Lysergic acid diethylamide toxicity: Difference between revisions
 
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==Background==
==Background==
d-lysergic acid diethylamide, more commonly known as LSD, was first synthesized in 1938 by the chemist Albert Hofmann in efforts to chemically create a blood stimulant.<ref>Hofmann A. "Die Geschichte des LSD-25". Triangel Sandoz Zeitschrift fur Medizinische Wissenschaften. 1955;2(3):117-24. (as cited in Ott J. Pharmacotheon. 1993. pg 123.)</ref>In 1943, Hoffman accidently ingested LSD for the first time, discovering its hallucinagenic properties, reportedly seeing "an uninterrupted stream of fantastic pictures, extraordinary shapes with intense, kaleidoscopelike play of colors."
*Also known as d-lysergic acid diethylamide and LSD
LSD became very popular in the 1960's and 1970's, making it a very important part of the "counterculture" movement, encouraging participants to  "turn on, tune in, drop out."


==Mechanism==
===Mechanism===
Serotonin like agent
*Similar to chemical properties of serotonin
**5-HT2 agonists, mediating excitatory neurotransmitter release.<ref>Ly, B. "Hallucinogens", ''Rosen's Emergency Medicine: Concepts and Clinical Practice''. 7th Ed. Pgs 2010-2012</ref> 
*LSD also binds to dopaminergic receptors, contributing to its psychogenic affects.<ref>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.</ref>


==Pharmacology==
===Pharmacology===
most potent psychoactive drug. Doses of 1 to 1.5 μg/kg produce psychedelic effects. The typical dose taken for an acid “trip” is approximately 25 to 100 μg.
*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.<br />
Time to onset
*Route of administration can be PO (most common), IM, or IV.<ref>Passie, T. "The Pharmacology of Lysergic Acid Diethylamide: A Review". CNS Neuroscience & Therapeutics, Volume 14, Issue 4,  pages 295–314, Winter 2008</ref>
Trip lasting
**PO: Usual Dose 100-250μg, Onset 30-45mins, Peak effect 1-2.5hrs, Total duration 9-12hrs
Distribution
**IM: Usual Dose 100-250μg, Onset 15-20mins, Peak effect 1hr, Total duration 9-10hrs
Tachyphylaxis
**IV: Usual Dose 40-180μg, Onset 3-5mins, Peak effect 1hr, Total duration 9-10hrs<br />
*Tolerance to LSD-25 builds up over consistent use and cross-tolerance has been demonstrated between LSD, [[mescaline]] and [[psilocybin]].<ref>Passie, T. "The Pharmacology of Lysergic Acid Diethylamide: A Review". CNS Neuroscience & Therapeutics, Volume 14, Issue 4, pages 295–314, Winter 2008</ref>


==Effects==
==Clinical Features==
Trip and what it looks like
*Effects begin around 20-40 minutes after injection
Good trip
*Euphoria
Bad trip
*Dizziness
Medical considerations
*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==
==Differential Diagnosis==
===Serotonin-Like Agents===
{{Hallucinogen types}}
LSD
Psilocybin and psilocin dimethyltryptamine (DMT) and 5-methoxy- dimethyltryptamine (5-MeO-DMT)
Hawaiian baby woodrose (Argyreia nervosa), Hawaiian woodrose (Merremia tuberosa), morning glory (Ipomoea violacea), and olili- uqui (Rivea corymbosa)
===Enactogens===
Designer amphetamines - MDMA, Bath Salts, Ecstasy
Mescaline
===Dissociative Agents===
PCP
Ketamine
Dextromethotphan
===Plant-based Hallucinogenics===
Marijuana
Salvia
Absinthe
Isoxazole Mushrooms


===Psychiatric Illnesses===
==Evaluation==
Schizophrenia
*Usually clinical, based on history and presentation
Schizo-affective disorder
''Most blood and urine tests are restricted to research and unavailable for clinical usage''
Dementia
Delirium


==Workup, Management, and Disposition==
===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.<ref>Passie, T. "The Pharmacology of Lysergic Acid Diethylamide: A Review". CNS Neuroscience & Therapeutics, Volume 14, Issue 4, pages 295–314, Winter 2008</ref>
 
==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]]<ref>Glaspy, J. "Drugs of Abuse". Emergency Medicine Manual, 6th Ed. Chapt 103, Pgs 502-504.</ref>''
 
==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
**Further work-up and admission is indicated for persistent psychosis or [[altered mental status]],


==See Also==
==See Also==
*[[Hallucinogens]]
*[[Hallucinations]]


==External Links==
==External Links==
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==References==
==References==
<references/>
<references/>
[[Category:Toxicology]]

Latest revision as of 20:38, 10 February 2021

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.
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