MEDICOLEGAL ASPECT OF

METHAMPETHAMINE
INGESTION/INTOXICATION

DR. JAYVEE S. GUERRERO RN MD

2ND YEAR EMERGENCY MEDICINE RESIDENT
UNIVERSITY OF THE PHILIPPINES – PHILIPPINE GENERAL HOSPITAL
OBJECTIVES
• TO Discuss a case of Methamphetamine
intoxication
• TO DISCUSS TO PHARMAKOKINETICS AND
PHARMACODYNAMIC OF METHAMPHETAMINE
• TO DISCUSS TREATMENT OF METHAMPHETAMINE
• To Discuss MEDICOLEGAL ASPECT/ Implications of
Drug Screening
CASE
SA

58 Male

From Caloocan city

Chief complaint: Seizures

PROFILE

× Known DM for 10 years non hypertensive

× Non Smoker, occasional alcoholic beverage
drinker
× Denies Illicit Drug USE
 patient is conversant speaks in
Airway: sentences no signs of airway
Primary survey obstruction

not in respiratory distress

Breathing: tachypneic no cyanosis no
retractions clear breath sounds

BP 190/100 no cyanosis full

Circulation:
equal pulses 02 sat: 98%

Disability GCS 15 AGITATED RESTLESS SEDATIVE GIVEN

no signs of external wounds/

Exposure:
biohazard materials
10 HOURS PTA

• Patient allegedly just returned home from work, upon arrival at home noted a group of police arrived
and conducted a “buy-bust” operation, later patient was taken to the police station.

7 hours PTA
• Patient allegedly was given 2 cups of 50ml water with notable acrid taste, few minutes later patient
experienced dizziness, lightheadedness, palpitations, diaphoresis, DOB, stiffening of extremities. Later
on patient loss consciousness associated with upward rolling of eyeballs. He was immediately rushed to
a private hospital and was given isoket drip and diazepam, Patient was referred to PGH for admission
and toxicologic consult.
Physical Examination

Physical Examination
Adynamic precordiun normal rate
BP : 190/100 CR: 100 RR: 22 Temp 37.0
regular rhythm no murmurs

Flat Soft non tender normoactive

Awake coherent in mild agitation restless
bowel sounds

Anicteric sclerae pale palpebral conjunctiva Grossly normal extremities no

reddish corneas no tonsillopharyngeal edema no cyanosis full equal pulses
congestion no cervical lymph adenopathy full range of motion flushed warm
no neck vein distention dry oral mucosa diaphoretic

Neuro Exam : pupils 3-5mm ERTL

symmetric chest expansion tachypneic no
retractions clear breath sounds intact CN EOMS intact no motor no
sensory deficit
 •Substance Ingestion
Assessment (Methampethamine) Non Accidental
T/C Deliberate with Moderate signs of
Acute Toxicity
 ED Management
NPO for TEMPORARILY
INSERT NGT
D5 0.9 NaCl x 8 HOURS
HOOK TO CARDIAC MONITOR
Medications
DIAZEPAM 5MG SIVP PRN FOR ACTIVE SEIZURES, SEVERE AGITATION
MDAC 100G IN 200cc WATER LAVAGE OUT UNTIL CLEAR, THE 50MG IN 100cc
WATER EVERY 6 HOURS FOR 48 HOURS
SODIUM SULFATE 15G IN 1OO CC WATER, MAY GIVE ONE DOSE AFTER THE 4TH
DOSE ACTIVATED CHARCOAL IF NO BM
NTG DRIP 10MG IN 90CC PNSS X 10CC/HR
Carvedilol 6.25mg/ tab BID

INSERT IFC
I&O MONITORING HOURLY, MAKE SURE PATIENT IS PROPERLY HYDRATED WITH
UO > 1M/KG/HR
COURSE IN THE WARDS
D:0 ECG Noramal Sinus Rhythm no axis
(9/4) deviation, Non specific ST wave
changes

URINE MAP MAP POSITIVE

• Admitted to PGH-ER  GenMed, THC THC NEGATIVE
Psychiatry
• Urine MAP: (+)  Toxicology URINE
• Managed as a SUBSTANCE INGESTION 5.0
(MAP) WITH MODERATE SIGNS OF pH
TOXICITY
Urine OPIATES, MDMA,
NEGATIVE
BENZO, Cocaine
 Creatine Kinase
COURSE IN THE WARDS
D:0 CREA 119

CK Tot 99441
CBC
(55-170)
RBC 4.06 WBC 16.8
CK MB (0-16) 104.6
Hgb 126 Neut 85

Hct 0.4 Lymph 6 Troponin (N<0.034)

