The Ocular Anticholinergic Crisis

The Ocular Anticholinergic Crisis

Tox Call

A startling episode with an inconsolable, hallucinating two year old highlights a rare ocular emergency

Prophylactic Antibiotics for Epistaxis

Prophylactic Antibiotics for Epistaxis

Where’s the Evidence?

While the majority of cases do not require medical attention, epistaxis remains a common presenting complaint in the ED

Upstairs Downstairs

Upstairs Downstairs

Director's Corner

How many clinical shifts does your chair need to work in order to stay current with the department?

Five-Year-Old With Dysuria, Abdominal Pain and Incontinence

Five-Year-Old With Dysuria, Abdominal Pain and Incontinence

Soundings

New patient is a 5-year-old male with a history of recurrent UTIs

Sudden Illness After Dental Procedure

Sudden Illness After Dental Procedure

Visual Dx

A 28-year-old male presents to the ED with a chief complaint of chest pain, coughing and shortness of breath

Bicep Tendon Rupture

Bicep Tendon Rupture

The Popeye Sign

A 45-year-old-male presents with sudden onset of pain and significant swelling to his right arm

Leaving Las Vegas... Hopefully

Leaving Las Vegas... Hopefully

By Greg Henry, MD

Notes on the human condition, the laws of thermodynamics, and spandex

Understanding ACEP’s Clinical Policy on Seizures

Understanding ACEP’s Clinical Policy on Seizures

ACEP's 2014 Seizure Guidelines

Dr. Rhonda Cadena, a neurointensivist and emergency physician educator at UNC, breaks down the critical updates

Mid-Level Providers

Mid-Level Providers

Who they are, what they do, and why they’re changing emergency medicine

How to make sense of the puzzle and improve your practice

When Patients Lie

When Patients Lie

How to Spot Deception, What You Can Do, and Why it Matters

Accusing anyone of lying is serious business, but when that person is your patient, the stakes are even higher

Raves and Saves

Raves and Saves

Advanced Emergency Management at Mass Gatherings

EM is crucial at drug-fueled electronic dance festivals, like this month’s Electric Zoo in New York  

Frontpage Slideshow | Copyright © 2006-2014 JoomlaWorks Ltd.
Home
Print
E-mail
Reprint
Educational Objectives:
After evaluating this article participants will be able to:
1. Recognize the toxic syndrome for common hallucinogens, resulting in more accurate toxicologic agent identification.
2. Reocgnize the potential complications associated with hallucinogens, resulting in more effective patient management.
3. Be familiar with common delivery systems and activities associated with hallucinogen exposure, resulting in more accurate diagnoses.


A 22-year-old male is brought to a stadium first aid station after being found running around naked at a Grateful Dead concert. He was noted to be agitated, paranoid, and visually hallucinating requiring full leather restraints. Friends of the patient claimed he ingested several “magic shrooms and blotter acid” prior to the concert.

The patient had the following vital signs: pulse 120/min; blood pressure 130/80mmHg; respiratory rate 32/min, and temperature 100.5 F. The patient’s pupils were equal and dilated. Heart exam revealed a regular tachycardic rate, lungs were clear to auscultation, abdomen was soft and nontender. Extremity exam demonstrated no needle tracks with good distal pulses. The neurological exam was nonfocal. His skin was noted to be flushed with a “Dead Head” tattoo prominently displayed on his left buttock.
       
Hallucinogenic Agents
Hallucinogenic or psychedelic drugs are any group of substances that produce distorted sensory perceptions, an altered sense of awareness, with a mental state characterized by hallucinations and feelings of euphoria or despair.

Hallucinogenic mushrooms as described in the case above include the species Psilocybin and Gymnophilis. The toxin has an LSD-like effect. Clinical effects include visual hallucinogens and gastrointestinal distress. Treatment is primarily supportive by providing a calm environment and benzodiazepine administration. More combative behavior may result if the mushrooms are “laced” with adulterants such as phencyclidine (PCP).

LSD
LSD was discovered in 1938 by Dr. Albert Hofmann. According to Hofmann “At home I lay down and sank into a not unpleasant intoxicated-like condition, characterized by an extremely stimulated imagination. In a dreamlike state, with eyes closed (I found the daylight to be unpleasantly glaring), I perceived an uninterrupted stream of fantastic pictures, extraordinary shapes with intense, kaleidoscopic play of colors.”

LSD is a tasteless, colorless, and odorless powder that can be dissolved in water and distributed on various carrier vehicles such as gelatin squares (“window panes”), sugar cubes, or colored paper (“blotter acid”). Although its popularity has waxed and waned since the 1960s, it is still produced illegally and used predominantly by high school and college students.  A study of patients treated during Chicago-area rock concerts in the mid 1990s found that LSD use was highly prevalent during concerts featuring the Grateful Dead.

