drug induced coma & abusive drugs dr. ml tse. basic concept brain activity = interplay of neuron...
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Drug Induced Coma&
Abusive DrugsDr. ML Tse
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Basic Concept
• Brain activity = Interplay of neuron depolarization
• Ion channel activities
• Voltage-gated IC & Ligand-linked IC
• Opening / Closing Production / Destruction control by receptor activites
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Molecular Basics
• Receptors– Ligand linked ionophore– G-protein coupled Cyclase activation ion
channels– Steroid hormone receptors DNA– Tyrosine kinase receptor (Insulin, growth
factors)
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Cellular Basics of Neurotransmission
• Neurotransmission +/-- Ionophores
Na,Ca,
K, Cl
Repolarization
Rest-70mV
Depolarization
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Cellular Basics of Neurotransmission
• Neuromodulation– Receptor mediated– Non-receptor mediated NO,
CO
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Basic Neuropharmacology
• Amino Acid Transmitters major CNS transmitters– Excitatory
• Glutamate (Glu)• Aspartate• Cystate• Homocystate
– Inhibitory -aminobutyric acid
(GABA)• Glycine• Taurine -alanine
• Purinoreceptors• Inhibitory
• Adenosine
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Glutamate Receptors
• AMPA (-amino-3-hydroxy-5-methyl-4-isoxazole propionate)
• NMDA (N-methyl-D-aspartate)
• Kainate
• mGlu: Metabotrophic receptor
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N-methyl-D-aspartate Receptor
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GABAA Receptor
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Convulsant
HydrazinesIsoniazid
Glutamate Glutamic Acid
Glutamic acid decarboxylasePyridoxal Phosphate
GABA
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Adenosine Receptor
• Diffuse CNS Inhibition “Blake” effect
• Sleep induction• Endogenous anti-
convulsant • xanthines
antagonist
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Serotonergic Pathways
• 5 HT – Midline of pons – locus ceruleus,
interpeduncular nucleus– Pacemaker like 1—5
spikes / sec– Inhibitory modulation– 2 systems: fine axons and
beaded large axons– Fine 5HT axons damage
by MDMA
– Pineal gland
Raphe pons
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NE pathways
• Locus Ceruleus in caudal pons
• 5 major tracts ,12, 1 Morphine, endorphins,
2 agonist (clonidine)Firing
• Amphetamines, TCA, Opioid withdrawal Firing
• Global orientation to external stimuli
Locus Ceruleus
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Dopaminergic Pathways
• Complex : utra short ; intermediate length; long systems-midbrain to neostriatum and limbic system
• D1 – 5 R• Learning behaviour,
memory, motor• ?Final common pathway
for addiction• Amphetamine, cocaine
antipsychotics
ventral tagamental
Substantia nigra
Prefrontal cortex
limbic
Putamencaudate
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Cholinergic Pathways
• Poorly understood• Acetycholine• Diffuse innervation• Cognition,
consciouness• Anti-cholinergics,
organophosphates• Alzheimer’s ?
cholinergic dysfunction
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Consciousness
Prefrontal cortex
Limbic system
Hyppocampus
Basal Ganglions
Sensory Afferent
Background A
rousal
Efferent
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Drug Induced Coma
• Direct effect on neurons– Receptor mediated– Non-receptor mediated
• Secondary Insult due metabolic disturbance– Seizure, coma, death as the final common
pathway of intoxication
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Management• Decontamination: ?cyanide• ABC, prevent secondary insult• H’stix• History• Toxidrome:
– Focal signsCT brain – Opioid, DUMBBELL, Serotonergic, Anti-cholinrgic,etc, convulsants….– Trial of naloxone– Stable unconscious Vs Unstable Unconscious– ECG: rate, QRS, QTc– Therapeutic use of other antidote
• ABG: ?MUDPILE; Osmolar gap,– Lactic acidosis with normal PaCO2 ?cellular asphysants
• Panadol level-co-ingestion?1 in 500• CXR, AXR• ??Urine screening
• Supportive
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Abusive Substances
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Sedative-Hypnotics
• Benzodiazepines (since 1955)– GABAA R agonist Cl channel sedative,anxiolytic,
muscle relaxing, amnesic– Peripheral benzodiazepine receptors (whole body):
mitochondrial outer membrane – adrenal, pituitary, reproductive, heart ; RBC
• GHB -hydroxybutyrate (since 1960s)– Bodybuilding, Mood-enhancer, Date-rape– Receptor in basal ganglion GH, enkephalin dopamine
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Benzos OD• Sleep like toxidrome• Children: ataxia• Paradoxical CNS effects: delirium, psychosis,
nightmares with age• Death due to combined overdose• Dx co-ingestion & supportive Mx• Routines screening not helpful:
– False –ve: • active metabolites, • triazolam & aprazolam: low active serum concentration• Flunitrazepine, clonazepine –ve immunoessay
– +ve result:• Co-ingestion common• Co-morbidity
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BenzosOD
• Routine flumazenil not recommended• Contraindications:
– Seizure Hx– Co-ingestion – Long term user– ECG evidence of TCA– Abnormal vitals
• Withdrawal– Anxiety, panic attacks, headache, tremors,
paresthesia, seizure
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GHB
• Toxidrome: cyclical coma:deep coma/agitated episodes, resp depression, rigidity, myoclonus face limbs, bradycardia
• Typically pull out the ET tube and fully awake in 6 hrs
• Flumazenil not consistent
• Withdrawal?