MCV 98.7 Eos 9
9/4 1.500 H >>1.670 H
MCH 31.0 Bas 0

MCHC 314 PT 13.3/97%/1.02

RDW 12.5
PTT 30.38/29.2
PC 274
COURSE IN THE WARDS
D:1

URINE MAP MAP POSITIVE

• Started with dexmetorini

• Olanzapine, clonidine
• MDAC day 1
COURSE IN THE WARDS
D:2
URINE MAP MAP POSITIVE

• ADMITTED TO WARD 3 Creatine Kinase

• STILL with Nicardipine Drip
• MDAC Day 2 CREA

• NO fever No Cough no DOB CK Tot (55-170) 25327

• Clear Breathsounds
CK MB (0-16) 243.5

Troponin (N<0.034)

9/6 0.632 H
COURSE IN THE WARDS
D:3

URINE MAP MAP POSITIVE

• MDAC day 3
COURSE IN THE WARDS URINE MAP MAP POSITIVE
D:4
CBC (9/7)
RBC 4.06 WBC 15.7

Hgb 115 Neut 79

• MDAC Day 4 Hct 0.36> Lymph 11

• NO fever No Cough no DOB MCV 98.7 Eos 10

• Clear Breathsounds
MCH 31.0 Bas 0

MCHC 314

RDW 12.5

PC 105
COURSE IN THE WARDS
D:5
URINE MAP MAP negative

CXR REQUESTED
• Patient developed fever 39.6 occasional
dry cough
• A> t/c HAP with Aspiration pneumonia
• Started with Piperacillin Tazobactam Blood GS/CS REQUESTED
COURSE IN THE WARDS CBC (9/9)
RBC 3.54 WBC 19.80
D:6 Hgb 111 Neut 0.93

Hct 0.36 Lymph 0.02

MCV 100.7 Eos 0.05

MCH 31.4 Bas 0.00

MCHC 312
• Patient developed fever 39.6 occasional
dry cough RDW 12.8
• A> t/c HAP with Aspiration pneumonia
PC 105
• Started with Piperacillin Tazobactam

Gram Positive Cocci in

Blood GS/CS
Pairs
Confluent opacities right upper lobe with
Chest xray
consolidation
COURSE IN THE WARDS
D: 7
PMN >25/LPF
SQ eph <25/LPF
Yeast: neg
Respiratory
• Noted Decreasing sensorium E2V3M4 Hypal element : neg
gram stain
• Intubated 7.5 level 20 Gram + cocci in pairs 2-6
• A> ARF from Sepsis from HAP, with 0if
aspiration component. AKI from Sepsis
from HAP Gram - Bacilli 5-10 OIF

• Started with Vancomycin

Troponin (N<0.034)

9/10 0.090
 COURSE IN THE WARDS
D: 8

• For Transfer to MICU pH: 7.378 BE: -3.7

• Noted CBG: High pCO2
33.7 mmHg O2St: 93.2
• A> DM Emergency HHS :
• ARF from Sepsis from HAP PO2: 66.90 mmHg TCO2: 21.1
• AKI from Sepsis
HCO mmol/
20.0 SBc: 21.2
3: L

BUN 36.4
SERUM ELEC K 4.2
TROLYTE Na- 160
Cl 134
COURSE IN THE WARDS
D10

• PCOD
• Sudden
Cardiac
• BP:0 • Initial • VFIB x Death
• HR: 0 Rhythm 3 from
• ACLS : • Asystol FATAL
ACTIVATED • VFIB e Arrhythmi
a
• (VFIB)
COURSE IN THE WARDS

FINAL DIAGNOSIS:
Acute Respiratory Failure from HAP
Severe Metabolic Acidosis from HHS
Fatal Arrhythmia (Vfib) from MAP toxicity
AKI from Sepsis from HAP
 DRUG PROFILE:
METHAMPHETAMINE

• synthetic derivative of
phenethylamine with
additional methyl group
• Excretion: urine (40-50%)
• Half-life: 12-34h
• Vd: 3-5 L/kg

Won, S. Hong, R.A., Shohet, R.V., et al (2013). Methamphetamine-associated cardiomyopathy. Clinical Cardiology 36, 12, 737-742
DRUG PROFILE:
METHAMPHETAMINE
• Cause increased release of dopamine, NE,
epinephrine, serotonin
• Blocks reuptake transporters
• Increased alertness, euphoria, energy,
decreased appetite
• Hyperactivity
• Loss of appetite
• Dilated pupil
• Flushed skin
• Excessive sweating
• Increased movement
DRUG PROFILE:
METHAMPHETAMINE
APPROACH TO THE MANAGEMENT OF METHAMPHETAMINE
INTOXICATION
Emergency Stabilization