LSD has sympathomimetic effects that can precede the onset of perceptual distortions.  These include tachycardia, tachypnea, hypertension, mydriasis, and hyperthermia.  The acute perceptual effects of LSD include a heightened sense of sound, shape, and color. Lights and other objects may seem to be surrounded be halos.  Moving objects may leave a trail of discrete afterimages in the visual field. An unusual perceptual change is synesthesia, the illusion that stimulation of one of the five senses is experienced through another sensory modality.  For example, sound may be experienced as shifting patterns of light and color. 

Acute psychiatric reactions caused by LSD include severe anxiety and panic attacks.  Ordinary thoughts and perceptions can seem grandiose or profound. Sensations of paranoia, depersonalization, and ego fragmentation can be terrifying, leading to the so-called “bad trip”.  Typically, the user is alert, oriented, and aware that the perceptual distortions and illusions are the result of drug ingestion.  

Flashbacks are perceptual distortions and hallucinations that occur in a user of LSD after the acute drug effects have worn off.  Often, they repeat the user’s previous hallucinogenic experience with LSD, and have been reported to occur several years after acute drug use.  They can be persistent and may be precipitated by stress, illness, SSRI use, and the use of ethanol or marijuana.  A more recent term for this phenomenon is hallucinogen persisting perception disorder (HPPD).  

The effects of LSD are usually not life threatening unless mixed with other drugs of abuse.  When morbidity or mortalities occur, they typically result from self-induced trauma.  The drugs of choice for a patient agitated after taking a hallucinogen who cannot be “talked down” are benzodiazepines and when severe, haloperidol (aka- the Haldol blow dart).

MeO-DIPT
MeO-DIPT is a synthetic tryptamine with structure and effects similar to those of psilocybin.  It is currently classified as a Schedule I controlled substance.  It has the street names “foxy-methoxy” or “foxy”, most likely because of its reputed aphrodisiac properties.  It has gastrointestinal and neurological effects, including nausea, vomiting, diarrhea, restlessness, and mydriasis. Larger doses cause perceptual effects similar to LSD. “Waxiness and plasticity” of the extremities has been described. It has been supplied as a “purple haze” tablet, a capsule, or on a sugar cube or blotting paper.    

Nexus
Nexus is a 2C-B- a psychedelic phenethylamine. According to one user “When I take Nexus, I merge with the music, become one with the crowd, and fuse with the whole of Planet Earth. This isn’t a drug, it’s a trance-dance sacrament.” In regard to its effects, another young man described it as “a cross between the warm, lovey-dovey feeling produced by Ecstasy and the visual patterning you get when you take magic mushrooms”.
 
Herbal Hallucinogens
Nutmeg (Myristica fragrans) is a mild hallucinogenic most commonly used experimentally by teenagers and college students. (Parental guidance is advised when adding to one’s holiday eggnog). GI toxicity and abdominal pain has been reported.  “Nutmeg liver” with hepatotoxicity has also been described.

Salvia divinorum is a newer “legal” hallucinogenic with opioid receptor activity. Mitragyma speciosa (Kratom) is now popular in Africa and Asia, particularly in Thailand and Malaysia. Morning glory and moon glow seeds are widely distributed hallucinogenic botanicals in the US with an LSD-like effect. Hawaiian wood rose is popular in the Pacific islands.

Absinthe
Absinthe is an extract of Artemesia absinthum, (oil of wormwood). This drug was popularized during the 1800’s in Paris, among impressionist artists like Vincent Van Gough as a euphoriant beverage, referred to as “the Green Fairy” due to its bright green color and mind altering properties. Due to the toxin thujone, seizures can result after high doses. Absinthe bars and drinks are sold in Europe and via the Internet. An Americanized version is now available but typically contains no thujone.

Toxic Toads
Hallucinogenic or toxic toads have been popularized by the act of “toad licking” or injecting the secretions of cane toads (Bufo marinus) containing the toxin bufotenine. This exotic psychedelic agent also possesses dangerous cardioglycoside (digitalis-like) side effects that can be fatal in toxic doses.
 

