
        1. Aspirin
        2. Nitroglycerin
        3. Consider Calcium Channel Blocker
      2. Contraindicated
        1. Avoid Beta Blockers (risk of unopposed alpha-adrenergic effects and coronary risk)
    8. Seizures
      1. See Status Epilepticus
    9. Fluid Resuscitation indications
      1. Volume deficit
      2. Rhabdomyolysis (alkalinize fluid with Sodium Bicarbonate)
  9. Complications: Class effect of stimulant Drugs of Abuse
    1. Myocardial Infarction
    2. Hypertensive Crisis
    3. Status Epilepticus
    4. Crack lung (Hemorrhagic alveolitis)
    5. Rhabdomyolysis
    6. Hyperthermia
    7. Agitated Delirium
  10. References
    1. Boyer and Hernon in Traub and Burns (2015) MethamphetamineIntoxication, UpToDate, accessed 1/10/2017
    2. Derlet (1989) J Emerg Med 7:157-61 [PubMed]

Sympathomimetic adverse reaction (C0413891)

Concepts Injury or Poisoning (T037)
SnomedCT 218841004, 218836007, 292479000
English AR - sympathomimetic NOS, Adv react to sympathomimetic, Adverse reaction to sympathomimetic NOS, Sympathomimetic adverse react, adverse effect of ANS drug therapy sympathomimetics (diagnosis), adverse effect of ANS drug therapy sympathomimetics, adverse reaction to sympathomimetics, Adverse reaction to sympathomimetic NOS (disorder), Adverse reaction to sympathomimetic (finding), Sympathomimetic adverse reaction, Sympathomimetic adverse reaction (disorder), Adverse reaction to sympathomimetic, Adverse reaction to sympathomimetic NOS (finding)
Spanish reacción adversa a simpaticomimético, reacción adversa a simpaticomimético, SAI, reacción adversa a simpaticomimético, SAI (trastorno), reacción adversa a simpaticomimético (hallazgo), reacción adversa a fármaco simpaticomimético (trastorno), reacción adversa a fármaco simpaticomimético, reacción adversa a simpaticomimético, SAI (hallazgo)
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Sympathomimetic overdose (C0573246)

Concepts Injury or Poisoning (T037)
SnomedCT 296372008
English Adrenergic overdose, Sympathomimetic overdose, Sympathomimetic overdose (disorder)
Spanish sobredosis de simpaticomimético (trastorno), sobredosis de simpaticomimético
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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