Methamphetamine intoxication in adults: Rapid overview of emergency management

To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222 for the nearest regional poison control center. Contact information for poison control centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links).

General

May be abused by nasal, oral, or IV route

Rapid onset of symptoms with long (~24 hours) duration of action

Clinical features

History may be difficult to obtain

Severe agitation can occur

Sympathomimetic toxidrome frequently present:

CNS stimulation (agitation, delirium, or acute psychosis)
Tachycardia
Hypertension
Dilated pupils (mydriasis)
Diaphoresis

Hyperthermia (variable; may be severe)

Laboratory analysis

Routine testing in poisoned patients

Fingerstick glucose
ECG to assess for conduction system impairment
Acetaminophen and salicylate levels
Pregnancy test in female patients of childbearing age

Basic electrolytes, BUN, creatinine

Metabolic acidosis, acute renal failure, and hyperkalemia may be seen in severe toxicity

Creatinine phosphokinase, serum lactate, aminotransferases, coagulation studies

Treatment

Agitation (control with aggressive sedation)

Benzodiazepines are first-line therapy; may need large doses
For severe agitation:
- Lorazepam, 4 mg IV, may repeat every 8 to 10 minutes, titrate to sedation
- Diazepam, 5 to 10 mg IV, may repeat every 8 to 10 minutes, titrate to sedation
- If lacking IV access, midazolam 5 to 10 mg IM, may repeat every 10 minutes, tit rate to sedation
Consider other agents (refer to UpToDate text) in cases of benzodiazepine failure

Paralysis and tracheal intubation may be necessary; succinylcholine should not be used for rapid sequence intubation

Critical hypertension

Benzodiazepines are first-line therapy (refer to dosing above)
Nitroprusside: start at 0.25 to 0.5 mcg/kg per minute, titrate to effect
Phentolamine: 1 to 2.5 mg IV for initial dose, titrate to effect, may repeat every 5 to 15 minutes with doses up to maximum 15 mg per dose
Avoid pure beta blockers; we suggest avoiding combined alpha- and beta-blocking medications in acute poisoning

Hyperthermia

Sedation with benzodiazepines (refer to dosing above); do not give antipyretics
Evaporative cooling measures
Cooling blankets
Neuromuscular paralysis in severe cases

IV: intravenous; CNS: central nervous system; ECG: electrocardiogram; BUN: blood urea nitrogen; IM: intramuscularly.

Graphic 73681 Version 14.0

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Methamphetamine intoxication in adults: Rapid overview of emergency management