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Phencyclidine overdose: An overview
collaboration with ACEP, has adopted standards for the accreditation of educational programs for the emergency medical technician. On the state level, the College has as a goal the development of close relations between chapters and state medical societies and the organization of sections of emergency medicine in each state medical society. If achieved, this will improve the effectiveness of chapters within each state and increase the interaction of emergency physicians within the state societies. Physicians can no longer be content to simply practice medicine. Medicine as we know it today is undergoing changes because of government intervention, rising health care costs, and the need for access to health care by all segments of our population. We must become concerned and involved with major social issues and attempt to effect changes for the benefit of
our patients. In order to maintain our freedom to practice medicine appropriately in the years to come, it is essential that we involve ourselves in the process of advocacy early in our careers and make our opinions heard. I urge each of you, through your county society, state society, the AMA, and the College, to become an active member and participant in these organizations which provide us with the opportunity to influence our professional future. Our membership is a formidable force for shaping the destiny of American medicine in such a way that the advancements of our past will continue into the future for the ultimate benefit of our patients. Leonard M. Riggs, Jr, MD President, A CEP
Phencyclidine Overdose: An Overview Patients with phencyclidine toxicity present a highly variable initial picture. Some patients will have serious problems, such as coma, respiratory failure, and seizures. Others may present with milder but still disconcerting symptoms, such as nystagmus, ataxia, and paranoid schizophrenia. Coma with eyes open and self-mutilation also have been reported} '2 The majority of patients, however, will present with minimal changes in sensorium, no life-threatening problems, and a t r a n s i e n t mild paranoia. While attempts have been made by some to relate these problems to blood levels and "stage" the toxicity, the emergency physician rarely is able to obtain rapid blood or urine confirmation of the drug. Treatment, then, must be based on the clinical evaluation of the patient over an observational time. ~Other than those with life-threatening symptoms, the less done for these patients, the better. The most frequent problems with PCP patients are the toxic consequences of excessive treatment. Somehow physicians seem to have decided that all PCP patients require acid diuresis, haloperidol and propranolol. In fact, 90% or more of these patients will do just fine with no treatment. Recent evidence suggests strongly that only 10% to 13% of an ingested dose of PCP can be excreted under the most ideal conditions of acid diuresis. Exposure of most of these patients to acid diuresis is an unnecessary hazard and is a procedure which should be reserved for those pa-
tients with serious PCP toxicity, where excretion of a portion may be of some benefit. It is contraindicated in patients with rhabdomyolysis. 3 The article by Patel et al in this issue of Annals reports eight cases of myoglobinuric renal failure. This observation is very important, for acid diuresis of these patients would have been totally inappropriate. Physicians seeing patients involved with PCP should take measures to avoid unnecessary treatment and should add an appropriate urinalysis to their evaluation. Measures to prevent further absorption, such as administration of charcoal, should be instituted, and further treatment with diazepam, haloperidol, or forced acid diuresis utilized only when absolutely necessary. 1'4 A quiet, supportive environment may be all t h a t is needed for the majority of patients. Barry Rumack, MD Annals Consulting Editor 1. Aronow R, Done AK: Phencyclidine overdose: an emerging concept of management. JACEP 7:56-59, 1978. 2. Grove VE: Painless self-injury after ingestion of ~angel dust." JAMA 242:655-656, 1979. 3. Barton CH, Sterling ML, Vaziri ND: Rhabdomyolysis and acute renal failure associated with phencyclidine intoxication. Arch Intern Med 40:568-569, 1980. 4. Picchioni AL, Consroe PF: Activated charcoal -- a phencyclidine antidote, or hog in dogs. N Engl J Med 300:202, 1979.
