Substance intoxication/withdrawal/treatment

Question 1

Alcohol intoxication

Answer 1

Disinhibition, emotional lability, slurred speech, ataxia, aggression, blackouts, hallucinations, memory impairment, impaired judgement, coma.

Question 2

Alcohol withdrawal symptoms

Answer 2

Mild withdrawal: Tremor ( first symptom), tachycardia, hypertension, agitation (within 48 hrs).
Alcoholic hallucination: visual hallucinations without delirium (12 - 48 hrs).
Delirium tremens: visual hallucinations with severe autonomic instability, delirium, seizures, and possibly death ( 2 - 7 days).

Question 3

Alcohol withdrawal Tx

Answer 3

Benzodiazepines (can require massive doses); thiamine, folate, and multivitamin replacement.

Question 4

Opioids intoxication and management

Answer 4

Euphoria leading to apathy, CNS depression, constipation, pupillary constriction, and respiratory depression ( life-threatening in overdose).
Naloxone and naltrexone are opioid receptor antagonists and reverse the effects of opioids; may require redosing due to short half-life.

Question 5

Opioids withdrawal

Answer 5

Not life-threatening
Anxiety, insomnia, flulike symptoms, piloerection, fever, rhinorrhea, lacrimation, yawning, nausea, stomach cramps, diarrhea, dilated pupils, hyperactive bowel sounds, muscle aches.
‘‘Hurts all over’’ and does not cause seizures.

Question 6

Opioids withdrawal Tx

Answer 6

Mild: ondansetron, loperamide, benzodiazepines, and NSAIDs.
Severe: clonidine for autonomic symptoms, buprenorphine or methadone for craving.

Question 7

Amphetamines intoxication and management

Answer 7

Psychomotor agitation, impaired judgement, HTN, pupillary dilation, tachycardia, fever, diaphoresis, anxiety, angina, euphoria, prolonged wakefulness/attention, arrythmias, delusions, seizures, hallucinations.
MDMA (methylenedioxy-methylamphetamine) ‘‘ecstasy’’ is an amphetamine with hallucinogenic properties; popular at dance parties or ‘‘raves’’ -> intoxications as above, plus hyperthermia, heat exhaustion, hyponatremia, may also precipitate serotonin syndrome.
Haloperidol can be given for severe agitation and symptom-targeted medications (antiemetics, NSAIDs…).

Question 8

Amphetamines withdrawal

Answer 8

Not life threatening
Depression/ Dysphoria, hyperphagia, hyper somnolence, constricted pupils, post-use “crash” with anxiety, lethargy, headache, stomach cramps, fatigue, nightmares.

Question 9

Amphetamines withdrawal Tx

Answer 9

IV Benzodiazepines and supportive tx.
Avoid pure B-blockers (lead to unopposed alpha activity, causing hypertensive crisis).

Question 10

Cocaine intoxication and management

Answer 10

Psychomotor agitation, euphoria, impaired judgement, tachycardia, pupillary dilation, hypertension, paranoia, hallucinations, “cocaine bugs” ( the feeling of bugs crawling under one’s skin) sudden death.
Chronic use causes weight loss, erythema of the nasal turbinates and septum, and behavioral changes.
ECG changes from ischemia are often seen (“cocaine chest pain”).
TX haloperidol for severe agitation along with symptom specific medications (ex: to control HTN).

Question 11

Cocaine withdrawal

Answer 11

Not life threatening
Depression, hyperphagia, constricted pupils, post-use “crash” with hypersomnolence, malaise, severe craving, angina, suicidality, nightmares.

Question 12

Cocaine withdrawal Tx

Answer 12

IV Benzodiazepines and supportive tx.
Avoid pure B-blockers (lead to unopposed alpha activity, causing hypertensive crisis).

Question 13

Barbiturates intoxication

Answer 13

Low safety margin; respiratory depression

Question 14

Barbiturates withdrawal

Answer 14

Rebound anxiety, seizures, delirium/hallucination, life-threatening cardiovascular collapse, tremor, insomnia.
May mimic alcohol withdrawal, but HTN/tachycardia usually absent.

Question 15

Barbiturates Tx

Answer 15

Benzodiazepines taper.

Question 16

Benzodiazepines intoxication

Answer 16

Interaction with alcohol, amnesia, ataxia, somnolence, mild respiratory depression.
Avoid using for insomnia in elderly pts.
Can cause paradoxical agitation even in relatively low doses.

Question 17

Benzodiazepines withdrawal

Answer 17

life threatening, Rebound anxiety, seizures, delirium/hallucination, tremor, insomnia, HTN, tachycardia, death.
May mimic alcohol withdrawal but HTN and tachycardia usually absent.

Question 18

Benzodiazepines Tx

Answer 18

Benzodiazepines taper.

Question 19

Nicotine Intoxication

Answer 19

Restlessness, insomnia, anxiety, arrythmias.

Question 20

Nicotine withdrawal

Answer 20

Irritability, headache, anxiety, weight gain, craving, bradycardia, difficulty concentrating, insomnia.

Question 21

Caffeine intoxication

Answer 21

Restlessness, insomnia, diuresis, muscle twitching, arrhythmias, tachycardia, flushed face, psychomotor agitation.

Question 22

Caffeine withdrawal

Answer 22

Headache, lethargy, depression, weight gain, irritability, craving.

Question 23

Synthetic opioids intoxication

Answer 23

Contains MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine, synthetic heroin) leading to Parkinson-like disorder and loss of pigmented neurons in the substantia nigra.

Question 24

Synthetic opioids withdrawal

Answer 24

None.

Question 25

Bath salts (synthetic cathinones) intoxication

Answer 25

Stimulant drug that causes agitation, combativeness, delirium, and psychosis that may last for weeks.

Question 26

Bath salts (synthetic cathinones) withdrawal

Answer 26

None.

Question 27

Marijuana (cannabis) intoxication

Answer 27

Euphoria, laughter, slowed sense of time, impaired judgement, social withdrawal, increased appetite, dry mouth, conjunctival injection, hallucinations, anxiety, paranoia, decreased motivation.

Question 28

Marijuana (cannabis) withdrawal

Answer 28

None.

Question 29

LSD (lysergic acid diethylamide) intoxication and management

Answer 29

Marked anxiety or depression, delusions, visual hallucinations, flashbacks, pupillary dilation, impaired judgment, diaphoresis, tachycardia, HTN, heightened senses (ex: colors become more intense).
Tx: Supportive counselling; traditional antipsychotics for psychotic symptoms; Benzodiazepines for anxiety.

Question 30

LSD (lysergic acid diethylamide) withdrawal

Answer 30

None.

Question 31

Phencyclidine hydrochloride (PCP) intoxication and management

Answer 31

Assaultive/ combative, belligerence, psychosis, violence, impulsiveness, psychomotor agitation, fever, tachycardia, vertical/horizontal nystagmus, HTN, impaired judgment, ataxia, seizures, delirium.
Tx: Give benzodiazepines, or haloperidol for severe symptoms; otherwise reassure.
Gastric lavage can help eliminate the drug.

Question 32

Phencyclidine hydrochloride (PCP) withdrawal

Answer 32

Recurrence of intoxication symptoms caused by reabsorption in the GI tract; sudden onset of severe, random violence.