Handcuffed and escorted by police, Kyle Reid, 38, arrives in your ED confused, agitated, and diaphoretic. The police tell you that they found him standing in the middle of a major highway, screaming obscenities and making threatening gestures to passing motorists with no discernible motivation. Bystanders called 911. Four police officers responded to the call and, after assessing the situation, believed Mr. Reid was either under the influence of illicit drugs or in need of psychiatric attention. He had to be subdued after he attacked the officers. Because he's still combative, he's given an injection of haloperidol.
When you examine Mr. Reid, you find that his airway is patent and he shows no signs of trauma. His breath sounds are clear bilaterally; he has palpable, strong peripheral pulses; and his pupils are equal and dilated to 6 to 7 mm bilaterally. He moves his extremities purposefully, though he exhibits some muscle rigidity. His skin is flushed, diaphoretic, and hot to touch. His abdomen is soft and nontender to palpation. Mr. Reid's vital signs are heart rate, 160 beats/minute; BP, 200/110 mm Hg; respirations, 44; temperature, 104.8[degrees] F (40.4[degrees] C) rectally.
As the staff undresses him, three bags of yellowish, crystalline, chunky material are found in his pockets and turned over to the police. Throughout the night he gradually becomes more lucid and cooperative, with a Glasgow Coma Scale score of 15. He admits he's been using "crystal," a street name for methamphetamine, and doesn't remember much of last evening. He says he hasn't slept in a week. When he's told what happened last night, Mr. Reid expressed remorse about his behavior.
What is methamphetamine?
Methamphetamine, a powerful central nervous system stimulant, is a synthetic analogue of the amphetamine family and a highly addictive street drug. Intoxication results from the increased stimulation of dopamine and nor-epinephrine receptors in the brain.1 The flood of dopamine enhances mood and movement, creating a general sense of well-being and excitability in the user. Common street names include "crystal meth," "ice," "crank," "stove top," "glass," "speed," and "lemon drops."2,3
The National Association of Counties surveyed hospitals in all 50 states in 2005, and 47% of respondents cited methamphetamine as the top illicit drug seen in presentations in their EDs.4
Methamphetamine is produced in thousands of illicit labs throughout this country. Drug Enforcement Administration records indicate an increase in methamphetamine lab seizures, from 263 in 1994 to over 7,500 in 2002, representing a 30-fold increase.5,6 Labs vary in size and are found in private homes, garages, hotel rooms, storage facilities, fields, car trunks, and public campgrounds. Large labs found in California and northern Mexico, known as "super labs," are capable of producing 10 pounds of methamphetamine during each production cycle; the smallest labs, known as "box labs," typically produce an ounce or less.5
Methamphetamine labs produce their product quickly with easily obtained household products. Recipes can be found on the Internet with little difficulty and the most common ingredients-pseudoephedrine, iodine, lithium from batteries, red phosphorus, and anhydrous ammo-nia-are easy to buy.2 Ingredients often vary by geographic location. The "Nazi" method uses anhydrous ammonia and lithium, and may be more common in the Midwest and agricultural states.7 The cold process replaces anhydrous ammonia and lithium with iodine and red phosphorus and is frequently used in areas where fertilizer is less readily available. Both methods require ephedrine, which can be extracted from pseudoephedrine-containing nasal decongestants.
Although methamphetamine labs vary in size and process, all labs use exceptional toxic chemicals and produce hazardous wastes. Each pound of methamphetamine produces 5 to 7 pounds of toxic waste.5 Methamphetamine producers (also known as "cookers") often dispose of waste by dumping it into rivers, streams, septic systems, drains, or on the ground, risking contamination of the water supply and soil.8,9
Methamphetamine cooking produces toxic fumes, which can spread outside of the lab through air ducts and ventilation systems. During the cooking process, a fine layer of methamphetamine is left on all surfaces, contaminating the lab and often leaving the building uninhabitable.10 High levels of contamination have been found in buildings months after labs have been closed down.7 Improper storage, handling, or mixing of ingredients can cause fire or explosion, exposing both those involved in the drug manufacture and responding law enforcement and emergency medical service personnel.
