Shaun L. Greene

Case series of individuals with analytically confirmed acute mephedrone toxicity.

Context. Previous reports of acute toxicity/harm associated with mephedrone use have been based on self-reported mephedrone use; toxicological screening has not been undertaken in these cases to determine whether mephedrone has been used. Objective. To report the first case series of analytically confirmed mephedrone-related acute toxicity. Materials and methods. Serum samples were collected from individuals presenting to an emergency department (ED) with acute toxicity related to self-reported mephedrone use. Toxicological analysis, by gas-chromatography coupled with mass-spectrometry and liquid chromatography with tandem mass-spectrometry was performed to qualitatively confirm mephedrone use. Symptoms/signs of acute mephedrone toxicity and basic physiological parameters were extracted from the routine ED records. Results. Acute mephedrone-related toxicity was analytically confirmed in seven male patients; the mean ± SD age was 24.6 ± 6.5 years (range 16–36 years). Agitation (four patients) was the most common symptom/sign reported; other common symptoms/signs included: palpitations (two patients); chest pain (two patients); self-limiting pre-hospital seizures (one patient) and headaches (one patient). The mean heart rate was 109.1 ± 21.8 (range 80–140) beats per minute; one patient had a “severe” tachycardia (heart rate of ≥140 bpm). The mean systolic blood pressure was 153.0 ± 39.6 (range 110–210) mmHg; three patients had clinically significant hypertension (systolic blood pressure ≥160 mmHg). Discussion. These analytically confirmed acute mephedrone toxicity presentations had clinical features of toxicity consistent with an acute sympathomimetic toxidrome (e.g. hypertension, tachycardia and agitation). These findings are similar to the pattern of toxicity seen with other sympathomimetic recreational drugs such as 3,4-Methylenedioxymethamphetamine (MDMA) and cocaine. Conclusion. The process for determining whether a novel psychoactive substance should be controlled often relies on demonstrated/proven acute harm associated with its use. It is important that clinical toxicologists undertake appropriate biological sampling and toxicological analyses in suspected cases of “novel psychoactive drug” toxicity. This will ensure that both clinicians and legislative authorities are informed of the confirmed pattern of toxicity associated with these drugs.

Review article: amphetamines and related drugs of abuse.

Acute amphetamine toxicity is a relatively common clinical scenario facing the Australasian emergency medicine physician. Rates of use in Australasia are amongst the highest in the world. Clinical effects are a consequence of peripheral and central adrenergic stimulation producing a sympathomimetic toxidrome and a spectrum of central nervous system effects. Assessment aims to detect the myriad of possible complications related to acute amphetamine exposure and to institute interventions to limit associated morbidity and mortality. Meticulous supportive care aided by judicial use of benzodiazepines forms the cornerstone of management. Beta blockers are contraindicated in managing cardiovascular complications. Agitation and hyperthermia must be treated aggressively. Discharge of non‐admitted patients from the emergency department should only occur once physiological parameters and mental state have returned to normal. All patients should receive education regarding the dangers of amphetamine use.

Medical and legal confusion surrounding gamma-hydroxybutyrate (GHB) and its precursors gamma-butyrolactone (GBL) and 1,4-butanediol (1,4BD)

BACKGROUND Gamma-hydroxybutyrate (GHB) is used as a recreational drug, with significant associated morbidity and mortality; it is therefore a class C drug under the Misuse of Drugs Act (1971). However, its precursors gamma-butyrolactone (GBL) and 1,4-butanediol (1,4BD) remain legally available despite having similar clinical effects. AIM The aim of this study was to determine whether the relative proportions of self-reported ingestions of GHB or its precursors GBL and 1,4BD were similar to those seen in analysis of seized drugs. DESIGN AND METHODS Retrospective review of our clinical toxicology database to identify all cases of self-reported recreational GHB, GBL and 1,4BD use associated with ED presentation in 2006. Additionally all seized substances on people attending local club venues were analysed by a Home Office approved laboratory to identify any illicit substances present. RESULTS In 2006, there were a total of 158 ED presentations, of which 150 (94.9%) and 8 (5.1%) were GHB and GBL self-reported ingestions respectively; 96.8% (153) were recreational use. Of the 418 samples seized, 225 (53.8%) were in liquid form; 85 (37.8%) contained GHB and 140 (62.2%) contained GBL. None of the seized samples contained 1,4BD and there were no self-reported 1,4BD ingestions. CONCLUSION Self-reported GHB ingestion was much more common than GBL ingestion, whereas GBL was more commonly found in the seized samples. These differences suggest that GBL use may be more common than previously thought and we suggest that there should be further debate about the legal status of the precursors of GHB.

