20
Treatment
Hyperadrenergic Symptoms of Stimulant Intoxication
63. When patients present with hyperadrenergic symptoms, clinicians
should provide ongoing monitoring and management of vital signs—
especially heart rate and blood pressure—to prevent complications
that may result from untreated sympathomimetic toxicity (CC-S).
64. Clinicians should treat patients in a stimulant-induced
hyperadrenergic state with gamma-aminobutyric acid (GABA)-
ergic agents (eg, benzodiazepines, phenobarbital, propofol);
benzodiazepines can be considered first-line treatment for this
purpose (L-S).
65. If the hyperadrenergic state persists despite appropriate
improvement in agitation and neuromuscular hyperactivity following
treatment with benzodiazepines or other GABAergic agent, clinicians
can consider adjunctive treatment with the following medications:
a. A beta blocker with concomitant alpha-1 antagonism (eg, carvedilol, labetalol;
M-C).
b. An alpha-2 adrenergic agonist (eg, dexmedetomidine for severe symptoms,
clonidine for mild to moderate symptoms; M-C).
c. Where beta blockers are contraindicated, clinicians can consider other
pharmacological options such as calcium channel blockers, alpha-1 adrenergic
antagonists, alpha-2 adrenergic agonists, and nitric oxide-mediated vasodilators,
with consideration of other clinically relevant signs and symptoms (M-C).
d. While calcium channel blockers, alpha-1 adrenergic antagonists, alpha-2
adrenergic agonists, and nitric oxide-mediated vasodilators may be most
beneficial in treating hypertension and vasospasm, clinicians should be alert
to potential side effects, including poor control over tachycardia or reflex
tachycardia (M-S).
66. If a patient with stimulant intoxication is experiencing a hypertensive
emergency, clinicians should:
a. use short-acting agents such as sodium nitroprusside, phentolamine, or
dihydropyridine calcium channel blockers (VL-S);
b. avoid long-acting antihypertensives to avoid abrupt hemodynamic collapse
(VL-S); and
c. use nitroglycerin if the patient exhibits signs or symptoms of cardiac ischemia
(VL-S).
Acute Issues and Complications
Chest Pain
67. For patients experiencing chest pain during stimulant intoxication,
clinicians should initiate treatment for the underlying intoxication
with GABAergic agents (eg, benzodiazepines, phenobarbital,
propofol) as long as there are no clinical contraindications (M-C).
