Stimulant ToxicityAPPROACH

TOXICOLOGY AND BEHAVIORAL · 19 SECTIONS

⚲

575 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Undifferentiated Overdose Opioid Toxicity Opioid Withdrawal Alcohol Intoxication Alcohol Withdrawal Stimulant Toxicity Pediatric Ingestion Carbon Monoxide Exposure Inhalational Or Chemical Exposure Suicidal Ideation And Self Harm Risk Assessment Acute Psychosis And Mania Symptoms Anxiety And Panic Symptoms Capacity Assessment And Safe Disposition Behavioral Escalation And Restraint Considerations

Pediatrics16▾

Environmental and Exposure4▾

01History/hx82

Presentation synopsis

›Exposure history core

›Suspected stimulant type

›Cocaine

›Methamphetamine

›Prescription amphetamine

›MDMA

›Synthetic cathinones

›Route

›Oral

›Intranasal

›Inhaled

›Smoked

›Injection

›Time course

›Time of last use

›Symptom onset relative to use

›Dose pattern

›Single use

›Binge

›New supplier or new formulation

›Co exposures

›Alcohol

›Opioids

›Benzodiazepines

›Cannabis

›Hallucinogens

›OTC decongestants

›Energy drinks

›Clinical trajectory

›Improving

›Worsening

OPQRST

›Onset

›Sudden onset

›Gradual onset

›Provocation and palliation

›Worse with exertion

›Worse with agitation

›Relief with rest

›Relief with cooling

›Quality

›Chest pressure

›Pleuritic pain

›Headache thunderclap

›Palpitations

›Region and radiation

›Substernal

›Jaw radiation

›Arm radiation

›Back radiation

›Severity

›Peak severity at onset

›Maximal severity now

›Timing

›Constant symptoms

›Episodic symptoms

›Duration of episodes

Associated symptoms

›Symptom clusters

›Agitation

›Anxiety

›Psychosis

›Chest pain

›Dyspnea

›Headache

›Focal neurologic symptoms

›Seizure

›Hyperthermia symptoms

›Heat intolerance

›Profuse sweating

›Rigidity

›Serotonergic symptoms

›Diarrhea

›Tremor

›Myoclonus

›Rhabdomyolysis symptoms

›Myalgias

›Dark urine

Context and baseline

›Baseline and prior episodes

›Prior stimulant toxicity

›Prior chest pain after stimulant use

›Prior seizure history

›Baseline psychiatric symptoms

›Baseline exercise or heat exposure tolerance

02Alarm Features/alarm31

Immediate escalation triggers

›High risk triggers

›Hyperthermia

›Core temperature at or above 40 C

›Altered mental status with hyperthermia

›Cardiovascular instability

›Hypotension

›Ventricular tachycardia

›Ventricular fibrillation

›Ischemia concern

›Ongoing chest pain

›New ischemic ECG changes

›Neurologic emergency

›Seizure

›Focal neurologic deficit

›Severe headache sudden onset

›Severe agitation

›Violent behavior

›Inability to obtain vital signs safely

›Respiratory compromise

›Hypoxemia

›Hypercapnia

Vital sign danger thresholds

›High risk vital patterns

›Severe hypertension with end organ symptoms

›Chest pain

›Neurologic deficit

›Tachycardia with symptoms

›Syncope

›Chest pain

›Tachypnea with distress

›Accessory muscle use

›Inability to speak full sentences

03Medications/meds28

Current and recent medications

›Medication reconciliation focus

›Prescription stimulants

›Amphetamine products

›Methylphenidate products

›Serotonergic agents

›SSRIs

›SNRIs

›MAO inhibitors

›Linezolid

›Tramadol

›QT prolonging agents

›Antipsychotics

›Macrolides

›Sympathomimetics

›Pseudoephedrine

›Phenylephrine

›Cardiovascular agents

›Beta blockers