Five-year trends in self-reported recreational drugs associated with presentation to a UK emergency department with suspected drug-related toxicity.

Objective User surveys show that there have been significant changes over the last decade in the recreational drugs that are available and being used. This study aims to determine whether there have been similar trends in the drug(s) used by individuals presenting to the emergency department (ED) with acute recreational drug toxicity. Methods Data on all poisoned patients presenting to our large inner-city ED are recorded prospectively on a dedicated clinical toxicology database. Presentations relating to the use of classical recreational drugs and/or novel psychoactive substances were identified retrospectively between 1 January 2006 and 31 December 2010. Results There was a significant increase between 2006 and 2010 in the number of individuals reporting the use of cocaine (119–222), &ggr;-hydroxybutyrate/&ggr;-butyrolactone (158–270), ketamine (58–81) and cannabis (18–68) and novel psychoactive substances (seven to 98). In particular, there was an increase in cathinones reported from none in 2006 to 82 in 2010. Only 3,4-methylenedioxymethamphetamine (MDMA) was associated with a downward trend in reported use from 140 in 2006 to 103 in 2010. Conclusion Data collection on the drug(s) used in individuals presenting to specialist clinical toxicology centres and/or sentinel EDs across Europe with acute recreational drug toxicity would help to determine the true pattern(s) of drug use and the acute harm associated with this use across Europe and trends over time.

Emergency department presentations in determining the effectiveness of drug control in the United Kingdom: mephedrone (4-methylmethcathinone) control appears to be effective using this model

Mephedrone (4-methylmethcathinone) and related cathinones were controlled in the United Kingdom on 16 April 2010. An analysis of presentations to the emergency department of patients with acute toxicity related to the use of mephedrone demonstrated that there was a peak in presentations prior to and a significant fall in presentations following the control of mephedrone. This suggests that the control of mephedrone in the United Kingdom may have been effective in reducing the acute harm associated with the drug.

Simple lightweight disposable continuous positive airways pressure mask to effectively treat acute pulmonary oedema: Randomized controlled trial

Objective:  To compare the novel Boussignac valve continuous positive airways pressure (CPAP) delivery mask and a standard closed‐circuit Drager CF800 CPAP system in the management of acute pulmonary oedema (APO) patients.

Paracetamol availability and recent changes in paracetamol poisoning: is the 1998 legislation limiting availability of paracetamol being followed?

Objective: To determine the degree of adherence to legislation introduced in 1998 restricting the availability of over the counter paracetamol. Design: A prospective observational study. Setting: An emergency department in an inner city London teaching hospital. Pharmacy and non-pharmacy outlets in south London. Main outcome measures: (1) The source of paracetamol ingested by 107 patients presenting with an acute paracetamol overdose (2001–2003) and (2) the ability to purchase paracetamol from pharmacy and non-pharmacy outlets in a manner contravening paracetamol pack size legislation (2004). Results: Potentially toxic amounts of paracetamol in excess of pack size restrictions were purchased in 70% (17 of 24) of outlets. Forty six per cent of patients who had ingested a potentially toxic dose of paracetamol obtained the tablets in a manner contravening the 1998 legislation. Conclusion: Legislation limiting the availability of over the counter paracetamol is not being adhered to in south London. A significant number of patients ingesting a potentially toxic dose of paracetamol report purchasing the tablets in a manner contravening the legislation. Studies that attempt to assess the impact of the legislation need to be interpreted in the context of these results. Measures to enforce current legislation may help to reduce the severity of paracetamol poisoning in the UK.

