Anticholinergic poisoning with adulterated intranasal cocaine

Misuse of Anticholinergic Medications: A Systematic Review

(1) Background: Over the last decade, misuse and diversion of medications has appeared to be increasingly concerning phenomena, including a range of different molecules. As current knowledge on the abuse of centrally acting anticholinergics is limited, the aim of the present study is to review the relevant published data, focusing on the following molecules: benztropine, biperiden, scopolamine, orphenadrine, and benzhexol/trihexyphenidyl (THP). (2) Methods: A systematic literature review was carried out using Pubmed, Scopus, and Web of Science databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Research methods were registered on PROSPERO (CRD42021257293). (3) Results: A total of 48 articles, including case reports, surveys, and retrospective case series analyses, were included. Most articles focused on benzhexol/THP (n = 25), and benztropine (n = 4). The routes of administration were mostly oral, and macrodoses together concomitant illicit drugs, e.g., cocaine, have been recorded. Toxidromes included both physical (e.g., tachycardia, tachypnoea, dilatated pupils, dry skin, urinary retention, ataxia, etc.) and psychiatric symptoms (e.g., anxiety, agitation, delirium, etc.). Fatal outcomes were very rare but reported. (4) Conclusion: Results from the present study show that anticholinergic misusing issues are both widespread worldwide and popular. Considering the potential adverse effects associated, healthcare professionals should be vigilant and monitor eventual misusing issues.

The Role of Dexmedetomidine in Pediatric Patients Presenting with an Anticholinergic Toxidrome

Background

We report two pediatric cases of anticholinergic toxidrome, including the youngest reported to date, in which standard therapeutic strategies were either contraindicated or ineffective, while treatment with dexmedetomidine was rapidly efficacious with no adverse effects. Moreover, with the recent shortage of physostigmine, we highlight an alternative treatment in this clinical setting. Case Summaries. In case 1, a two-year-old had an overdose presenting with an anticholinergic toxidrome. However, his hypopnea precluded the use of benzodiazepines due to the high likelihood of intubation. In case 2, a 14-year-old had a polypharmacy overdose inducing agitated delirium that was refractory to high-dose benzodiazepines. Due to the unknown ingestion, physostigmine was avoided. In both cases, dexmedetomidine helped the patient remain calm and metabolize the ingestions.

Conclusion

Our experience suggests that dexmedetomidine may be a useful adjunct in anticholinergic presentations in the setting of polypharmacy, when standard therapy is proven ineffective, contraindicated, or unavailable.

Acute Cocaine Toxicity: Pharmacology and Clinical Presentations in Adult and Pediatric Populations

Cocaine remains the most prevalent drug responsible for emergency department (ED) visits. A majority of acute cocaine toxicity cases involve young, habitual, adult cocaine users and often present with a range of cardiac, neurologic, gastrointestinal (GI) or renal symptoms. In addition, atypical populations (neonates, infants, toddlers, young children and adolescents) are presenting in EDs with varying symptoms that are unknowingly associated with cocaine exposure. Unfortunately, juvenile presentations are generally anecdotal in nature, and while enlightening, are difficult to quantify epidemiologically. Outlining the types of symptom presentation in these young populations may assist healthcare providers in expediting proper treatment for such demographic groups. Therefore, this review examines the current knowledge regarding cocaine's pharmacologic activity as it relates to its potential toxicity, and outlines the clinical manifestations of cocaine exposure and toxicity in adult and pediatric populations. We conclude from the available clinical reports that there must be a higher index of suspicion in the pediatric population to identify exposed infants and children. Improved recognition and identification in both typical and atypical populations will result in better characterization of acute cocaine toxicity.

Analysis of street cocaine samples in nasal fluid by Raman spectroscopy

The principal objective of this work was to demonstrate the capability of Raman spectroscopy to detect small amounts of cocaine in nasal fluid, and to identify the main drug and the most widely used cutting agents. Initially, standard samples were analysed and sampling conditions were studied by comparing different swabs used for the sample collection. Once the most appropriate swab was selected, which permitted a relatively simple detection of the standard cocaine hydrochloride, qualitative analyses of real samples were carried out. Three street cocaine samples were analysed, and the presence of cutting substances was highlighted by the appearance of different bands not corresponding to the ones of the standard cocaine. To identify the substances present in each sample, the spectra of the street cocaine samples were collected and compared with a digital library created on purpose with the spectra of the most common cutting agents. In this case, correlation coefficients permitted to recognize the most important substances presumably present in the samples, and gave an estimation of the purity of the cocaine. However, when nasal fluid was present, its strong signal could overlap or interfere with the smaller signal of the cutting substances, hindering their identification.

