Coma, Hyperthermia and Bleeding Associated with Massive LSD Overdose

THE WESTERN Journal of Medicine Refer to: Klock JC, Boerner U, Becker CE: Coma, hyperthermia and bleeding associated with massive LSD overdose-A report of eight cases. West J Med 120:183-188, Mar 1973

Eight patients were seen within 15 minutes of intranasal self-administration of large amounts of pure D-lysergic acid diethylamide (LSD) tartrate powder. Emesis and collapse occurred along with signs of sympathetic overactivity, hyperthermia, coma and respiratory arrest. Mild generalized bleeding occurred in several patients and evidence of platelet dysfunction was present in all. Serum and gastric concentrations of LSD tartrate ranged from 2.1 to 26 nanograms per ml and 1,000 to 7,000 ,g per 100 ml, respectively. With supportive care, all patients recovered. Massive LSD overdose in man is life-threatening and produces striking and distinctive manifestations. ALTHOUGH THERE HAVE BEEN many reports of over-dose with D-lysergic acid diethylamide (LSD) in man, little toxicologic data are available. The physiologic effects of LSD in doses greater than 1 mg have not been studied in man and the lethal dose must be interpolated from animal studies. We performed extensive toxicologic studies on eight people who took large doses of LSD; the results and clinical-toxicologic correlations are reported herein. From the Division of Clinical Pharmacology, the Toxicology Laboratory, and the Medical Service, San Francisco General Hospital, and the Department of Medicine, University of California, San Francisco. Presented by invitation at the American Academy of Clinical Toxicology Meeting, San Diego, California, August 2, 1973. Submitted August 30, 1973. Reprint requests to: J. C. Klock, MD, Department of Medicine, Division of Hematology, Room 506 M, University of California, San Francisco, San Francisco, CA 94143.

Coma, Hyperthermia and Bleeding Associated with Massive LSD Overdose A Report of Eight Cases JOHN C. KLOCK, MD UDO BOERNER, MS CHARLES E. BECKER, MD San Francisco

Reports of Cases On 29 July 1972, four women and four men ranging in age from 19 to 39 years were admitted to the emergency room at San Francisco General Hospital for drug overdose. Following a dinner party, they had "snorted" (inhaled through a straw placed in one nostril) a small amount of cocaine and a quantity of white powder believed to be cocaine. All eight were reported to have snorted at least two "lines" (rows of powder measuring approximately 3 x 4 X 30 mm) of the second substance. Within 5 minutes they experienced anxiety, restlessness, generalized parasthesias and muscle discomfort, vomiting and physical collapse. Ten minutes later they were admitted to the emergency room in varying degrees of intoxication (Table 1 and Appendix). THE WESTERN JOURNAL OF MEDICINE

183

LSD OVERDOSE

TABLE 1.-Clinical Manifestations of Massive LSD Overdose in Eight Patients Age, Sex

Blood Pressure (mm Hg)

209

130/90

6

120

104.0

8

+

Coma, respiratory

2.199

130/30

33

200

107.0

7

+

Coma, respiratory arrest, diarrhea Writhing and dystonic

Patient No.

1 .

Respirations

Pulse

(breaths/min) (beats/min)

Temperature (OF)

Pupils (mm)

Bleeding

Other

arrest 3

.....

289

160/60

24

150

99.5

8

-

4

.....

339

110/70

9

110

98.0

8

+

movements, diarrhea

Coma, respiratory

arrest, aspiration 5.395 6.29a 7 . 285a

130/80 230/130 130/80

20 30 20

120 112 170

100.8 98.8 98.6

7 6 6

-

Coma, aspiration Coma, aspiration Hyperactive, psychotic,

8.28a

190/95

20

120

102.4

7

+

Hyperactive, psychotic, hallucinating

Figure

1.-Gross

Patient 1

and

of autologous clots from

The

hallucinating

a

appearance

normal

serum

Patient 1

normal

control

of

control

the

blood

(left)

clot

clot

and

from

results

incubation at 370C for 6 hours of and

a

normal

specimen is

control

the

to

clot (right). right in each

picture. Five were

were

comatose when first seen

extremely hyperactive

with

severe

and most visual and

auditory hallucinations at some point during their course. Three required endotracheal intubation and assisted ventilation and three

aspirated

vom-

itus. All had sinus fixed

tachycardia, widely dilated and pupils, emesis, flushing and sweating. Fever

developed in four and diarrhea

hypertension was present in patient had convulsions. All

in two. Transient

three had

patients

and

no

coagulopathy

as

manifested by the inability to form firm clots and

absence of clot retraction in the blood tubes. Seven had

showed

guaiac-positive

exidence

of

in

two,

bleeding

in two, gross hematuria

oozing at venipuncture sites in three and of blood in the vomitus or stool in

small amounts

all four patients).

184

specimen

Toxicologic Data Specimens of blood, urine and gastric contents were obtained on admission from seven patients and analyses were performed as follows.

vomitus and four

mild generalized

(microscopic hematuria

Laboratory data showed normal or negative values (see Appendix) for the following: blood glucose and serum sodium, potassium, and bicarbonate levels, hemoglobin (13.0 to 16.4 grams per deciliter), platelet count (186,000 to 458,000 per microliter), prothrombin time (11.0 to 12.5 seconds) and partial thromboplastin time (19.3 to 38.7 seconds), chest roentgenograms and electrocardiograms. Results of liver and renal function tests were within normal limits in the three patients studied. Direct examination of the blood clots and results of clot retraction tests on several patients showed friable clots that fell apart easily without dissection, and absence of clot retraction (Figure 1). Supportive care included respiratory assistance, use of hypothermic blankets, and administration of antibiotics and corticosteroids when indicated. Bleeding was mild and disappeared within 4 to 6 hours. Blood transfusions were unnecessary and all patients recovered completely within 12 hours. All were discharged or left the hospital within 48 hours of admission. No residua were observed in a year of direct followup of five patients.

MARCH 1974 * 120 * 3

Gastric Content Extraction of the gastric contents for toxicologic screening was performed according to the method of Sunshine' and analyzed by thin layer

LSD OVERDOSE TABLE 2.-Toxicologic Data Obtained in Seven Patients with Massive LSD Overdose* Patient No.

Blood Ethanol Cocainet (%) (pg/ml)

1 0 .0 2 ... 0.08 3 0 .0 4 ...NT 5 ... 0 6 ... 4 7 ... 0.02 *NT = not tested.

LSD (ng/ml)

0 0 0 NT 0 0 0

NT NT 26.0 NT 6.6

11.6 2.1

Urine

Gastric

LSD Cocainet (0g/ml) (mg/100 ml)

0

1.3 10.0 NT 0 0 NT

7.0 NT NT

1.2