The Agony of Ecstasy in PICU and Other Tales... a Play in 3 Acts - NTI 2016 Session

Street drugs are only one of the hazards children are exposed to. We can't protect them all the time so knowing what they might be doing - and what it might do to them - is essential to keeping them alive.

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The Agony of Ecstasy in PICU and Other Tales... a Play in 3 Acts - NTI 2016 Session

It used to be that children admitted to the PICU following a drug ingestion had gotten into Grandma's purse, or climbed up on the bathroom sink, or maybe tasted something from under the kitchen sink. Older kids might have swallowed a handful of Tylenol after a fight with a parent or boyfriend. And sometimes a teenager sampled a little of everything in the family liquor cabinet and was well beyond drunk. Often, it was easy to estimate how much of what was swallowed and when. Caring for them post ingestion was pretty well scripted and there were only occasional serious sequelae.

But in recent years more adolescents have been experimenting with designer drugs, the so-called "rave drugs" that have a multitude of names and an equally varied list of ingredients. These drugs have found their way into all segments of society, from big city to small town and availability cuts across the socioeconomic scale. There is no way to tell by looking at them if they're what they're advertised to be, what's really in them or how potent they are. Quality control? They may have been "cooked" in somebody's garage using a postal scale and a mixing bowl. (I once watched the RCMP bust a meth lab across the street from my house. For real.) Even if someone can tell you what and how much they think was taken, it's almost impossible to be sure what the effects may be; polypharmacy is so common there may be numerous seemingly contradictory effects seen. Those who were partying with the patient aren't likely to be any more lucid or forthcoming than the patient is, and any information they might provide may only reflect their own besotted state. So when an intoxicated teen is admitted through the ER and is unresponsive, time and the unknown are the enemy. Where does the health care team start?

First, having a basic understanding of the attractive properties of the drug(s) taken may help with identification of the active agent. Knowing the why can provide clues to the what. There are fewer clues to the how much, at least initially. Stimulants and dissociatives are typically the drugs of choice. "Ecstasy", the most common street name for the most common of rave drugs, is 3,4-methylenedioxymethamphetamine - MDMA. It produces euphoria, heightened sensation, alteration in the sense of time, increased stamina, hypersexuality and hallucinations. What's not to love? It dramatically improves the rave experience, in measured doses of course. Cocaine, ADHD drugs like Ritalin and Concerta are other stimulants that may be part of the cocktail. Georgia Home Boy is one of the street names for the dissociative gamma hydroxybutyric acid - GHB, another drug that may be ingested by teens in social situations. It too produces euphoria; other desired effects include analgesia, amnesia and hallucinations. GHB is most often mixed with alcohol, which potentiates its onset of effect and its amnestic properties. While recreational use of GHB is common, its main draw in the teenage set is to decrease inhibition and resistance to sexual advances. Special K - ketamine - is a drug we're all familiar with; it's one of the most-frequently stolen drugs during break-ins at veterinary clinics. Fentanyl is another drug we know well that has found its way into parties and raves with predictable consequences. In 2014 fentanyl overdose deaths (all ages) increased in the Calgary, Alberta metropolitan area (population 1.4 million) by 77.5%.

That statistic provides a glimpse into Act 2. The second part of this article will examine the dark underbelly of these drugs and care of the patient to optimize outcomes. Stay tuned...

Act 2: The Agony of Ecstasy, Act 2 - NTI 2016 Session

Act 3: The Agony of Ecstasy - Act 3... Ringing the Curtain Down

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NotReady4PrimeTime

About NotReady4PrimeTime, RN

Pediatric Critical Care Columnist

Certified Pediatric Critical Care Nurse and parent of multi-handicapped adult son, married to computer geek.

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Specializes in Official allnurses account.

Thank you. Great article!

Any slides to share?

So how was the session? Please tell us. :up:

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Specializes in Nephrology, Cardiology, ER, ICU.

So timely with the increased numbers of overdoses. Thank you

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Specializes in Peds, Med-Surg, Disaster Nsg, Parish Nsg.

Looking forward to attending this session in the morning.

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Specializes in Nephrology, Cardiology, ER, ICU.

Great and informative session this am!!!! Thank you

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Specializes in Adult MICU/SICU.

Many of the designer drugs I've never even heard of - yikes!

