Sympathomimetic Toxicity

Aka: Sympathomimetic Toxicity, Adrenergic Overdose, Sympathomimetic Overdose, Sympathomimetic Adverse Reaction, Stimulant Overdose, Stimulant Intoxication, Stimulant Poisoning

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II. Causes: Illicit

  1. Cocaine
  2. Amphetamines (MDMA or Ecstasy, Methamphetamine)
  3. Synthetic Cathinones (Psychoactive Bath Salts)

III. Symptoms

  1. Anxiety
  2. Agitation
  3. Euphoria
  4. Increased alertness
  5. Increased vigilance

IV. Associated Conditions

  1. Serotonin Syndrome
  2. Rhabdomyolysis

V. 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

VI. 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
  9. Skin
    1. Diaphoresis
      1. Contrast with Dry Skin in Anticholinergic Toxicity

VII. Labs

  1. See Unknown Ingestion
  2. Comprehensive metabolic panel
  3. Serum Lactic Acid
  4. Venous Blood Gas
  5. Urinalysis for Myoglobinuria (positive dipstick for blood but microscopy negative for RBCs)
  6. Creatinine phosphokinase (CPK)
    1. Evaluate for Rhabdomyolysis

VIII. 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 and airway protected
  2. Anxiety or Agitation
    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
      1. Consider, but risk of QTc Prolongation and provocation of hyperthermia
  3. Seizures
    1. See Status Epilepticus
    2. Benzodiazepines (see Agitation as above)
    3. Phenobarbital
  4. Rapid Sequence Intubation
    1. Rocuronium
    2. Avoid Succinylcholine (due to potential for Hyperkalemia in Sympathomimetic Overdose)
  5. 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
  6. 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, esp. with Cocaine)
  7. 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
  8. 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)
  9. Fluid Resuscitation indications
    1. Volume deficit
    2. Hyperdynamic state is associated with increased insensible losses
    3. Rhabdomyolysis (alkalinize fluid with Sodium Bicarbonate)
  10. Thunderclap Headache or foca

IX. 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

X. References

  1. Boyer and Hernon in Traub and Burns (2015) Methamphetamine Intoxication, UpToDate, accessed 1/10/2017
  2. Thapar (2022) Crit Dec Emerg Med 36(2): 19-24
  3. Derlet (1989) J Emerg Med 7:157-61 [PubMed]

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