Hallucinogen

Aka: Hallucinogen, Lysergic Acid Diethylamide, Lysergic Acid, LSD, Mescaline, Psilocybin, Psychedelic, Psychotomimetic

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II. Types: Classic Hallucinogens (Psychedelics)

  1. Mechanism
    1. Classic Hallucinogens (Psychedelic agents) act at 5-HT2A receptors
    2. Decreases brain Blood Flow to the default mode network, that in part differentiates self from non-self
      1. Results in dissociation effects of Hallucinogens
  2. Lysergic Acid Diethylamide (LSD)
    1. Street Names: Acid, Sugar, Cubes, Trips, Windowpane, Blotter
    2. LSD is semisynthetically derived from ergot alkaloids
    3. LSD (50-400 ug): 8-12 hour duration
  3. Mescaline
    1. Street Names: Buttons, beans, Cactus
    2. Mescaline naturally derived from peyote
    3. Mescaline (250-600 mg): 8-12 hour duration
  4. Psilocybin
    1. Street Names: Magic Mushrooms, Mushrooms, Los Ninos
    2. Psilocybin naturally derived from Psilocybe
    3. Psilocybin (10-50 mg): 6-8 hour duration
  5. Dimethyltryptamine (DMT)
    1. Street Names: Business Trip
    2. Substituted tryptamine found naturally in plants and animals
    3. Rapid onset with 5-15 minute duration when inhaled or injected
      1. Duration prolonged with ingestion and when taken with MAO Inhibitor (e.g. ayahuasca brew)
    4. Resources
      1. https://en.wikipedia.org/wiki/N,N-Dimethyltryptamine
  6. Salvia (Salvia divinorum)
    1. Herb in mint family found in southern Mexico
    2. Herb leaves are chewed for Hallucinogenic effect (duration 30 minutes)

III. Types: Other Hallucinogens

  1. Dissociative Agents
    1. Ketamine
    2. Phencyclidine (PCP)
  2. Delirium-Inducing Agents
    1. See Medication Causes of Delirium in the Elderly
    2. See Medication Causes of Psychosis
    3. Anticholinergic Toxicity (e.g. Diphenhydramine)

IV. Signs

  1. See Intentional Drug Overdose
  2. Varies widely based on substance used (which is often unknown)
    1. Polysubstance ingestion is common
    2. Adulterated drugs, variable street names and unique designer drugs are common
  3. Psychosis
    1. Hallucinations
    2. Delusions
    3. Paranoia
  4. Other findings with Lysergic Acid Diethylamide (LSD)
    1. Hyper-suggestible state
    2. Sympathomimetic Effects (LSD)
      1. Pupil Dilation
      2. Hypertension
      3. Tachycardia
      4. Hyperreflexia
      5. Fever
    3. Non-specific symptoms
      1. Dizziness
      2. Weakness
      3. Somnolence
      4. Nausea
      5. Paresthesias

V. Labs

  1. See Unknown Ingestion
  2. Evaluate Renal Function and Creatine Kinase for Rhabdomyolysis in severe Intoxication
  3. Evaluate Serum Sodium for Hyponatremia

VI. Complications: Toxicity

  1. Serotonin Syndrome
    1. Lysergic Acid Diethylamide (LSD) has high affinity for Serotonin receptors
    2. NBOMe has even higher Serotonin receptor affinity than LSD
  2. Amphetamine-like reaction
    1. Hyperthermia
    2. Rhabdomyolysis
    3. Cerebral Infarction
  3. Water Intoxication with severe Hyponatremia
    1. See Hyponatremia Management
    2. Most common with MDMA (Ecstasy)
    3. Observe for Seizures

VII. Management: Hallucinogen Intoxication

  1. See Calming the Agitated Patient
  2. Evaluate for secondary physical injury (common in LSD Intoxication)
  3. Accidental Ingestion in children
    1. Gastric Decontamination is not indicated in LSD ingestion unless polysubstance ingestion
  4. Benzodiazepines (e.g. Midazolam, Lorazepam) are first-line agents
  5. Avoid Neuroleptics (e.g. Haloperidol) in most cases
    1. Risk of Drug Interaction with Hallucinogens used (esp. Anticholinergic Agents)
  6. Provide calm and supportive environment
    1. Isolated room with minimal stimuli and dim lighting
  7. Disposition
    1. Stable patients may be discharged after 1-2 hours of observation with a sober adult
    2. Persistent Psychedelic effects warrant longer observation (higher risk of death related to Traumatic Injury)

VIII. References

  1. McCollum (2020) EMRap 20(4):9-10

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