2025 – PAGE 208 – EMERGENCY MEDICINE & TOXICOLOGY

NICOTINE/TOBACCO/SMOKING

Nicotine from smoking or chewing tobacco increases alertness, relaxation, and memory, and decreases appetite. Children exposed to second-hand smoke are more likely to have reactive airway disease, upper- and lower-respiratory tract infections (URIs and PNAs), otitis media, and pneumonias.

DEXTROMETHORPHAN

Found in OTC cough medicine with a weak action at opioid receptors. Common signs of abuse are nystagmus, delirium/agitation, slurred speech, hyperreflexia, CNS depression, tachycardia, and visual hallucinations.

PEARL: Phenylephrine and pseudoephedrine are also found in most OTC cough medications.

PEARL: Pseudoephedrine is the precursor for manufacturing methamphetamines.

ANTIHISTAMINES

Diphenhydramine ingestion can lead to sedation, but also can result in antimuscarinic toxicity. Symptoms include confusion, hyperthermia, blurred vision, photophobia, dry mouth, tachycardia, and urinary retention.

PEARL: Cardiotoxicity can result in prolongation of the QRS interval, dysrhythmia, and rarely death

HYDROCARBON INGESTION

Hydrocarbon toxicity can result from ingestion of furniture polish/cleaner, gasoline, kerosene, and lighter fluid. Some of these hydrocarbons fall under the term “MINERAL SPIRITS.” Symptoms of hydrocarbon ingestion may include cough, tachypnea, nausea, and vomiting. Toxicity can eventually lead to hypoxia and ARDS. Symptoms occur quickly, so if there are no respiratory symptoms and a CXR is normal at 6 hours post-ingestion, patients may be discharged from the ER. Otherwise, admit for supportive therapy (which could include intubation).

HYDROCARBON INHALATION

Hydrocarbon inhalation, often from inhalant abuse, can result in symptoms including ataxia, weakness (can get rhabdomyolysis), nystagmus, possible hallucinations, and slurred speech. Toxicity may cause respiratory acidosis OR alkalosis. The patient can appear drunk and will often feel hung-over afterwards. Chronic use can result in GI symptoms and encephalopathy. It can lead to death from arrhythmias, aspiration, or asphyxia.

SEROTONIN SYNDROME

Potentially life-threatening condition due to increased serotonergic activity in the CNS. Triad of mental status changes, autonomic hyperactivity, and neuromuscular excitability. Be careful in the perioperative setting and treat by removing the drug, charcoal, benzodiazepines for agitation, active cooling, and support the ABC’s.

MDMA

MDMA (3,4-methylenedioxymethamphetamine, also called Molly, Mandy, or ecstasy) is an amphetamine that is similar to serotonin, so it can cause symptoms related to both amphetamine toxicity (hyperthermia, agitation, hypertension, tachycardia) and serotonergic toxicity (serotonin syndrome, SIADH, hyponatremia).

URINE DRUG SCREENING

Often detects amphetamines, barbiturates, benzodiazepines, cocaine, opiates, phencyclidine, and THC

• Amphetamines false + with ADHD medications, decongestants, MDMA, ephedrine, bupropion
• Phencyclidine (PCP) false + with ketamine, dextromethorphan, diphenhydramine
• Marijuana (THC) false + with PPI’s, NSAID’s, dronabinol, efavirenz