Lysergic acid diethylamide toxicity

Background

  • Also known as d-lysergic acid diethylamide and LSD

Mechanism

  • Similar to chemical properties of serotonin
    • 5-HT2 agonists, mediating excitatory neurotransmitter release.[1]
  • LSD also binds to dopaminergic receptors, contributing to its psychogenic affects.[2]

Pharmacology

  • Known as one of the most potent psychoactive drug, doses of minimum of 25μg. Doses of 1 to 1.5 μg/kg produce psychedelic effects, with the “optimum” dosage for a typical fully unfolded LSD reaction is estimated to be in the range of 100–200 μg.
  • Route of administration can be PO (most common), IM, or IV.[3]
    • PO: Usual Dose 100-250μg, Onset 30-45mins, Peak effect 1-2.5hrs, Total duration 9-12hrs
    • IM: Usual Dose 100-250μg, Onset 15-20mins, Peak effect 1hr, Total duration 9-10hrs
    • IV: Usual Dose 40-180μg, Onset 3-5mins, Peak effect 1hr, Total duration 9-10hrs
  • Tolerance to LSD-25 builds up over consistent use and cross-tolerance has been demonstrated between LSD, mescaline and psilocybin.[4]

Clinical Features

  • Effects begin around 20-40 minutes after injection
  • Euphoria
  • Dizziness
  • Visual and auditory hallucinations
  • Synesthesia ("seeing sounds" and "hearing colors")
  • Paranoia
  • Acute panic reactions / agitation
  • Effects taper off after about 6-8 hours, depending on dose

Differential Diagnosis

Hallucinations

Serotonin-Like Agents

Enactogens

Dissociative Agents

Plant-based Hallucinogenics

  • Marijuana
  • Salvia
  • Absinthe
  • Isoxazole Mushrooms
  • Hawaiian baby woodrose (Argyreia nervosa)
  • Hawaiian woodrose (Merremia tuberosa)
  • Morning glory (Ipomoea violacea)
  • Olili- uqui (Rivea corymbosa)

Organic causes

Other Toxicologic Causes

Psychiatric Causes [5]

Evaluation

  • Usually clinical, based on history and presentation

Most blood and urine tests are restricted to research and unavailable for clinical usage

Research Tests

  • Found in blood specimens (6–12 hours) and urine (2–4 days) after usage
  • Metabolite (2-oxo-3-hydroxy-LSD) present in urine for a longer time than LSD itself.[6]

Management

  • Principally supportive
  • Assess for signs of trauma or exposure
  • Assure patient and staff safety
  • Agitation:
    • Ativan 1-2mg IV, titrate to effect
    • Haloperidol 5-10mg IV, titrate to effect (use as 2nd line agent as may lower seizure threshold)

Consider co-ingestions, hypoglycemia, and risk for rhabdomyolysis[7]

Disposition

  • Simple LSD ingestion can be safely discharged after a period of observation, once patient has returned to sober baseline and has a safe disposition plan (~4-6 hours)
  • Symptoms lasting longer than 8-12hrs can be managed in an observation unit or admitted

See Also

External Links

References

  1. Ly, B. "Hallucinogens", Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th Ed. Pgs 2010-2012
  2. Marona-Lewicka D, Thisted RA, Nichols DE (2005). "Distinct temporal phases in the behavioral pharmacology of LSD: Dopamine D2 receptor-mediated effects in the rat and implications for psychosis". Psychopharmacology 180 (3): 427–435.
  3. Passie, T. "The Pharmacology of Lysergic Acid Diethylamide: A Review". CNS Neuroscience & Therapeutics, Volume 14, Issue 4, pages 295–314, Winter 2008
  4. Passie, T. "The Pharmacology of Lysergic Acid Diethylamide: A Review". CNS Neuroscience & Therapeutics, Volume 14, Issue 4, pages 295–314, Winter 2008
  5. Visual Hallucinations: Differential Diagnosis and Treatment. PMID PMC2660156
  6. Passie, T. "The Pharmacology of Lysergic Acid Diethylamide: A Review". CNS Neuroscience & Therapeutics, Volume 14, Issue 4, pages 295–314, Winter 2008
  7. Glaspy, J. "Drugs of Abuse". Emergency Medicine Manual, 6th Ed. Chapt 103, Pgs 502-504.