Definition & scope

Stimulant intoxication describes the clinical effects that follow recent stimulant use. Presentations range from mild sympathomimetic symptoms to severe toxicity with hyperthermia, seizures, rhabdomyolysis, arrhythmias, myocardial ischaemia and cerebrovascular events.

Clinical features — common and severe

• Common: agitation, anxiety, tachycardia, hypertension, diaphoresis, mydriasis, insomnia, increased energy.
• Severe: hyperthermia, delirium, severe psychosis, seizures, rhabdomyolysis, acute coronary syndrome, stroke, malignant arrhythmias.

Initial assessment — ABC + rapid targeted history

1. Airway, Breathing, Circulation — secure as required; oxygen and IV access early.
2. Rapid observations — temperature, HR, BP, RR, SpO₂, GCS, capillary glucose.
3. Focused history: time/route/quantity of use (if known), co-ingestants, medical history, medications, pregnancy status and previous seizures or cardiac disease.
4. Collateral from companions/EMS and scene clues (packaging, pills, plant material) are often decisive.

Key investigations

• ECG for arrhythmia or ischemia; serial troponins if chest pain or high risk.
• Bloods: CBC, electrolytes, renal & liver function, CK, coagulation, ABG if respiratory compromise, serum glucose, lactate.
• Urine drug screen/serum toxicology if available (note limitations for novel agents).
• CT head for focal neurology or head injury; chest x‑ray if aspiration suspected.

Immediate management — practical algorithm

1. Environment: quiet room, reduce stimulation, provide reassurance and continuous monitoring.
2. Agitation & sympathomimetic state: benzodiazepines (e.g., lorazepam) titrated to sedation—repeat as needed; benzodiazepines address anxiety, hypertension and reduce risk of complications.
3. Psychosis: benzodiazepines first-line; if psychosis persists or there is high-risk behaviour, use antipsychotics (olanzapine or haloperidol) cautiously and monitor QTc.
4. Hyperthermia: immediate active cooling (external cooling, ice packs, evaporative cooling), IV fluids, treat seizures and consider ICU for refractory hyperthermia.
5. Seizures: benzodiazepines immediately, then second-line antiseizure medications per local protocols; consider ICU for status epilepticus.
6. Rhabdomyolysis: aggressive IV fluids, monitor CK and renal function; consult nephrology if oliguria or rising creatinine.
7. Cardiac complications: treat chest pain per ACS protocols with cardiology involvement; avoid beta-blocker monotherapy in suspected cocaine intoxication—use benzodiazepines and nitrates and consult cardiology.

Medication highlights & cautions

• Benzodiazepines are the cornerstone—use titrated doses until calm and safe.
• Antipsychotics helpful for enduring psychosis but monitor for extrapyramidal effects and QT prolongation; olanzapine oral/IM is often preferred for its sedating properties.
• Antihypertensives: short-acting agents (e.g., labetalol with caution) can be used for severe hypertension; avoid pure beta blockers without specialist input in cocaine intoxication.
• Avoid physical restraint when possible—if used, ensure frequent monitoring and sedation to prevent agitation-related complications.

Disposition & escalation criteria

• ICU/HDU admission for: refractory hyperthermia, hyperreflexia with autonomic instability, rhabdomyolysis with renal threat, status epilepticus, ACS requiring intensive care, or uncontrolled agitation requiring ventilatory support.
• Medical ward admission for: significant metabolic derangement, rising CK, troponin elevation, or need for repeated monitoring and IV fluids.
• Short-stay observation for mild–moderate intoxication with social stability and reliable follow-up.
• Outpatient referral to addiction services and psychiatry after medical stability—offer contingency management or CBT where available.

Follow-up care & prevention

• Arrange early addiction service follow-up and psychosocial interventions (contingency management has strong evidence for stimulant disorders).
• Screen for comorbid mental health disorders and refer to psychiatry where indicated.
• Provide harm reduction advice (avoid mixing substances, stay hydrated, do not use alone, naloxone for opioid risk) and link to community resources.

Key takeaways

• Stimulant intoxication can be life-threatening—manage with a safety-first, protocolised approach focusing on benzodiazepines, cooling, fluids and monitoring for organ complications.
• Benzodiazepines are first-line for agitation, seizures and sympathomimetic effects; antipsychotics are second-line for persistent psychosis.
• Monitor for hyperthermia, rhabdomyolysis, cardiac ischemia and seizures—escalate to ICU early when criteria met.
• Link medically stabilised patients to addiction services (contingency management, CBT) and mental health follow-up to reduce relapse risk.