My son was given ketamine by an oral surgeon 2 summers ago when he had his wisdom teeth pulled. At 20 y.o. he had difficulty voiding for almost 3 days - I was furious, having paid a king's ransom for this misery. Since when do humans give this Rx med to other humans any more? I would imagine anyone who comes to the ER S/P ketamine ingestion will be getting a standard Foley during their stay.

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Specializes in Education, FP, LNC, Forensics, ED, OB.

I would have loved to have been there. Great Article.

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Specializes in NICU, PICU, PCVICU and peds oncology.

My son was given ketamine by an oral surgeon 2 summers ago when he had his wisdom teeth pulled. At 20 y.o. he had difficulty voiding for almost 3 days - I was furious, having paid a king's ransom for this misery. Since when do humans give this Rx med to other humans any more? I would imagine anyone who comes to the ER S/P ketamine ingestion will be getting a standard Foley during their stay.

We use ketamine a lot on my unit for various procedural sedation situations, including rapid sequence intubations and especially for burn dressing changes. It's a very effective drug with a short half life and it has fewer hemodynamic effects than some of the other drugs we could use. Urinary retention is a very rare side effect; we see it more often with fentanyl, morphine and hydromorphone than we do with ketamine. As for ketamine overdoses, they don't typically seek treatment in the ER. The onset of effect is very swift, as you'll see in Act Two, and the half life is quite short.

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Specializes in kids.

Great article, have used ketamine in a compound cream for foot pain in a 98 year old lady. That was new for me!

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Specializes in Adult MICU/SICU.

Prior to becoming an RN, I worked for an oral surgeon in the late 1980's who used a standard demerol/versed IVP combo with a TKO NS gtt (he did mine as well in 1985 before I worked for him) no one ever complained of urinary retention, and I had no difficulties myself (other than feeling green around the gills from the Rx Percocet).

I realize methods of practice change over time (no one uses this method of sedation for colonoscopies any more) however this was exactly the "cocktail" my husband was administered by another local oral surgeon in 2011. He complained of many things afterward { :) } but urinary retention was not one of those complaints.

My son has had other surgeries (fractured clavical with pin retention, inguinal hernia repair) and never had post op urinary retention.

This was a horrible experience … if you've ever seen your own child strain to try to empty their bladder - well it stays with you. We went to the ER. This sedation method for oral surgery just did not seem usual or customary in my personal opinion.

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Prior to becoming an RN, I worked for an oral surgeon in the late 1980's who used a standard demerol/versed IVP combo with a TKO NS gtt (he did mine as well in 1985 before I worked for him) no one ever complained of urinary retention, and I had no difficulties myself (other than feeling green around the gills from the Rx Percocet).

I realize methods of practice change over time (no one uses this method of sedation for colonoscopies any more) however this was exactly the "cocktail" my husband was administered by another local oral surgeon in 2011. He complained of many things afterward { :) } but urinary retention was not one of those complaints.

My son has had other surgeries (fractured clavical with pin retention, inguinal hernia repair) and never had post op urinary retention.

This was a horrible experience … if you've ever seen your own child strain to try to empty their bladder - well it stays with you. We went to the ER. This sedation method for oral surgery just did not seem usual or customary in my personal opinion.

Not to totally derail this thread but...

Actually if you look at the literature there has been a huge renewed interest in Ketamine for conscious sedation in humans, especially in pre hospital and emergency settings and especially with kids. Off the top of my head i can't recall the many reasons it is often the drug of choice these days but i believe there is less respiratory depression among other things.

Ketamine is also increasingly used in pain management and palliative settings-many post op pts are given ketamine gtts along with their dilaudid pcas with far better pain control using less medications than dilaudid alone and there have been promising studies using ketamine on palliative pts with extreme tolerance to opiates- the ketamine not only relieves the pain but often actually dramatically reduces tolerance and thus reduces the amount of opiate needed.

This is just within the last 5 or maybe 10 years but you won't have to look far to find a multitude of articles about it.

Of course, it also remains popular as a club and sometimes date rape drug as the OP mentions.

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Specializes in NICU, PICU, PCVICU and peds oncology.

Ketamine is very popular with the physicians I work with for many reasons. It has rapid onset of effect, it causes no respiratory depression or hypotension, has no proarrhythmic effects and has a short half-life so it's useful for lots of things. Children older than 3 years may have emergence reactions so we typically will also give a small dose of a benzo the prevent that. Propofol may be more suitable for older kids and adults but for our population we try not to make it the mainstay of our sedation because of the risk of PRIS.

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