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Management of Sympathomimetic Overdose Including Designer Drugs

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Evidence-Based Critical Care

Abstract

Sympathomimetic drugs include a vast array of medicinal compounds and drugs of abuse that act to either mimic or modify the actions of catecholamines (epinephrine, norepinephrine, dopamine) within the sympathetic nervous system. (Table 8.1) Some act as direct agonists at peripheral alpha- and/or beta-adrenergic receptors (e.g. phenylephrine, dobutamine). Others activate the sympathetic nervous system indirectly by either enhancing the release of neurotransmitters (e.g. ephedrine, methamphetamine), or inhibiting neurotransmitter reuptake (e.g. cocaine). Depending on the drug, these effects may predominate in either the central nervous system or at peripheral nerve synapses. Furthermore, many of these drugs modulate activity at serotonin receptors in the central nervous system (e.g. MDMA).

In clinically toxic exposures, hypertensive crisis and profound vasoconstriction can occur that may lead to ischemic injury of critical organs including the heart and brain. Additional cardiovascular effects include tachycardia and cardiac arrhythmias, and vascular injury including aortic dissection and cerebral hemorrhage. Many of these drugs can cause profound hyperpyrexia. Neuropsychiatric effects can include agitation, psychosis and seizures. In severe cases, rhabdomyolysis and disseminated intravascular coagulation may occur. Metabolic derangements may include hyperglycemia, acidosis, and electrolyte imbalance.

Management of these patients may be quite challenging. Treatment strategies should be uniquely tailored to the clinical effects of the drug. GI contamination should be considered early when a toxic oral ingestion is suspected. Attention should be focused on ensuring adequate hydration and correction of metabolic abnormalities. Seizures, agitation and psychosis are generally treated with liberal use of intravenous benzodiazepines. Non-selective alpha/beta-adrenergic blockers should be used aggressively when hypertensive crisis or end organ ischemia is of concern. The use of external cooling techniques is paramount when hyperpyrexia occurs.

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Authors and Affiliations

  1. Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI, USA

    Vivian Lam & Robert W. Shaffer

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  1. Vivian Lam
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  2. Robert W. Shaffer
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Correspondence to Robert W. Shaffer .

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Editors and Affiliations

  1. Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, USA

    Robert C. Hyzy

  2. Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, USA

    Jakob McSparron

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Lam, V., Shaffer, R.W. (2020). Management of Sympathomimetic Overdose Including Designer Drugs. In: Hyzy, R.C., McSparron, J. (eds) Evidence-Based Critical Care. Springer, Cham. https://doi.org/10.1007/978-3-030-26710-0_8

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  • DOI: https://doi.org/10.1007/978-3-030-26710-0_8

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