The methamphetamine high
Methamphetamine is made into a crystal-like material or powder that may appear yellow or white. The drug can be ingested in a variety of ways. Inhalation (smoking) and intranasal (snorting) consumption are the most common routes of use; however, methamphetamine can be injected I.V. and administered rectally as well.11
Methamphetamine stimulates the release of high levels of dopamine into the region of the brain responsible for the feeling of intense pleasure, resulting in a euphoria that users seek to reexperience with subsequent use.12 Tolerance for the drug develops as use becomes chronic and addiction develops quickly-often with the first use. Users ingest higher doses of the drug, increase the frequency of use, or change their route of ingestion in an attempt to intensify the desirable effects of the drug.11 The initial rush may be instantaneous if injected, or felt in as little as 5 minutes via the intranasal route. The euphoric effects may last up to 12 hours. Users report feeling alert and energetic.
Problems develop with chronic use as addicts cease to eat and sleep, binging on the drug almost continually (referred to as a "run") and injecting the drug as frequently as every 2 hours until they can no longer function, so they crash. Users may sleep for days and appear to be dead.11
Unfortunately, chronic use and addiction causes structural changes in the brain's dopamine pathways, leading to the inhibition of dopamine reuptake. Severe depression and psychosis in users is a common finding. Other adverse effects, such as seizures, myocardial infarction, dysrhythmias, and stroke may occur, as well as hyperthermia and rhabdomyolysis.13 Other symptoms include nausea, irritability, insomnia, dry mouth, dilated pupils, diaphoresis, and tremors.11,12 Chemical contamination and burns can result from production mishaps. Abusers frequently pick at their skin and may present with skin abscesses. Damage to teeth stems from the corrosive chemical precursors used to make methamphetamine. All of these consequences result in increased admissions to EDs, burn centers, and ICUs.11
Care of first responders
From January 1, 2000, until June 30, 2004,1,791 methamphetamine lab events were reported to the Hazardous Substances Emergency Events Surveillance system, resulting in injuries to 947 first responders and members of the general public.14 The most frequently reported injuries were respiratory irritation (39%), followed by headache (26%), eye irritation (8%), and burns (8%). Injuries required medical treatment 43% of the time.
Fifty-six percent of the injuries reported were to law enforcement officers.14 Police officers often lack the personal protective equipment that firefighters use and may not know they're entering a hazardous environment. Law enforcement often is unaware of the presence of a methamphetamine lab until an accident occurs. First responders are subject to injuries secondary to byproduct contamination, toxic fumes, fire and explosion, or purposeful contamination by perpetrators attempting to avoid arrest.2,8
Injuries to first responders are often due to inhalation of toxic fumes. Methamphetamine fumes can cause shortness of breath, bronchospasm, pulmonary edema, eye irritation, confusion, dizziness, nausea and vomiting, headache, and throat irritation.2,5,7 Contact with contaminated surfaces in the lab can produce skin irritation and burns. Involved personnel should be decontaminated at the scene by scrubbing under running water for 15 minutes. Clothes should be bagged.15 First responders who don't use protective equipment designed to shield their uniforms and shoes, as well as those who don't follow decontamination procedures at the scene, risk contaminating ambulances, fire trucks, and patrol cars, as well as fellow responders and hospital facilities.
Care of users
Patients experiencing methamphetamine intoxication, such as Mr. Reid, can be unpredictable and volatile. "Tweakers," those who have been abusing methamphetamine continually, most likely haven't slept in many days. They're often irritable, and they may have paranoid thoughts and exhibit violent behavior. First responders and other healthcare professionals should approach these patients with caution, while maintaining a safe distance. Keep stimulation such as noise and bright lights to a minimum, and keep your voice at an even pitch.16 Approaching a methamphetamine tweaker is never the time to argue with him. Enlist the help of hospital security or police whenever possible, and avoid antagonizing the patient.
Mr. Reid is triaged directly to a treatment room in the ED. Place him on a cardiac monitor, automatic noninvasive BP machine, and pulse oximeter. Establish a large-bore I.V. for an infusion of 0.9% sodium chloride solution, and administer lorazepam as ordered for agitation.
Obtain blood specimens for complete blood cell (CBC) count; chemistry panel; cardiac markers; and alcohol, sali-cylate, and acetaminophen levels. Also draw specimens for two sets of blood cultures and place the specimens on hold pending the CBC result. Because of Mr. Reid's altered mental status and fever, bacterial meningitis was considered in the differential diagnosis. An indwelling urinary catheter was placed and a sample of dark amber urine was sent for a drug screen, which was positive for amphetamines.
