PSYCHOBEHAVIORAL DISORDERS■ Treatment is positive pressure oxygenation, intubation if indicated, and
use of PEEP.
OPIOIDWITHDRAWAL
■ Symptoms/exam: Include anxiety, nausea/vomiting, lacrimation, rhinor-
rhea, papillary dilatation, piloerection, diaphoresis, diarrhea, yawning, and
insomnia
■ Treatment: Can give clonidine, antiemetics, antidiarrheal agents, and refer
to treatment center; buprenophrine best used in conjunction with a drug
recovery center
Phencyclidine (PCP) and Hallucinogens
PCP is a dissociative anesthetic that is structurally related to ketamine. It is a
glutamate agonistat the NMDA (N-methyl-D-aspartate) receptor. Dextro-
methorphanhas similar effects to PCP.
SYMPTOMS/EXAM
■ Peak effects occur approximately 15–30 minutes after inhaling PCP and
can be up to 2 hours after oral doses.
■ Symptoms/Exam: Variable. Patient can present with behavioral problems
(anger, aggression, irritability), impaired judgment, vertical or horizontal
nystagmus, hypertension, tachycardia, CNS depression or stimulation,
physical violence, catatonia, coma, or seizures. Pupil size is also variable.
DIFFERENTIAL
Alcohol withdrawal or intoxication, trauma, meningitis, hypoglycemia, hypoxia,
sedative/hypnotic withdrawal, acute psychosis, other intoxication (cocaine,
amphetamine)
DIAGNOSIS
Diagnosis is clinical. Toxicology studies are not useful (chronic PCP users can
test positive long after last use).
TREATMENT
Treatment is supportive. Give benzodiazepines for seizures, IV fluids for rhabdo-
myolysis, cooling for hyperthermia and activated charcoal for oral PCP use.
Other medical causes need to be ruled out.
OTHERHALLUCINOGENS
See Table 16.4.
A 30-year-old woman on chronic benzodiazepines presents with auto-
nomic hyperactivity, tremulousness, nausea/vomiting, transient visual, tactile,
and auditory hallucinations, and proceeds to have a grand mal seizure. What
is the most important consideration in the treatment of this patient?
This is benzodiazepine withdrawal, and benzodiazepine administration is
indicated. This patient can be very tolerant and may require large doses for treat-
ment of her symptoms.