›Calcium channel blockers

›Anticoagulants and antiplatelets

›DOACs

›Warfarin

›Aspirin

Adherence and changes

›Recent changes

›Dose escalation

›Missed doses

›Recent new prescription

›Recent discontinuation of sedatives

04Diet/diet9

Intake and hydration

›Recent intake patterns

›Reduced oral intake

›Vomiting limiting intake

›Dehydration risk

›Prolonged exertion

Stimulant co exposures

›Dietary stimulant exposure

›Caffeine amount

›Energy drinks

›Pre workout supplements

05Review of Systems/ros26

Cardiopulmonary

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

›Palpitations

›Syncope

›Hemoptysis

Neurologic and psychiatric

›Neuropsychiatric symptoms

›Headache

›Vision changes

›Weakness

›Numbness

›Seizure

›Confusion

›Hallucinations

›Suicidal thoughts

GI and GU

›GI and GU symptoms

›Abdominal pain

›Nausea

›Vomiting

›Diarrhea

›Decreased urine output

›Dark urine

Infectious and inflammatory

›Infection mimics

›Fever

›Rigors

›Recent sick contacts

06Collateral History and Family History/chafh8

Collateral and reliability

›Collateral sources

›EMS report

›Family or friends

›Pharmacy records

Family history

›Inherited and early disease

›Premature coronary disease

›Sudden cardiac death

›Inherited arrhythmia syndromes

07Risk Factors/rf17

Patient level risks

›Cardiovascular risk

›Known coronary artery disease

›Hypertension

›Diabetes mellitus

›Smoking

›Neurologic risk

›Prior stroke or TIA

›Intracranial aneurysm

›Psychiatric and substance use risk

›Stimulant use disorder

›Polysubstance use

›Prior severe agitation

Situational risks

›Exposure risks

›Heat exposure

›Prolonged physical restraint

›Prolonged exertion

›Limited access to water

08Differential Diagnosis/ddx51

Life threatening

›Must not miss

›Acute coronary syndrome (I21.9)

›Chest pain

›Ischemic ECG changes

›Aortic dissection (I71.00)

›Severe chest or back pain

›Pulse deficit

›Intracranial hemorrhage (I61.9)

›Sudden severe headache

›Focal neurologic deficit

›Ischemic stroke (I63.9)

›Focal neurologic deficit

›Time last known well

›Ventricular dysrhythmia (I49.9)

›Syncope

›Wide complex tachycardia

›Hyperthermia syndromes

›Heat stroke (T67.01)

›Serotonin syndrome (T43.295)

›Severe rhabdomyolysis (M62.82)

›Hyperkalemia

›Acute kidney injury

›Sepsis mimic (A41.9)

›Fever

›Hypotension

Common

›Common alternatives

›Panic attack (F41.0)

›Normal exam between episodes

›No hyperthermia

›Primary psychotic disorder (F29)

›Symptoms without toxidrome

›Normal vitals

›Dehydration with tachycardia (E86.0)

›Poor intake

›Orthostatic symptoms

›Cannabis related anxiety (F12.980)

›Recent cannabis exposure

›Prominent anxiety

Less common

›Less common and mimics

›Thyrotoxicosis (E05.90)

›Hyperreflexia

›Goiter

›Pheochromocytoma crisis (E27.5)

›Paroxysmal episodes

›Headache sweating palpitations

›Anticholinergic toxicity

›Dry skin

›Urinary retention

›Alcohol withdrawal (F10.239)

›Tremor

›Autonomic hyperactivity

09Past Medical History/pmh16

Relevant conditions and baseline

›Baseline medical status

›Coronary artery disease

›Prior MI

›Prior PCI or CABG

›Heart failure (I50.9)

›Baseline dyspnea

›Baseline diuretic use

›Seizure disorder (G40.909)

›Typical seizure pattern

›Antiseizure medications

›Chronic kidney disease (N18.9)