Treatment of cocaine cardiovascular toxicity: a systematic review

INTRODUCTION

Cocaine abuse is a major worldwide health problem. Patients with acute cocaine toxicity presenting to the emergency department may require urgent treatment for tachycardia, dysrhythmia, hypertension, and coronary vasospasm, leading to pathological sequelae such as acute coronary syndrome, stroke, and death.

OBJECTIVE

The objective of this study is to review the current evidence for pharmacological treatment of cardiovascular toxicity resulting from cocaine abuse.

METHODS

MEDLINE, PsycINFO, Database of Abstracts of Reviews of Effects (DARE), OpenGrey, Google Scholar, and the Cochrane Library were searched from inception to November 2015. Articles on pharmacological treatment involving human subjects and cocaine were selected and reviewed. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines. Treatment recommendations were compared to current American College of Cardiology/American Heart Association guidelines. Special attention was given to adverse drug events or treatment failure. The search resulted in 2376 articles with 120 eligible involving 2358 human subjects. Benzodiazepines and other GABA-active agents: There were five high-quality (CEBM Level I/II) studies, three retrospective (Level III), and 25 case series/reports (Level IV/V) supporting the use of benzodiazepines and other GABA-active agents in 234 subjects with eight treatment failures. Benzodiazepines may not always effectively mitigate tachycardia, hypertension, and vasospasm from cocaine toxicity. Calcium channel blockers: There were seven Level I/II, one Level III, and seven Level IV/V studies involving 107 subjects and one treatment failure. Calcium channel blockers may decrease hypertension and coronary vasospasm, but not necessarily tachycardia. Nitric oxide-mediated vasodilators: There were six Level I/II, one Level III, and 25 Level IV/V studies conducted in 246 subjects with 11 treatment failures and two adverse drug events. Nitroglycerin may lead to severe hypotension and reflex tachycardia. Alpha-adrenoceptor blocking drugs: There were two Level I studies and three case reports. Alpha-1 blockers may improve hypertension and vasospasm, but not tachycardia, although evidence is limited. Alpha-2-adrenoceptor agonists: There were two high-quality studies and one case report detailing the successful use of dexmedetomidine. Beta-blockers and β/α-blockers: There were nine Level I/II, seven Level III, and 34 Level IV/V studies of β-blockers, with 1744 subjects, seven adverse drug events, and three treatment failures. No adverse events were reported for use of combined β/α-blockers such as labetalol and carvedilol, which were effective in attenuating both hypertension and tachycardia. Antipsychotics: Seven Level I/II studies, three Level III studies, and seven Level IV/V case series and reports involving 168 subjects have been published. Antipsychotics may improve agitation and psychosis, but with inconsistent reduction in tachycardia and hypertension and risk of extrapyramidal adverse effects. Other agents: There was only one high level study of morphine, which reversed cocaine-induced coronary vasoconstriction but increased heart rate. Other agents reviewed included lidocaine, sodium bicarbonate, amiodarone, procainamide, propofol, intravenous lipid emulsion, propofol, and ketamine.

CONCLUSIONS

High-quality evidence for pharmacological treatment of cocaine cardiovascular toxicity is limited but can guide acute management of associated tachycardia, dysrhythmia, hypertension, and coronary vasospasm. Future randomized prospective trials are needed to evaluate new agents and further define optimal treatment of cocaine-toxic patients.

Drug-induced hyperthermic syndromes: part I. Hyperthermia in overdose

Drugs and natural compounds that affect the thermoregulatory system can induce or contribute to hyperthermia when used in excess. Hyperthermia associated with drug overdose is dangerous and potentially lethal. This article reviews the body's process of maintaining thermodynamic equilibrium, and describes the mechanisms by which it is influenced by sympathomimetic and anticholinergic drugs, salicylates, and thyroid replacement medications. Appropriate treatment strategies such as cooling and the administration of counteractive medications are discussed.

[Severe atropine poisoning mimicking acute stroke]

INTRODUCTION

Atropine is a strong antagonist of muscarinic receptors widely used in various diseases because of its anticholinergic action.

CASE-REPORT

We report here a case of accidental poisoning due to ingestion of atropine eyes drops that caused severe neurologic disorders mimicking an acute stroke. Correct diagnosis was finally made by detecting atropine in the cerebrospinal fluid of the patient.

CONCLUSIONS

Atropinic poisoning can induce misleading neuropsychiatric disorders mimicking stroke. Therefore, this diagnosis should be considered in patients presenting an unexplained encephalopathy with anticholinergic manifestations, especially when bilateral mydriasis occurs.

Confirmed glyburide poisoning from ingestion of "street Valium"

BACKGROUND

Pharmaceuticals with little to no abuse potential are often sold surreptitiously as drugs of abuse on the street. Anecdotally, sulfonylureas are suspected to be commonly sold as "street Valium."

