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Management advice for patients presenting with the effects of New Psychoactive Substances (NPS) to the Emergency Department. This includes the management of serotonin toxicity and the intoxicated child/adolescent flowchart to aid in discharge management.
Children and adolescents presenting to the Emergency Department after taking an NPS.
Emergency Department nursing and medical staff.
New Psychoactive Substances, formerly known as ‘legal highs’, are substances that are produced to mimic the effects of traditional recreational drugs. Since 2008 the presence of these drugs in our communities has been increasing. As of November 2018, over 700 substances are being monitored by the European Monitoring Centre for Drugs and Drug Addiction . The Novel Psychoactive Substances Act, introduced in 2016, means that it is now illegal to sell Novel Psychoactive Substances, therefore most are bought online. They are often labelled as ‘Research Chemicals,’ ‘Herbal Incense, ‘Bath Salts’ or ‘Plant Food’ and are often labelled ‘Not for human consumption.’ New substances quickly replace banned substances.
Younger people increasingly use these drugs and multiple substances are often taken simultaneously. The chemicals in the drug often differ from the written description and the composition of one product may vary from month to month. This makes the psychoactive and toxicological effects of these drugs highly unpredictable in the short term, with unknown long-term effects. Most have never been tested on humans in a controlled environment therefore our knowledge about these substances is very limited. We are slowly acquiring more information about the toxidromes of certain drugs as patients present to Emergency Departments.
These substances present significant diagnostic and management problems to Emergency Departments in individual cases, however, we know that groups may share drugs. Multiple patients may therefore present to Emergency Departments simultaneously with toxic effects of NPS, as was seen at Glasgow Royal Infirmary in 2013.
In Scotland in 2013 there were 113 deaths where NPS were present and a 16 year old died in Lankshire in August 2014 after taking an NPS.
The most commonly used groups of NPS in the UK are:
Below is a description of the effects and side effects of the more common NPS in the UK. It is important to remember that the market for these drugs is constantly changing and patients may be unaware or unable to tell you what they have taken. You must therefore treat each toxidrome as you find it (eg; hypotension, arrhythmias, seizures, pyrexia), whilst maintaining a broad differential diagnosis (sepsis may present in a similar manner).
Adverse effects of illicit drups, including NPSs can be reported to the Report Illicit Drug Reactions (RIDR) pilot project. Details are on toxbase.
(eg: Bombay Blue, Annihilation, Clockwork Orange, Doctor Green Thumb, Exodus, Herbal Haze, Joker, Sensate, Pineapple Express, Spice, Herbal Incense)
These chemicals mimic the effects, and are often more potent than, the active component of cannabis (THC).
Method of Ingestion: Usually smoked but can be ingested
Desired effects: Similar to cannabis - relaxation, euphoria and dissociative state
Management: See Toxbase ‘Synthetic Cannabinoid Receptor Agonists’
Synthetics Cathinones & Phenylamines (Gogaine, Ching, Mr. White, Columbiana, Charly Sheen, Dust till Dawn, Ivory Wave, Blue Stuff, Bath Salts, Sniff)
Mephedrone (Magic, Bubbles, M-Cat, Meow Meow, Plant Food)
Method of Ingestion: Snorted as a powder, ingested in tablet form, ingested as powder wrapped in cigarette paper (‘bombing’), or injected
Desired Effects: Similar to that of amphetamines, cocaine and MDMA – euphoria, increased alertness, intensified emotions and boosted self-esteem
Management : See Toxbase under specific drug or ‘Amfetamines and other stimulants’ and Serotonin Toxicity
If Hyperthermia refer to Serotoxin Toxicity Guidance below
(Eg: Phenazepam, Etizolam, Diclazepam, Flubromazolam, Flubromazepam)
The primary toxicity of benzodiazepines ins CNS depression. These Benzodiazepinetype NPS may be many times more potent that Diazepam.
Desired Effects: Same as Diazepam - sedation, anxiolysis, hypnosis.
Management - see Toxbase under specific drug or drug class
Flumazenil is an appropriate treatment in patients poisoned only by benzodiazepines who develop reduced ventilation and coma who would otherwise require mechanical ventilation. It should not be used as a diagnostic test and should not be use in patients who have co-ingested medicines that may cause seizures. (See toxbase)
Serotonin toxicity is a serious side effect of ingestion of NPS. Features may occur insidiously over a period of hours to minutes and are characterized by altered mental state, neuromuscular hyperactivity and autonomic instability.
In severe toxicity, uncontrolled hyperpyrexia leads to rhabdomyolysis, renal failure, acidosis, hypocalcaemia, hyperkalaemia, DIC and death. It is therefore paramount that it is diagnosed and treated early.
This flow chart can help aid diagnosis of Serotonin Toxicity (Formed from the Hunter Serotonin Toxicity Criteria (Sensitivity 84%, specificity 97%):
*There is no evidence to support the use of Dantrolene effectivement in serotonin toxic patients.
Investigations: (Dictated to by presentation)
Mild toxicity - U&Es, CK, Glucose, VBG, ECG
Moderate / severe toxicity - U&Es, FBC, LFTS, Ca2+, Coag, CK, VBG, Glucose, ECG
Role of urine toxicology - Helpful for surveillance of agents only. Does not change management as most NPS NOT detected.
Opiate - avoid Fentanyl/Alfentanil due to serotonergic action
Recommended induction agent:
Muscle relaxant - Rocuronium 1mg/kg for induction
Depolarising neuromuscular blockers (Suxamethonium) are contraindicated
* There is no evidence to support the use of Dantrolene effectiveness in serotonin toxic patients.
Important points about management of serotonin toxicity management:
Last reviewed: 03 September 2019
Next review: 30 September 2021
Author(s): Dr Steven Rainey (Emergency Medicine Consultant, Glasgow Royal Infirmary)
Co-Author(s): Dr Richard Stevenson, (Emergency Medicine Consultant, Glasgow Royal Infirmary); Dr Siobhan Sweeney (Paediatric Emergency Medicine Consultant, RHCG); Correspondence author: Dr Steve Foster (Paediatric Emergency Medicine Consultant, RHCG).
Approved By: Clinical Effectiveness
Reviewer Name(s): Paediatric Clinical Effectiveness & Risk Committee