›Baseline creatinine

›Dialysis status

›Pregnancy status

›Known pregnancy

›Postpartum period

10Physical Exam/exam51

General and vital pattern

›Toxidrome and severity

›Mental status

›Alert and oriented

›Confused

›Delirious

›Agitation level

›Mild

›Moderate

›Severe

›Temperature type

›Core temperature availability

›Peripheral temperature limitations

›Hydration

›Dry mucous membranes

›Capillary refill delay

Cardiovascular and respiratory

›Cardiorespiratory exam

›Heart rate and rhythm

›Regular tachycardia

›Irregular rhythm

›Perfusion

›Cool extremities

›Diaphoresis

›Chest findings

›Crackles

›Wheeze

›Signs of ischemia

›Diaphoresis with chest pain

›New murmur

Neurologic and tox findings

›Neurotox exam

›Pupils

›Mydriasis

›Reactivity

›Tone and reflexes

›Hyperreflexia

›Clonus

›Tremor and myoclonus

›Tremor

›Myoclonus

›Focal deficits

›Face arm speech abnormalities

›Ataxia

Skin and musculoskeletal

›Skin and muscle injury

›Diaphoresis pattern

›Profuse sweating

›Dry skin

›Rigidity

›Generalized

›Focal

›Trauma signs

›Head injury signs

›Needle marks

11Lab Studies/labs42

Core ED labs

›Initial laboratory evaluation

›Point of care glucose

›Hypoglycemia alternate diagnosis

›Hyperglycemia stress response

›Electrolytes and renal function

›Sodium

›Potassium

›Creatinine

›Creatine kinase

›Rhabdomyolysis severity marker

›Trend with treatment

›Liver enzymes

›Hyperthermia related injury

›Acetaminophen co ingestion clues

›Venous or arterial blood gas

›Acidosis severity

›Hypercapnia in hypoventilation after sedation

›Lactate

›Shock marker

›Seizure marker

›CBC

›Infection mimic

›Hemoconcentration dehydration

Cardiac and tox focused

›High yield additional labs

›Troponin with serial strategy

›Indicated with chest pain

›Indicated with ischemic ECG changes

›Pregnancy test

›Medication selection implications

›Disposition implications

›Acetaminophen level

›Mixed ingestion screen

›Time dependent interpretation

›Salicylate level

›Mixed ingestion screen

›Acid base clues

›Urinalysis

›Myoglobinuria surrogate

›Dehydration

›Urine drug screen

›Limited acute decision value

›Useful for documentation and collateral

12Imaging/img27

Scoring Systems

›Risk stratification tools

›ACS risk tools local protocol dependent

›HEART score for chest pain pathways

›Limitations with stimulant associated vasospasm

›Rhabdomyolysis complication risk

›CK trend plus creatinine trend

›Potassium and acid base status

MRI

›MRI indications

›Stroke evaluation when CT nondiagnostic

›Toxic leukoencephalopathy concern

›MRI constraints

›Unstable patient

›Severe agitation limiting safety

›CT indications

›CT head for severe headache or focal deficit

›CT head for seizure with persistent altered mental status

›CT chest with dissection concern

›CT cautions

›Contrast nephropathy risk in rhabdomyolysis and AKI

›Radiation exposure and pregnancy considerations

Ultrasound

›POCUS applications

›Cardiac ultrasound for cardiomyopathy and effusion

›Lung ultrasound for pulmonary edema

›IVC assessment for volume status

›POCUS limitations

›Operator dependence

›Poor windows in severe agitation

13Special Tests/spec17

Bedside monitoring and procedures

›Critical bedside tests

›Core temperature measurement

›Esophageal in intubated patient

›Rectal when safe and available

›Continuous end tidal CO2

›Hypoventilation after sedation

›Early respiratory compromise

›Point of care ketones when indicated

›DKA mimic

›Starvation ketosis

Targeted diagnostic procedures

›Procedures when indicated

›Lumbar puncture for meningitis encephalitis concern

›Fever with altered mental status

›Severe headache with normal CT

›Continuous bladder temperature probe local protocol dependent

›Severe hyperthermia monitoring

›Cooling response tracking

14ECG/ecg13

Indications and high risk patterns

›ECG evaluation

›Immediate ECG for chest pain

›Immediate ECG for palpitations or syncope

›Continuous telemetry for significant tachycardia

›High risk ECG findings

›ST elevation or depression

›QTc prolongation

›Wide QRS

›Ventricular ectopy

Serial strategy

›Repeat ECG triggers

›Persistent chest pain

›Rising troponin

›New hemodynamic instability

15Assessment/ax20

Working diagnosis and severity

›Stimulant toxicity syndrome

›Sympathomimetic toxidrome

›Tachycardia

›Hypertension

›Mydriasis

›Diaphoresis

›Complication screen

›ACS and coronary vasospasm

›Hyperthermia syndrome

›Serotonin syndrome risk

›Rhabdomyolysis and AKI

›Seizure

›Stroke or intracranial hemorrhage

Key alternative diagnoses

›Competing diagnoses prioritized by risk

›Sepsis mimic

›Fever source

›Hypotension

›Thyrotoxicosis

›Hyperreflexia

›Weight loss history

16Plan/plan86

First 5 minutes

›Immediate stabilization

›Airway and breathing

›Supplemental oxygen for hypoxemia

›Capnography if sedated

›Circulation and monitoring

›Cardiac monitor

›Frequent blood pressure checks

›Two large bore IV lines when severe

›Rapid bedside tests

›Point of care glucose

›Core temperature when possible

Agitation and psychosis control

›Sedation strategy

›Benzodiazepines first line

