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Methamphetamine Intoxication Management — MRCPsych Paper B MCQ

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ModerateSubstance MisuseMethamphetamine Intoxication ManagementMRCPsych Paper B

A 31-year-old man is brought to the emergency department 2 hours after smoking crystal methamphetamine. He is severely agitated and diaphoretic. His temperature is 40.1°C, pulse 148 beats/min and blood pressure 176/104 mmHg. His pupils are dilated, oxygen saturation is 98% on air and there is no respiratory depression. Following an initial ABC assessment, which management strategy is most appropriate?

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Correct answer: D — Titrated benzodiazepines, active cooling, intravenous fluids and cardiorenal monitoring

This is severe methamphetamine intoxication producing a sympathomimetic toxidrome: marked agitation, diaphoresis, hyperthermia, tachycardia, hypertension and mydriasis. Benzodiazepines are first-line for agitation and reduce excessive sympathetic and muscular activity. Hyperthermia requires immediate active cooling, while intravenous fluids and monitoring should address dehydration, dysrhythmia, myocardial ischaemia, electrolyte disturbance, rhabdomyolysis and acute kidney injury. Haloperidol may sometimes be used as an adjunct for persistent psychosis or agitation, but it is not the preferred sole initial treatment in this hyperthermic patient. Methadone treats opioid dependence, while naloxone is indicated for opioid-induced respiratory depression, which is absent. Activated charcoal is inappropriate after smoked methamphetamine and would create aspiration risk in a severely agitated patient.

Reference: Wodarz N et al. Evidence-Based Guidelines for the Pharmacological Management of Acute Methamphetamine-Related Disorders and Toxicity. Pharmacopsychiatry. 2017;50(3):87–95. https://pubmed.ncbi.nlm.nih.gov/28297728/