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Party Pills
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Opioid
• Opium, extract of poppy (Papaver somniferum) contains ≥10% morphine
• Heroin (diamorphine) since 1874, marketed by Bayer 1898, preferred : euphoric, rush
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Opioid Receptors
: euphoria, analgesia, respiration: miosis, spinal analgesia: ?analgesia, dopamine nigrostriatal : not considered as opioid R, ,: ??• G-protein linked• Euphoria, addiction : Dopamine release &
-R stimulation in mesolimbic system
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Clinical Presentation
• M & M more due to IV use, cutting agent, contaminant, poor health
• Overdose: – Typical toxidrome
• Fentanyl: muscle rigidity, urine screen -ve• Dextromethorphan: anti-cholinergic• Methadone: choreoathetosis
– pulmonary edema• Direct effect• Neurogenic: acute withdrawal on naloxone, high PaCO2• Forceful inspiration against closed glottisnegative
intrathoric pressure
• Withdrawal• Bodypacker
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Pitfalls in Mx
• Urine immunoessay– +ve codeine, poppy seed – --ve synthetic opioid
• Naloxone– Bag-valve mask ventilation– Small incremental dose
0.1mg– Adequate respiration as
end-point– Infusion: 2/3 effective
bolus / hour
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Party Drugs
• Amphetamines
• LSD
• Ketamine
• Cocaine
• Nematazepam
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Clinical Presentation
• Acute– Bad trips– Injury– Specific problems related to the substance
• Chronic– Poor immune, poor health– Psychiatric: brain damage?
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• Ecstacy– May or may not
contains MDMA – ketamine, MA,
barbituate, benzo, panado
– Different strength
• Unpredictable effect
Party Pills
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Trip
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Good Trip
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Bad Trip
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Amphetamines
• Speed sulph, uppers, whizz: powder form
• Ice: crystalized form of metamphetamine
epinephrine
amphetamineMethamphetamine
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Amphetamines
• 179 entries of designer amphetamines
Phenylethylamines I Have Known And Loved
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Amphetamine
• Presynaptic Dopamine and Catecholamine release
• Peripheral and Sympathomimetic
• Central:– NE Alertness – DA Glu behavioral and psycho – 5-HT (high dose) thermoregulation,
psychosis
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MDMA( 3,4-
methylenedioxymethamphetamine)
serotoninMDMA
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MDMA
• Ecstasy, XTC, Adam
• Stimulant(amphetamine) + mild hallucinogenic (weak LSD)
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Clinical Presentation
• Tweaking
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Clinical Presentation
• Heat stroke• Intracerebral haemorrhage• Dysrrhythmias• Cerebral infarct• Myocardial ischaemia• Pneumothorax, pneumomediastinum• Hyponatraemia• Rhabdomyolysis• Injury• Fine-5HT neuron damage in braincognitive,
psychiatric, behavioral problem
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Rx
• Benzodiazepine: usually at toxicological dose
• Haloperidol
• Minimize physical restrain
• Cooling
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Cocaine
• Leaves of coca plant in S. America
• Use in religious rituals since 6th century
• Identified in 1857• Add in Coca-cola• >6 Million >12y.o.
Americans had tried
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Cocaine powder
Crack cocaine
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Cocaine
• Fast Na channel blockage
• Catecholamine reuptake inhibition
• CNS stimulation: cortexbrain stem– DA reuptake inhibition excitatory amino acids
• Activemetabolites: benzoylecgonine, norcocaine
• More dangerous with alcohol
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Clinical Presentation
• Hyperthermia• Myocardial ischaemia, dysrhythmia, aortic
dissection• ICH, Cerebral infarction, seizures• PneumoT / M, Pulmonary edema• Rhabdomyolysis• Gut ischaemia• Cardiomyopathies
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Cocaine
• Benzo for agitation, HT
• IV Nitrate, phentolamine, morphine,verapamil for ACS
• Diltiazem, Verapamil for atrial arrhythmia
• NaHCO3, lignocaine, amiodarone for ventricular arrhythmia
• Torsade (K channel blocking): MgSO4
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Hallucinogens
• Lysergamids – LSD: D-lysergic acid diethylamide
• Indolealkylamines– Ibogaie– Psilocybin
• Phenylethylamines– Mescaline, MDMA
• Tetrahydrocannibinoids– Marijunana– Hashish
• Anticholinergics– Jimsonweed(Datura stramonium)
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LSD
• 1938 by Albert Hoffmann, popularized in 60s
• 5-HT2 antagonist – diminish filtering of sensory input hallucination
Glutamate ,D1, D2• Indirect sympathetic stimulation in locus
ceruleus• Psychological effect varies on dose,
emotionexpectations, environment.
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LSD
• In the form of blotting paper
• “Fing-Ba”
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Clinical Presentation
• Bad trip: panic reactions, frightening illusions, sense of loss of self-control
• Hyperthermia• Mydriasis, HT, tachycardia, diaphoresis–
usually less severe• Mx:
– Benzodiazepine +/-- haloperidol– Minimize physical restrain– Rx hyperthermia and rarely rhabdomyolysis
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Ketamine
• Related to Phencyclidine (Angel dust)
• Dissociative anaesthetic
• Microwaving Ketelar
• Out-of body feel
• NMDA blockage
• Biogenic amine reuptake blockage: NE DA
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• Ketamine inhalation device
• Ketamine powder
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Clinical Presentation
• Psychomotor disturbance• Delirious to comatose• Nystamus• Vomiting• Injury• Sympathetic / muscarinic symptoms• Mx: Benzo +/-- Haloperidol , quiet environment• Brain damage– Olney’s lesion: NMDA
antagonist neurotoxicity.