›Lorazepam IV 1 mg to 2 mg

›Repeat every 5 minutes to 10 minutes to effect

›Diazepam IV 5 mg to 10 mg

›If severe agitation with immediate danger

›Ketamine IM 4 mg/kg local protocol dependent

›Airway readiness and capnography

›Antipsychotic adjunct for persistent psychosis

›Droperidol IM 5 mg to 10 mg local protocol dependent

›Haloperidol IM 5 mg to 10 mg

›QTc monitoring when feasible

Hyperthermia management

›Cooling and organ protection

›Active external cooling

›Ice packs to axilla and groin

›Evaporative cooling with mist and fan

›IV fluids

›Isotonic crystalloid bolus 10 mL/kg to 20 mL/kg

›Reassess lung exam and oxygenation after each bolus

›Severe hyperthermia with rigidity or refractory agitation

›Intubation for control and safety

›Nondepolarizing paralysis local protocol dependent

›Avoid succinylcholine when rhabdomyolysis or hyperkalemia risk

›Antipyretics

›Limited utility in hyperthermia syndromes

›Prioritize active cooling

Hypertension and tachycardia

›Hemodynamic control principles

›Treat agitation and pain first

›Benzodiazepines reduce catecholamine surge

›Reassess blood pressure after sedation

›Persistent severe hypertension with end organ concern

›Nitroglycerin for ischemic chest pain

›Nitroprusside infusion local protocol dependent

›Phentolamine for suspected alpha mediated crisis local protocol dependent

›Beta blocker cautions

›Avoid isolated beta blocker in cocaine associated chest pain

›Consider specialist input for mixed alpha beta agents local protocol dependent

Chest pain and ACS pathway

›Ischemia management

›Aspirin PO 160 mg to 325 mg if no contraindication

›Nitroglycerin SL 0.4 mg every 5 minutes up to 3 doses if not hypotensive

›Benzodiazepines for sympathetic surge

›Serial troponin and serial ECG

›Cardiology consult for persistent ischemia or ST elevation

Seizure management

›Seizure control

›Benzodiazepines first line

›Lorazepam IV 2 mg to 4 mg

›Repeat once if ongoing seizure

›Second line antiseizure medication

›Levetiracetam IV 60 mg/kg maximum 4500 mg local protocol dependent

›Valproate IV 40 mg/kg local protocol dependent

›Refractory status epilepticus

›Airway control

›Continuous infusion sedation local protocol dependent

Rhabdomyolysis and renal protection

›Rhabdomyolysis bundle

›Aggressive isotonic crystalloid

›Titrate to urine output goal local protocol dependent

›Monitor for pulmonary edema

›Electrolyte management

›Hyperkalemia protocol if present

›Correct hypocalcemia only if symptomatic

›Avoid nephrotoxins

›NSAIDs

›Contrast when alternatives available

Serotonin syndrome branch

›Serotonergic toxicity management

›Stop serotonergic agents

›Benzodiazepines for agitation and myoclonus

›Cyproheptadine PO or NG local protocol dependent

›Initial 12 mg

›Then 2 mg every 2 hours until response

›Maintenance 8 mg every 6 hours

Reassessment loop

›Iterative reassessment

›Vital signs every 5 minutes to 15 minutes in severe cases

›Mental status trend after each medication dose

›Temperature trend during cooling

›Repeat electrolytes and CK based on severity

17Disposition/dispo22

Level of care criteria

›ICU criteria

›Core temperature at or above 40 C

›Refractory severe agitation requiring deep sedation

›Recurrent seizures or status epilepticus

›Ventricular dysrhythmia

›Ongoing ischemia or hemodynamic instability

›Severe metabolic acidosis

›AKI with hyperkalemia or oliguria

Admission and observation

›Inpatient admission criteria

›Rhabdomyolysis with rising creatinine

›Persistent psychosis beyond intoxication window

›Complications requiring serial labs or monitoring

›Observation pathway criteria

›Symptoms improving with stable vital signs

›Normal ECG and negative initial troponin with planned repeat per pathway

›No hyperthermia

Discharge criteria

›ED discharge criteria

›Baseline mental status restored

›Vital signs stable without parenteral sedation

›No chest pain and no ischemic ECG changes

›No evolving lab abnormality suggesting rhabdomyolysis or AKI

›Reliable supervision and follow up

18Discharge Instructions/di23

Copy discharge instructions

›Summary

›You were treated for symptoms consistent with stimulant intoxication

›Stimulants can cause dangerous high temperature heart problems and seizures

›Medications and substances

›Do not use cocaine methamphetamine MDMA or other stimulants

›Avoid energy drinks and high caffeine until fully recovered

›Take only medications as prescribed

›Hydration and rest

›Drink fluids regularly

›Avoid heavy exercise and heat exposure for 48 hours

›Follow up

›Primary care follow up in 1 day to 3 days

›Addiction medicine or counseling referral if willing

›Return to ED now for

›Chest pain

›Trouble breathing

›Fainting

›Severe headache

›Weakness or numbness

›Seizure

›Fever or overheating

›Confusion or severe agitation

›Very dark urine or no urination

19References/r6

Guidelines and key sources

›Core references

›American College of Medical Toxicology guidance on sympathomimetic toxicity management (year varies)

›American Heart Association scientific statement on cocaine associated chest pain and myocardial infarction (2008)