Improvement in the management of acutely poisoned patients using an electronic database, prospective audit and targeted educational intervention

Problem: The need to improve the clinical assessment and management of acutely poisoned patients presenting to an NHS hospital emergency department (ED). Design: Creation of an electronic clinical toxicology database to prospectively collect all aspects of clinical information on poisoned-patient presentations. Systematic analysis of collated information to identify shortfalls in patient assessment and management. Bimonthly audit meetings, and design and implementation of educational interventions to address identified shortfalls. Ongoing audit to demonstrate continued improvement in patient care. Background and setting: ED in tertiary-level inner-city London teaching hospital. Study conducted by staff from the ED and clinical toxicology service. Key measures for improvement: Demonstration of overall reduction in the incidence of predefined shortfalls in patient assessment and management during 12-month study period. Strategies for improvement: Targeted educational lectures and case-based clinical scenarios addressing identified deficiencies in the knowledge required to effectively manage poisoned patients. Weekly case-based anonymised feedback report sent electronically to staff involved in caring for poisoned patients. Effects of change: Implementation of targeted teaching of ED staff and regular electronic distribution of teaching cases. Between the first and second 6 months of the study, there was a significant increase in the proportion of presentations for which clinical management was graded as “good” (77.6% to 89.4%, p<0.0001) and a significant reduction in the proportion of “major” (9.9% to 5.8%, p = 0.012) and “minor” (12.6% to 4.8%, p<0.0001) shortfalls. Lessons learnt: Systematic collection of clinical information, using a dedicated electronic database and subsequent review and audit of collated data by interested clinicians, enabled design and implementation of targeted educational interventions to address shortfalls in patient management. This process has led to significant improvements in the clinical care of acutely poisoned patients presenting to the ED.

Emergency department presentations with suspected acute coronary syndrome – frequency of self-reported cocaine use

The objective of this study was to assess the prevalence of self-reported cocaine use in individuals presenting to the Emergency Department (ED) with suspected myocardial ischaemia/acute coronary syndrome (ACS). A retrospective review (1 January to 31 December 2008) of all suspected myocardial ischaemia/ACS presentations to our ED was undertaken. Basic demographic data and use/nonuse of cocaine were recorded from notes; where appropriate the route of use, concomitant use of other recreational drugs/ethanol, presenting features and treatment(s) were extracted. Self-reported cocaine use was recorded in 54 (1.9%) of the 2810 presentations. The mean±SD age of those who self-reported the use of cocaine (28.9±9.0) was significantly lower than those who did not (52.3±12.7) (P<0.0001). Twenty (37.0%) of those with cocaine use had one or more features of potential cocaine (sympathomimetic) toxicity at presentation to the ED. In conclusion, self-reported recent cocaine use was documented in a clinically significant minority of patients with suspected myocardial ischaemia/ACS.

Is cocaine use recognised as a risk factor for acute coronary syndrome by doctors in the UK

Background: Cocaine is a sympathomimetic agent that can cause coronary artery vasospasm leading to myocardial ischaemia, acute coronary syndrome and acute myocardial infarction (ACS/AMI). The management of cocaine-induced ACS/AMI is different to classical atheromatous ACS/MI, because the mechanisms are different. Methods: Knowledge study—Junior medical staff were given a scenario of a patient with ACS and asked to identify potential risk factors for ACS and which ones they routinely asked about in clinical practice. Retrospective study—Retrospective notes reviews of patients with suspected and proven (elevated troponin T concentration) ACS were undertaken to determine the recording of cocaine use/non-use in clinical notes. Results: Knowledge study—There was no significant difference in the knowledge that cocaine was a risk factor compared to other “classical” cardiovascular risk factors, but juniors doctors were less likely to ask routinely about cocaine use compared to other “classical” risk factors (52.9% vs >90%, respectively). Retrospective study—Cocaine use or non-use was documented in 3.7% (4/109) and 4% (2/50) of clinical notes of patients with suspected and proven ACS, respectively. Discussion: Although junior medical staff are aware that cocaine is a risk factor for ACS/AMI, they are less likely to ask about it in routine clinical practice or record its use/non-use in clinical notes. It is essential that patients presenting with suspected ACS are asked about cocaine use, since the management of these patients is different to those with ACS secondary to “classical” cardiovascular risk factors.