Continuous Clinical Evaluation

Decontamination and Enhanced Elimination

Supportive therapy

Disposition
APPROACH TO THE MANAGEMENT OF METHAMPHETAMINE
INTOXICATION
EMERGENCY STABILIZATION

CORRECTION OF LIFE THREATENING COMPLICATIONS OF

MAP INTOXICATION SUCH AS AGITATION, SEIZURES,
HYPERTENSION HYPERTHERMIA, HEMORRHAGIC STROKES,
SUDDEN CARDIAC DEATH
APPROACH TO THE MANAGEMENT OF METHAMPHETAMINE
INTOXICATION
CONTINIOUS CLINICAL EVALUATION

CONTINUOUS CARDIAC MONITORING

WATCH OUT FOR SEIZURES, DELIRUM
RENAL FAILURE
APPROACH TO THE MANAGEMENT OF METHAMPHETAMINE
INTOXICATION
DECONTAMINATION AND ENHANNCED ELIMINATION

GASTRIC LAVAGE
MULTIPLE ACTIVATED CHARCOAL
SODIUM SULFATE
APPROACH TO THE MANAGEMENT OF METHAMPHETAMINE
INTOXICATION
SUPPORTIVE THERAPY
APPROACH TO THE MANAGEMENT OF METHAMPHETAMINE
INTOXICATION
DISPOSITION

ADMIT UNTIL RESOLUTION OF SYMPTOMS

FOLLOW UP CARE
REFERAL TO PSYCHIARTY (BEHAVIORAL MEDICINE)
REFER TO REHABILITATION
MEDICOLEGAL ASPECT

OF

Drug Screening
DANGEROUS DRUG ACT OF 2002

• ARTICLE III SECTION 36 Authorized Drug Testing.

Authorized drug testing shall be done by any government
forensic laboratories or by any of the drug testing
laboratories accredited and monitored by the DOH to
safeguard the quality of test results
• The following shall be subjected to undergo drug testing:
• (a) Applicants for driver's license. – No driver's license shall be issued or renewed to
any person unless he/she presents a certification that he/she has undergone a
mandatory drug test and indicating thereon that he/she is free from the use of
dangerous drugs;
• (b) Applicants for firearm's license and for permit to carry firearms outside of
residence. – All applicants for firearm's license and permit to carry firearms outside of
residence shall undergo a mandatory drug test to ensure that they are free from the
use of dangerous drugs: Provided, That all persons who by the nature of their
profession carry firearms shall undergo drug testing;
• (c) Students of secondary and tertiary schools. – Students of secondary and tertiary
schools shall, pursuant to the related rules and regulations as contained in the school's
student handbook and with notice to the parents, undergo a random drug testing:
Provided, That all drug testing expenses whether in public or private schools under this
Section will be borne by the government;
• (d) Officers and employees of public and private offices. – Officers and employees of public and
private offices, whether domestic or overseas, shall be subjected to undergo a random drug test as
contained in the company's work rules and regulations, which shall be borne by the employer, for
purposes of reducing the risk in the workplace. Any officer or employee found positive for use of
dangerous drugs shall be dealt with administratively which shall be a ground for suspension or
termination, subject to the provisions of Article 282 of the Labor Code and pertinent provisions of the
Civil Service Law;
• (e) Officers and members of the military, police and other law enforcement agencies. – Officers and
members of the military, police and other law enforcement agencies shall undergo an annual
mandatory drug test;
• (f) All persons charged before the prosecutor's office with a criminal offense having an imposable
penalty of imprisonment of not less than six (6) years and one (1) day shall have to undergo a
mandatory drug test;
• (g) All candidates for public office whether appointed or elected both in the national or local
government shall undergo a mandatory drug test.
Sec. 38. Laboratory Examination or Test on Apprehended/Arrested Offenders.
Subject to Section 15 of this Act, any person apprehended or arrested for violating the provisions of this Act
shall be subjected to screening laboratory examination or test within twenty-four (24) hours, if the
apprehending or arresting officer has reasonable ground to believe that the person apprehended or arrested,
on account of physical signs or symptoms or other visible or outward manifestation, is under the influence of
dangerous drugs.

If found to be positive, the results of the screening laboratory examination or test shall be challenged within
fifteen (15) days after receipt of the result through a confirmatory test conducted in any accredited analytical
laboratory equipment with a gas chromatograph/mass spectrometry equipment or some such modern and
accepted method, if confirmed the same shall be prima facie evidence that such person has used dangerous
drugs, which is without prejudice for the prosecution for other violations of the provisions of this Act: Provided,
That a positive screening laboratory test must be confirmed for it to be valid in a court of law.