›American Academy of Clinical Toxicology and American College of Medical Toxicology position on serotonin syndrome management (year varies)

›American College of Emergency Physicians clinical policy on severe agitation and chemical sedation in the ED (year varies)

›Wilderness Medical Society practice guidelines for exertional heat illness and heat stroke (year varies)

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Stimulant ToxicityAPPROACH

TOXICOLOGY AND BEHAVIORAL · 19 SECTIONS

⚲

575 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx82

Presentation synopsis

›Exposure history core

›Suspected stimulant type

›Cocaine

›Methamphetamine

›Prescription amphetamine

›MDMA

›Synthetic cathinones

›Route

›Oral

›Intranasal

›Inhaled

›Smoked

›Injection

›Time course

›Time of last use

›Symptom onset relative to use

›Dose pattern

›Single use

›Binge

›New supplier or new formulation

›Co exposures

›Alcohol

›Opioids

›Benzodiazepines

›Cannabis

›Hallucinogens

›OTC decongestants

›Energy drinks

›Clinical trajectory

›Improving

›Worsening

OPQRST

›Onset

›Sudden onset

›Gradual onset

›Provocation and palliation

›Worse with exertion

›Worse with agitation

›Relief with rest

›Relief with cooling

›Quality

›Chest pressure

›Pleuritic pain

›Headache thunderclap

›Palpitations

›Region and radiation

›Substernal

›Jaw radiation

›Arm radiation

›Back radiation

›Severity

›Peak severity at onset

›Maximal severity now

›Timing

›Constant symptoms

›Episodic symptoms

›Duration of episodes

Associated symptoms

›Symptom clusters

›Agitation

›Anxiety

›Psychosis

›Chest pain

›Dyspnea

›Headache

›Focal neurologic symptoms

›Seizure

›Hyperthermia symptoms

›Heat intolerance

›Profuse sweating

›Rigidity

›Serotonergic symptoms

›Diarrhea

›Tremor

›Myoclonus

›Rhabdomyolysis symptoms

›Myalgias

›Dark urine

Context and baseline

›Baseline and prior episodes

›Prior stimulant toxicity

›Prior chest pain after stimulant use

›Prior seizure history

›Baseline psychiatric symptoms

›Baseline exercise or heat exposure tolerance

02Alarm Features/alarm31

Immediate escalation triggers

›High risk triggers

›Hyperthermia

›Core temperature at or above 40 C

›Altered mental status with hyperthermia

›Cardiovascular instability

›Hypotension

›Ventricular tachycardia

›Ventricular fibrillation

›Ischemia concern

›Ongoing chest pain

›New ischemic ECG changes

›Neurologic emergency

›Seizure

›Focal neurologic deficit

›Severe headache sudden onset

›Severe agitation

›Violent behavior

›Inability to obtain vital signs safely

›Respiratory compromise

›Hypoxemia

›Hypercapnia

Vital sign danger thresholds

›High risk vital patterns

›Severe hypertension with end organ symptoms

›Chest pain

›Neurologic deficit

›Tachycardia with symptoms

›Syncope

›Chest pain

›Tachypnea with distress

›Accessory muscle use

›Inability to speak full sentences

03Medications/meds28

Current and recent medications

›Medication reconciliation focus

›Prescription stimulants

›Amphetamine products

›Methylphenidate products

›Serotonergic agents

›SSRIs

›SNRIs

›MAO inhibitors

›Linezolid

›Tramadol

›QT prolonging agents

›Antipsychotics

›Macrolides

›Sympathomimetics

›Pseudoephedrine

›Phenylephrine

›Cardiovascular agents

›Beta blockers

›Calcium channel blockers