RRC (Nee LREC) By any standard, the Liaison Residency Endorsement Committee (LREC), formed in January 1975, has been a success. The original dual sponsorship of the American College of Emergency Physicians (ACEP) and the University Association for Emergency Medicine (UAEM) was joined by the American Board of Emergency Medicine (ABEM) in May 1976. The Committee has served emergency medicine education well by providing quality control, critique and consultation
Bo/595
Ann Emerg Med
to the developing residencies, and useful information for medical students and physicians applying to residencies. It is a unique body that developed clout and respect by its contemplated decisions, use of emergency medicine site surveyors and, finally, specific mention in the regulations of Sections 7, 8, and 9 of the Public Health Services Act. Early on, endorsement procedures were adopted in accordance with the Liaison
9:11 (November) 1980
our patients. In order to maintain our freedom to practice medicine appropriately in the years to come, it is essential that we involve ourselves in the process of advocacy early in our careers and make our opinions heard. I urge each of you, through your county society, state society, the AMA, and the College, to become an active member and participant in these organizations which provide us with the opportunity to influence our professional future. Our membership is a formidable force for shaping the destiny of American medicine in such a way that the advancements of our past will continue into the future for the ultimate benefit of our patients. Leonard M. Riggs, Jr, MD President, A CEP
Phencyclidine Overdose: An Overview Patients with phencyclidine toxicity present a highly variable initial picture. Some patients will have serious problems, such as coma, respiratory failure, and seizures. Others may present with milder but still disconcerting symptoms, such as nystagmus, ataxia, and paranoid schizophrenia. Coma with eyes open and self-mutilation also have been reported} '2 The majority of patients, however, will present with minimal changes in sensorium, no life-threatening problems, and a t r a n s i e n t mild paranoia. While attempts have been made by some to relate these problems to blood levels and "stage" the toxicity, the emergency physician rarely is able to obtain rapid blood or urine confirmation of the drug. Treatment, then, must be based on the clinical evaluation of the patient over an observational time. ~Other than those with life-threatening symptoms, the less done for these patients, the better. The most frequent problems with PCP patients are the toxic consequences of excessive treatment. Somehow physicians seem to have decided that all PCP patients require acid diuresis, haloperidol and propranolol. In fact, 90% or more of these patients will do just fine with no treatment. Recent evidence suggests strongly that only 10% to 13% of an ingested dose of PCP can be excreted under the most ideal conditions of acid diuresis. Exposure of most of these patients to acid diuresis is an unnecessary hazard and is a procedure which should be reserved for those pa-
tients with serious PCP toxicity, where excretion of a portion may be of some benefit. It is contraindicated in patients with rhabdomyolysis. 3 The article by Patel et al in this issue of Annals reports eight cases of myoglobinuric renal failure. This observation is very important, for acid diuresis of these patients would have been totally inappropriate. Physicians seeing patients involved with PCP should take measures to avoid unnecessary treatment and should add an appropriate urinalysis to their evaluation. Measures to prevent further absorption, such as administration of charcoal, should be instituted, and further treatment with diazepam, haloperidol, or forced acid diuresis utilized only when absolutely necessary. 1'4 A quiet, supportive environment may be all t h a t is needed for the majority of patients. Barry Rumack, MD Annals Consulting Editor 1. Aronow R, Done AK: Phencyclidine overdose: an emerging concept of management. JACEP 7:56-59, 1978. 2. Grove VE: Painless self-injury after ingestion of ~angel dust." JAMA 242:655-656, 1979. 3. Barton CH, Sterling ML, Vaziri ND: Rhabdomyolysis and acute renal failure associated with phencyclidine intoxication. Arch Intern Med 40:568-569, 1980. 4. Picchioni AL, Consroe PF: Activated charcoal -- a phencyclidine antidote, or hog in dogs. N Engl J Med 300:202, 1979.
RRC (Nee LREC) By any standard, the Liaison Residency Endorsement Committee (LREC), formed in January 1975, has been a success. The original dual sponsorship of the American College of Emergency Physicians (ACEP) and the University Association for Emergency Medicine (UAEM) was joined by the American Board of Emergency Medicine (ABEM) in May 1976. The Committee has served emergency medicine education well by providing quality control, critique and consultation
Bo/595
Ann Emerg Med
to the developing residencies, and useful information for medical students and physicians applying to residencies. It is a unique body that developed clout and respect by its contemplated decisions, use of emergency medicine site surveyors and, finally, specific mention in the regulations of Sections 7, 8, and 9 of the Public Health Services Act. Early on, endorsement procedures were adopted in accordance with the Liaison
9:11 (November) 1980