 

 



REFERENCES
Abraham HD, Aldridge AM. Adverse consequences of lysergic acid diethylamide. Addiction 1993;88:1327.
Abraham HD, Aldridge AM, Gogia P. The psychopharmacology of hallucinogens. Neuropsychopharm 1996;14:285-298.
Aghajanian GK, Marek GJ. Serotonin and hallucinogens Neuropsychopharm 1999;21:16S-23S.
Babu KM, McCurdy CR, Boyer EW. Opioid receptors and legal highs: Salvia divinorum and Kratom. Clin Toxicol, 46(2):146-52, 2008.
Brady ET. A note on morning glory seed intoxication.  Am J Hosp Pharm 1968;25:88.
Brown RT, Braden NJ. Hallucinogens. Pediatr Clin North Am 1987;34:341-347.
Callaway CW, Clark RF. Hyperthermia in psychostimulant overdose. Ann Emerg Med 1994;24:68.
Cohen S, Ditman KS. Complications associated with lysergic acid diethylamide (LSD-25) JAMA 1962;181:161-2.
DuPont RL, Verebey K.  The role of the laboratory in the diagnosis of LSD and ecstasy psychosis.  Psychiatric Ann  1994;24:142.
Erickson TB, Aks SE, Koenigsberg M. Drug use patterns at major rock concert events. Ann Emerg Med 1 996;28:22-26.
Griffin OH, Miller BL, Khey DN. Legally high? Legal considerations of Salvia divinorum. J Psychoactive Drugs. 2008 ;40(2):183-91
Gussow L: LSD and other Hallucinogenics. In: Pediatric Toxicology: Diagnosis and Management of the Poisoned Child. Erickson T, Ahrens W, Aks S, Baum C, Ling L: Eds McGraw-Hill, New York, 1st Ed , 2005, 398-402.
Gussow L EM News Toxicology Cormer.
Hanrahan JP, Gordon MA: Mushroom poisoning: Case reports and a review of therapy.  JAMA 1984;251:1057.
Hofmann A: How LSD originated. J Psychedelic Drugs 1979;11:53-60.
Ingram AL: Morning glory seed reaction. JAMA 1959;171:1342-4.
Klock JC, Boerner U, Becker CE.  Coma, hyperthermia and bleeding associated with massive LSD overdose: A report of eight cases.  West J Med  1973;120:183.
Kulig K. LSD Emerg Med Clin North Amer 1990;8:551-8.
Leikin JB, Krantz AJ, Zell-Kanter M et al.  Clinical features and management of intoxication due to hallucinogenic drugs.  Med Toxicol Adverse Drug Exp 1989;4:423-50.
Lyttle T, Goldstein D, Gartz J: Bufo toads and bufotenine: Fact and fiction surrounding an alleged psychedelic. J Psychoactive Drugs 1996;28:267-290.
Markel H, Lee A, Homes RD et al: LSD flashback syndrome exacerbated by selective serotonin reuptake inhibitor antidepressants in adolescents. J Pediatr 1994;125:817-19.
Mathias S, Lubman DI, Hides L. Substance-induced psychosis: a diagnostic conundrum. J Clin Psychiatry  2008; 69: 358-67.
Miller PL, Gay GR, Ferris KC et al: Treatment of acute, adverse psychedelic reactions: “I’ve tripped and I can’t get down”. J Psychoactive Drugs 1992;24:277-279.
Passie T, Seifert J, Schneider U et al. The pharmacology of psilocybin. Addition Biol 2002;7:357-64.
Radford DJ, Gillies AD, Hinds JA, Duffy P.Naturally occurring cardiac glycosides. Med J Aust. 1986 ;144(10):540-4.
Richardson WH, Clark RF, Gerard WC.Another hazard of college drinking: the black light concoction. Ann Emerg Med 2003; 41: 890-1
Schultes RE: Hallucinogens of plant origin. Science 1969;163:245-254.
Schwartz RH: LSD: Its rise, fall, and renewed popularity among high school students. Pediatr Clin North Am 1995;42:403-13.
Schwartz RH, Smith DE. Hallucinogenic mushrooms. Clin Pediatr 1988;27:70-73.
Smith DE, Seymour RB. LSD: History and toxicity.  Psychiatric Ann  1994;24:145.
Ulrich RF, Patten BM: The rise, decline, and fall of LSD. Perspectives Biol Med 1991;34:561-578.
Vale A. LSD. Medicine  2007; 35: 654-5.
Vohra R, Seefeld A, Cantrell FL, Clark RF. Salvia divinorum: exposures reported to a statewide poison control system over 10 years. J Emerg Med. 2009.

     

    Popular Authors

    • Greg Henry
    • Rick Bukata
    • Mark Plaster
    • Kevin Klauer
    • Jesse Pines
    • David Newman
    • Rich Levitan
    • Ghazala Sharieff
    • Nicholas Genes
    • Jeannette Wolfe
    • William Sullivan
    • Michael Silverman

    Subscribe to EPM