›Anticoagulants and antiplatelets

›DOACs

›Warfarin

›Aspirin

Adherence and changes

›Recent changes

›Dose escalation

›Missed doses

›Recent new prescription

›Recent discontinuation of sedatives

04Diet/diet9

Intake and hydration

›Recent intake patterns

›Reduced oral intake

›Vomiting limiting intake

›Dehydration risk

›Prolonged exertion

Stimulant co exposures

›Dietary stimulant exposure

›Caffeine amount

›Energy drinks

›Pre workout supplements

05Review of Systems/ros26

Cardiopulmonary

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

›Palpitations

›Syncope

›Hemoptysis

Neurologic and psychiatric

›Neuropsychiatric symptoms

›Headache

›Vision changes

›Weakness

›Numbness

›Seizure

›Confusion

›Hallucinations

›Suicidal thoughts

GI and GU

›GI and GU symptoms

›Abdominal pain

›Nausea

›Vomiting

›Diarrhea

›Decreased urine output

›Dark urine

Infectious and inflammatory

›Infection mimics

›Fever

›Rigors

›Recent sick contacts

06Collateral History and Family History/chafh8

Collateral and reliability

›Collateral sources

›EMS report

›Family or friends

›Pharmacy records

Family history

›Inherited and early disease

›Premature coronary disease

›Sudden cardiac death

›Inherited arrhythmia syndromes

07Risk Factors/rf17

Patient level risks

›Cardiovascular risk

›Known coronary artery disease

›Hypertension

›Diabetes mellitus

›Smoking

›Neurologic risk

›Prior stroke or TIA

›Intracranial aneurysm

›Psychiatric and substance use risk

›Stimulant use disorder

›Polysubstance use

›Prior severe agitation

Situational risks

›Exposure risks

›Heat exposure

›Prolonged physical restraint

›Prolonged exertion

›Limited access to water

08Differential Diagnosis/ddx51

Life threatening

›Must not miss

›Acute coronary syndrome (I21.9)

›Chest pain

›Ischemic ECG changes

›Aortic dissection (I71.00)

›Severe chest or back pain

›Pulse deficit

›Intracranial hemorrhage (I61.9)

›Sudden severe headache

›Focal neurologic deficit

›Ischemic stroke (I63.9)

›Focal neurologic deficit

›Time last known well

›Ventricular dysrhythmia (I49.9)

›Syncope

›Wide complex tachycardia

›Hyperthermia syndromes

›Heat stroke (T67.01)

›Serotonin syndrome (T43.295)

›Severe rhabdomyolysis (M62.82)

›Hyperkalemia

›Acute kidney injury

›Sepsis mimic (A41.9)

›Fever

›Hypotension

Common

›Common alternatives

›Panic attack (F41.0)

›Normal exam between episodes

›No hyperthermia

›Primary psychotic disorder (F29)

›Symptoms without toxidrome

›Normal vitals

›Dehydration with tachycardia (E86.0)

›Poor intake

›Orthostatic symptoms

›Cannabis related anxiety (F12.980)

›Recent cannabis exposure

›Prominent anxiety

Less common

›Less common and mimics

›Thyrotoxicosis (E05.90)

›Hyperreflexia

›Goiter

›Pheochromocytoma crisis (E27.5)

›Paroxysmal episodes

›Headache sweating palpitations

›Anticholinergic toxicity

›Dry skin

›Urinary retention

›Alcohol withdrawal (F10.239)

›Tremor

›Autonomic hyperactivity

09Past Medical History/pmh16

Relevant conditions and baseline

›Baseline medical status

›Coronary artery disease

›Prior MI

›Prior PCI or CABG

›Heart failure (I50.9)

›Baseline dyspnea

›Baseline diuretic use

›Seizure disorder (G40.909)

›Typical seizure pattern

›Antiseizure medications

›Chronic kidney disease (N18.9)

