How are patients with phenylethylamine exposures managed?
Management of a patient with a substituted phenylethylamine exposure is similar to management of those with cocaine overdose. Attention to the life-threatening clinical effects of psychomotor agitation, hyperthermia, and seizures is paramount. Appropriate supportive care includes intravenous (IV) benzodiazepines to control agitation and muscle rigidity, replacement of lost volume with crystalloids, and active cooling measures. Failure of benzodiazepines (preferably in conjunction with continuous electroencephalogram monitoring) to control rigidity may lead to the need for propofol and/or result in paralysis. Similar to patients with cocaine intoxication, some may experience ischemic chest pain, and the usual protocol of sedation, nitroglycerin, morphine, and an antiplatelet drug is appropriate.
Identification of phenylethylamines typically requires specialized laboratory testing since most will not trigger a positive result on a standard urine immunoassay. Many specialized laboratories have test catalogs on their Web sites listing under the “stimulants panel” which drugs can be identified. However, none of these assays is likely truly comprehensive, and minor alterations or substitutions to the compounds result in new analogs that may not be in the reference laboratory’s identification library.
Case Conclusion
The patient was initially restrained and given 5 mg IV diazepam, which was followed by escalating doses every 5 minutes to a total of 35 mg for effect. He had a rectal temperature of 102.5˚F and was externally cooled after sedation. After 20 minutes, he had a generalized convulsion; an additional 10 mg of IV diazepam terminated the seizure, but he remained hyperthermic at 104˚F. The patient was intubated, placed on a propofol infusion, and admitted to the intensive care unit where his temperature was carefully monitored. The following day his temperature had normalized and he was weaned from the ventilator and discharged to the floor for monitoring. On hospital day 3, he was discharged in stable condition.
Mr Waldrop is a fourth-year medical student at the State University of New York, Upstate Medical University, Syracuse. Dr Nacca is a fellow in medical toxicology, department of emergency medicine, State University of New York, Upstate Medical University, Syracuse. Dr Nelson, editor of “Case Studies in Toxicology,” is a professor in the department of emergency medicine, and director of the medical toxicology fellowship program at the New York University School of Medicine and the New York City Poison Control Center. He is also associate editor, toxicology, of the EMERGENCY MEDICINE editorial board.