CASE REPORTS

Two patients presented with altered mental status and persistent hypoglycemia requiring continuous intravenous dextrose, in the context of suspected attempted benzodiazepine abuse. Supratherapeutic glyburide levels of 1198 and 647 ng/mL were measured in these patients.

CONCLUSIONS

These are two cases of glyburide poisonings from ingestion of "street Valium" that have been confirmed by laboratory testing.

Composition, purity and perceived quality of street cocaine in France

BACKGROUND

There is little knowledge about the composition and cocaine content of street cocaine, nor about what users know about it.

METHOD

373 cocaine users were face to face interviewed between May and December 2006 about the last sample of cocaine they had consumed and residual amounts of the substances actually used were analysed using gas phase chromatography coupled to mass spectrometry (GC-MS). Users rated the perceived quality of their product ("good", "average", "poor"), its "estimated percentage of cocaine" and any cutting agents it contained. Price, quantity, place of purchase (street, dealer's premise, appointment), mode of administration (sniffing, injection, smoking) and the supposed nature of the sample (natural, synthetic, no distinction ever made) were also reported. Perceived quality was modelled using multivariate multinomial regression.

RESULTS

The median cocaine content was 22%. Altogether, 343 samples contained cocaine, among which 75% contained at least one adulterant. The most frequently occurring were phenacetin (54% of the samples), caffeine (17%), paracetamol (14%), diltiazem and lidocaïne (11%). Users showed relatively poor discrimination concerning cocaine purity, and only 12% reported at least one of the detected adulterants. The major determinants of their perception of cocaine quality were: place of purchase, natural origin, price per gram, actual cocaine content and mode of administration.

CONCLUSION

The composition of street cocaine is largely unknown to users. Users' perceptions of cocaine quality are based partly on false beliefs and certain administration modes. This may contribute to favouring very risky practices. The effects of adulterants on users' health should be investigated.

An analysis of cocaine powder in the Netherlands: content and health hazards due to adulterants

AIMS

To report on trends in the content and adulterants present in street cocaine (powder) in the Netherlands and to describe the associated health hazards.

DESIGN AND PARTICIPANTS

Drug consumers handed in samples of cocaine powder from 1999 to 2007 for analysis. Reports were compiled of users' experiences with the samples received.

MEASUREMENTS AND ANALYSIS

Linear regression analysis was used to assess the trend in adulterated cocaine powder across the study period, and comparison of reported adverse effects of adulterated with those of unadulterated cocaine by Fisher's exact test.

FINDINGS

There has been a statistically significant upward trend in the occurrence of adulterated cocaine powder over the years. Adulterated cocaine was associated more frequently with reported adverse effects than unadulterated cocaine. Phenacetin, hydroxyzine and diltiazem appeared to be three adulterants contributing to these adverse effects.

CONCLUSIONS

An increase in adulterants was detected in the analysed cocaine powder between 1999 and 2007. This increase is associated with relatively more adverse effects with cocaine use. The cardiac and hallucinatory effects that were reported more frequently are not understood clearly. Adverse effects are likely to be due to several factors, including interactions of adulterants with cocaine and the route of administration.

Laboratory confirmation of scopolamine co-intoxication in patients using tainted heroin

BACKGROUND

First described in 1995, at least 325 patients with a history of heroin use have since required emergency medical evaluation in several eastern US cities, because of an anticholinergic toxidrome following use of heroin. This co-intoxication has been alleged to result from an atropine-like compound. We report the clinical findings and laboratory analysis of one of several individuals who presented to our Emergency Department during this epidemic.

CASE REPORT

A 23-year-old male was one of 3 patients brought to the Emergency Department due to agitated behavior after insufflating heroin. Following physical and chemical restraint, vital signs were pulse 134 bpm, BP 160/90 mm Hg, RR 24/min, and T 37.3 degrees C. Physical examination was remarkable for dilated pupils 8-9 mm without nystagmus, along with dry mouth, decreased bowel sounds, and flushed dry skin. A bladder catheter was placed and 500 mL of urine was obtained. Electrocardiogram revealed sinus tachycardia only. Additional sedation was required for 12 hours until normal mental status returned. A small sample of the "heroin" used was obtained and analyzed. Scopolamine was confirmed by gas chromatography-mass spectrometry. Further evidence of scopolamine intoxication was supported by identifying scopolamine in the urine of this patient.

CONCLUSION

Gas chromatography-mass spectrometry revealed scopolamine to be the cause of anticholinergic findings in a patient following use of tainted heroin. It is unclear whether scopolamine is an adulterant or contaminant in this heroin. Patients with anticholinergic findings following use of heroin may be co-intoxicated with scopolamine.