›Baseline creatinine

›Dialysis status

›Pregnancy status

›Known pregnancy

›Postpartum period

10Physical Exam/exam51

General and vital pattern

›Toxidrome and severity

›Mental status

›Alert and oriented

›Confused

›Delirious

›Agitation level

›Mild

›Moderate

›Severe

›Temperature type

›Core temperature availability

›Peripheral temperature limitations

›Hydration

›Dry mucous membranes

›Capillary refill delay

Cardiovascular and respiratory

›Cardiorespiratory exam

›Heart rate and rhythm

›Regular tachycardia

›Irregular rhythm

›Perfusion

›Cool extremities

›Diaphoresis

›Chest findings

›Crackles

›Wheeze

›Signs of ischemia

›Diaphoresis with chest pain

›New murmur

Neurologic and tox findings

›Neurotox exam

›Pupils

›Mydriasis

›Reactivity

›Tone and reflexes

›Hyperreflexia

›Clonus

›Tremor and myoclonus

›Tremor

›Myoclonus

›Focal deficits

›Face arm speech abnormalities

›Ataxia

Skin and musculoskeletal

›Skin and muscle injury

›Diaphoresis pattern

›Profuse sweating

›Dry skin

›Rigidity

›Generalized

›Focal

›Trauma signs

›Head injury signs

›Needle marks

11Lab Studies/labs42

Core ED labs

›Initial laboratory evaluation

›Point of care glucose

›Hypoglycemia alternate diagnosis

›Hyperglycemia stress response

›Electrolytes and renal function

›Sodium

›Potassium

›Creatinine

›Creatine kinase

›Rhabdomyolysis severity marker

›Trend with treatment

›Liver enzymes

›Hyperthermia related injury

›Acetaminophen co ingestion clues

›Venous or arterial blood gas

›Acidosis severity

›Hypercapnia in hypoventilation after sedation

›Lactate

›Shock marker

›Seizure marker

›CBC

›Infection mimic

›Hemoconcentration dehydration

Cardiac and tox focused

›High yield additional labs

›Troponin with serial strategy

›Indicated with chest pain

›Indicated with ischemic ECG changes

›Pregnancy test

›Medication selection implications

›Disposition implications

›Acetaminophen level

›Mixed ingestion screen

›Time dependent interpretation

›Salicylate level

›Mixed ingestion screen

›Acid base clues

›Urinalysis

›Myoglobinuria surrogate

›Dehydration

›Urine drug screen

›Limited acute decision value

›Useful for documentation and collateral

12Imaging/img27

Scoring Systems

›Risk stratification tools

›ACS risk tools local protocol dependent

›HEART score for chest pain pathways

›Limitations with stimulant associated vasospasm

›Rhabdomyolysis complication risk

›CK trend plus creatinine trend

›Potassium and acid base status

MRI

›MRI indications

›Stroke evaluation when CT nondiagnostic

›Toxic leukoencephalopathy concern

›MRI constraints

›Unstable patient

›Severe agitation limiting safety

›CT indications

›CT head for severe headache or focal deficit

›CT head for seizure with persistent altered mental status

›CT chest with dissection concern

›CT cautions

›Contrast nephropathy risk in rhabdomyolysis and AKI

›Radiation exposure and pregnancy considerations

Ultrasound

›POCUS applications

›Cardiac ultrasound for cardiomyopathy and effusion

›Lung ultrasound for pulmonary edema

›IVC assessment for volume status

›POCUS limitations

›Operator dependence

›Poor windows in severe agitation

13Special Tests/spec17

Bedside monitoring and procedures

›Critical bedside tests

›Core temperature measurement

›Esophageal in intubated patient

›Rectal when safe and available

›Continuous end tidal CO2

›Hypoventilation after sedation

›Early respiratory compromise

›Point of care ketones when indicated

›DKA mimic

›Starvation ketosis

Targeted diagnostic procedures

›Procedures when indicated

›Lumbar puncture for meningitis encephalitis concern

›Fever with altered mental status

›Severe headache with normal CT

›Continuous bladder temperature probe local protocol dependent

›Severe hyperthermia monitoring

›Cooling response tracking

14ECG/ecg13

Indications and high risk patterns

›ECG evaluation

›Immediate ECG for chest pain

›Immediate ECG for palpitations or syncope

›Continuous telemetry for significant tachycardia

›High risk ECG findings

›ST elevation or depression

›QTc prolongation

›Wide QRS

›Ventricular ectopy

Serial strategy

›Repeat ECG triggers

›Persistent chest pain

›Rising troponin

›New hemodynamic instability

15Assessment/ax20

Working diagnosis and severity

›Stimulant toxicity syndrome

›Sympathomimetic toxidrome

›Tachycardia

›Hypertension

›Mydriasis

›Diaphoresis

›Complication screen

›ACS and coronary vasospasm

›Hyperthermia syndrome

›Serotonin syndrome risk

›Rhabdomyolysis and AKI

›Seizure

›Stroke or intracranial hemorrhage

Key alternative diagnoses

›Competing diagnoses prioritized by risk

›Sepsis mimic

›Fever source

›Hypotension

›Thyrotoxicosis

›Hyperreflexia

›Weight loss history

16Plan/plan86

First 5 minutes

›Immediate stabilization

›Airway and breathing

›Supplemental oxygen for hypoxemia

›Capnography if sedated

›Circulation and monitoring

›Cardiac monitor

›Frequent blood pressure checks

›Two large bore IV lines when severe

›Rapid bedside tests

›Point of care glucose

›Core temperature when possible

Agitation and psychosis control

›Sedation strategy

›Benzodiazepines first line

›Lorazepam IV 1 mg to 2 mg

›Repeat every 5 minutes to 10 minutes to effect

›Diazepam IV 5 mg to 10 mg

›If severe agitation with immediate danger

›Ketamine IM 4 mg/kg local protocol dependent

›Airway readiness and capnography