Now that Mr. Reid's agitation is controlled, you can perform an ECG, which shows no signs of injury, ischemia, or infarct. He has a regular, narrow-complex tachycardia with a rate consistently between 150 and 170 beats/minute. His Spo2 is 100% on supplemental oxygen and he remains hypertensive. Administer I.V. labetalol as ordered to control catecholamine-induced hypertension.
All Mr. Reid's lab test results are within normal limits except for blood urea nitrogen (BUN), creatinine, and creatine kinase (CK), which are elevated, and the urine drug screen, which is positive for amphetamines. Because the acetaminophen level test is negative, you administer an acetaminophen suppository to reduce fever. A computed tomography scan of the brain rules out intracranial hemorrhage.
The healthcare provider decides against standard gastric decontamination because no one knows when Mr. Reid took the methamphetamine, which is absorbed readily at the time of ingestion. Activated charcoal administration is most helpful if given within 1 hour of methamphetamine ingestion.
His tachycardia is a result of both the increased sympathetic tone and Mr. Reid's hyperthermic state. The labetalol reduced his BP and heart rate to within normal limits. The health care provider also decided to treat Mr. Reid's tachycardia with I.V. fluids and his hyperthermia with cooling measures. Without supportive treatment, Mr. Reid is at risk for decreased cardiac output, myocardial infarction, and cardiogenic shock. The intensive care residents were called to assess Mr. Reid for admission to the medical ICU.
Methamphetamine toxicity also puts the patient at risk for developing rhabdomyolysis, or the breakdown of skeletal muscle fibers and the release of toxic cellular contents into the circulation. The most well known causes of rhabdomyolysis are tissue trauma (such as crush injuries or burns) or tissue compression (such as compartment syndrome or prolonged immobilization). Methamphetamine overdose and Mr. Reid's ensuing hyperexcitability, exertion, and increased metabolic rate are a lesser-known cause of rhabdomyolysis, accounting for about 7% of cases.17 Muscle tremors and the concentrated color of Mr. Reid's urine in the presence of the elevated BUN, creatinine, and CK with negative troponin all suggest muscle cell breakdown and the threat of acute renal failure.13,18 A urinalysis was sent and was negative for myoglobin. Early fluid resuscitation was most likely responsible for preventing further renal damage.
Hyperthermia in methamphetamine toxicity generally isn't a fever resulting from systemic infection, but rather from increased metabolic demands secondary to increased motor activity and hypothalamus dysfunction.19 Mr. Reid's CBC count was normal. Because neurotransmitters such as dopamine, norepinephrine, and serotonin contribute to regulating the hypothalamus, and subsequently body temperature, drugs such as methamphetamine, which alter the hypothalamic levels of these neurotransmitters, can also ultimately alter the body's ability to maintain normal temperature. Body temperature will rise and eventually exhaust supplies of adenosine triphosphate. Energy production in skeletal muscle becomes impaired, again increasing the risk of rhabdomyolysis.17 Mr. Reid's diaphoresis is the body's attempt at heat dissipation, though the resulting fluid losses could potentiate persistent hyperthermia if rehydration isn't achieved.
Attaining medical stability
Mr. Reid was admitted to the medical ICU, and over the next 24 hours his vital signs continued to normalize. His temperature responded to a temperature-regulating blanket and the I.V. fluids and stabilized at 99.5[degrees] F (37.5[degrees] C). His heart rate also responded, and by the next morning he was in normal sinus rhythm with a rate of 92 beats/minute. His BP stabilized at 144/82 mm Hg.
He needed lorazepam during the night to help with his anxiety and tremors and to prevent a potential seizure. He continued to show no signs of myocardial ischemia, injury, or infarct.
Mr. Reid was medically stable, although he still had a serious addiction to methamphetamine. Psychiatric and social services were consulted. He agreed to speak with the psychiatric crisis nurse on call. She was satisfied that he wasn't suicidal or homicidal when not under the influence of the drug and didn't need involuntary commitment. However, she recommended referrals to inpatient drug rehabilitation. Mr. Reid declined this service and signed himself out of the hospital against medical advice the following day. (The police were notified but had his address and didn't ask for Mr. Reid to be held.)
Recognize the signs
As methamphetamine use spreads across the United States, ED and critical care nurses must be aware of the signs and symptoms of methamphetamine abuse. Understanding the physical and psychological effects of methamphetamine on the body lets you develop a more effective, holistic plan of care for these patients.