›Antipsychotic adjunct for persistent psychosis

›Droperidol IM 5 mg to 10 mg local protocol dependent

›Haloperidol IM 5 mg to 10 mg

›QTc monitoring when feasible

Hyperthermia management

›Cooling and organ protection

›Active external cooling

›Ice packs to axilla and groin

›Evaporative cooling with mist and fan

›IV fluids

›Isotonic crystalloid bolus 10 mL/kg to 20 mL/kg

›Reassess lung exam and oxygenation after each bolus

›Severe hyperthermia with rigidity or refractory agitation

›Intubation for control and safety

›Nondepolarizing paralysis local protocol dependent

›Avoid succinylcholine when rhabdomyolysis or hyperkalemia risk

›Antipyretics

›Limited utility in hyperthermia syndromes

›Prioritize active cooling

Hypertension and tachycardia

›Hemodynamic control principles

›Treat agitation and pain first

›Benzodiazepines reduce catecholamine surge

›Reassess blood pressure after sedation

›Persistent severe hypertension with end organ concern

›Nitroglycerin for ischemic chest pain

›Nitroprusside infusion local protocol dependent

›Phentolamine for suspected alpha mediated crisis local protocol dependent

›Beta blocker cautions

›Avoid isolated beta blocker in cocaine associated chest pain

›Consider specialist input for mixed alpha beta agents local protocol dependent

Chest pain and ACS pathway

›Ischemia management

›Aspirin PO 160 mg to 325 mg if no contraindication

›Nitroglycerin SL 0.4 mg every 5 minutes up to 3 doses if not hypotensive

›Benzodiazepines for sympathetic surge

›Serial troponin and serial ECG

›Cardiology consult for persistent ischemia or ST elevation

Seizure management

›Seizure control

›Benzodiazepines first line

›Lorazepam IV 2 mg to 4 mg

›Repeat once if ongoing seizure

›Second line antiseizure medication

›Levetiracetam IV 60 mg/kg maximum 4500 mg local protocol dependent

›Valproate IV 40 mg/kg local protocol dependent

›Refractory status epilepticus

›Airway control

›Continuous infusion sedation local protocol dependent

Rhabdomyolysis and renal protection

›Rhabdomyolysis bundle

›Aggressive isotonic crystalloid

›Titrate to urine output goal local protocol dependent

›Monitor for pulmonary edema

›Electrolyte management

›Hyperkalemia protocol if present

›Correct hypocalcemia only if symptomatic

›Avoid nephrotoxins

›NSAIDs

›Contrast when alternatives available

Serotonin syndrome branch

›Serotonergic toxicity management

›Stop serotonergic agents

›Benzodiazepines for agitation and myoclonus

›Cyproheptadine PO or NG local protocol dependent

›Initial 12 mg

›Then 2 mg every 2 hours until response

›Maintenance 8 mg every 6 hours

Reassessment loop

›Iterative reassessment

›Vital signs every 5 minutes to 15 minutes in severe cases

›Mental status trend after each medication dose

›Temperature trend during cooling

›Repeat electrolytes and CK based on severity

17Disposition/dispo22

Level of care criteria

›ICU criteria

›Core temperature at or above 40 C

›Refractory severe agitation requiring deep sedation

›Recurrent seizures or status epilepticus

›Ventricular dysrhythmia

›Ongoing ischemia or hemodynamic instability

›Severe metabolic acidosis

›AKI with hyperkalemia or oliguria

Admission and observation

›Inpatient admission criteria

›Rhabdomyolysis with rising creatinine

›Persistent psychosis beyond intoxication window

›Complications requiring serial labs or monitoring

›Observation pathway criteria

›Symptoms improving with stable vital signs

›Normal ECG and negative initial troponin with planned repeat per pathway

›No hyperthermia

Discharge criteria

›ED discharge criteria

›Baseline mental status restored

›Vital signs stable without parenteral sedation

›No chest pain and no ischemic ECG changes

›No evolving lab abnormality suggesting rhabdomyolysis or AKI

›Reliable supervision and follow up

18Discharge Instructions/di23

Copy discharge instructions

›Summary

›You were treated for symptoms consistent with stimulant intoxication

›Stimulants can cause dangerous high temperature heart problems and seizures

›Medications and substances

›Do not use cocaine methamphetamine MDMA or other stimulants

›Avoid energy drinks and high caffeine until fully recovered

›Take only medications as prescribed

›Hydration and rest

›Drink fluids regularly

›Avoid heavy exercise and heat exposure for 48 hours

›Follow up

›Primary care follow up in 1 day to 3 days

›Addiction medicine or counseling referral if willing

›Return to ED now for

›Chest pain

›Trouble breathing

›Fainting

›Severe headache

›Weakness or numbness

›Seizure

›Fever or overheating

›Confusion or severe agitation

›Very dark urine or no urination

19References/r6

Guidelines and key sources

›Core references

›American College of Medical Toxicology guidance on sympathomimetic toxicity management (year varies)

›American Heart Association scientific statement on cocaine associated chest pain and myocardial infarction (2008)

›American Academy of Clinical Toxicology and American College of Medical Toxicology position on serotonin syndrome management (year varies)

›American College of Emergency Physicians clinical policy on severe agitation and chemical sedation in the ED (year varies)

›Wilderness Medical Society practice guidelines for exertional heat illness and heat stroke (year varies)

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.