INTRODUCTION:Recreational drugs affect the cardiovascular system through distinct mechanisms; however, data regarding their cardiovascular impact in the emergency department setting is limited. This study aimed to assess the incidence of cardiovascular effects following recreational drug use in presentations to the emergency department, identify the main drug groups involved, and compare cases with and without cardiovascular effects. METHODS:Data were extracted from the European Drug Emergency Network (Euro-DEN Plus) dataset from October 2013 to December 2021. Recreational drugs were categorised into ten main drug groups: opioids, cocaine, crack cocaine, cannabis, 3,4-methylenedioxymethamfetamine, amfetamine-type stimulants, gamma-hydroxybutyrate and gamma-butyrolactone, hallucinogens, benzodiazepines, and ketamine. RESULTS:Among 59,571 presentations, 13,905 (23.3%) involved cardiovascular effects. Cocaine (OR 3.19, 95% CI 2.99-3.39) and 3,4 methylenedioxymethamphetamine (OR 1.18, 95% CI 1.13-1.23) showed the strongest associations with cardiovascular features, including chest pain, palpitations, hypertension, and arrhythmias. Opioids (OR 0.35, 95% CI 0.31-0.38) and benzodiazepines (OR 0.38, 95% CI 0.32-0.44) were associated with less frequent cardiovascular features. Patients with cardiovascular features exhibited higher median values for temperature, heart rate, blood pressure, and respiratory rate (p <0.001). Cardiovascular features were associated with an increased risk of intubation (OR 1.91, 95% CI 1.70-2.15), critical care admission (OR 2.18, 95% CI 2.00-2.38), and mortality (OR 15.8, 95% CI 7.36-33.9). DISCUSSION:Cardiovascular effects were common in acute recreational drug toxicity. Cocaine and amfetamine-type stimulants increased the risk of chest pain and arrhythmias, with chest pain being a key indicator of acute coronary syndrome. Cardiovascular effects were more frequently observed with cocaine than with crack cocaine. Cannabis was positively associated with palpitations but not arrhythmias. Gamma-hydroxybutyrate and gamma-butyrolactone, opioids, and benzodiazepines were linked to hypotension. The presence of cardiovascular effects was associated with worse outcomes, underscoring the need for thorough cardiac assessment. CONCLUSIONS:Cardiovascular effects were present in almost a quarter of emergency department presentations with acute recreational drug toxicity, particularly involving cocaine and 3,4 methylenedioxymethamphetamine.

IntroductionKetamine, an anesthetic and analgesic agent with increasing recreational use, is associated with significant physical and psychiatric harm, yet evidence-based detoxification protocols remain limited. This case series describes the clinical features, management strategies and outcomes of patients admitted for inpatient ketamine detoxification.MethodsA retrospective review was conducted of patients admitted for ketamine detoxification between 2023 and 2025. Data collected included demographics, ketamine use patterns, psychiatric comorbidity, clinical presentation, investigations, treatment and discharge outcomes.ResultsNine patients (5 female; mean age 30.2 +/- 3.4 years) met inclusion criteria. Mean duration of ketamine use was 10.0 +/- 6.5 years, with a median daily intake of 4.3 g. Psychiatric comorbidity was common, including anxiety/depression (n = 4), PTSD (n = 3), ADHD (n = 3) and deliberate self-harm (n = 4). All patients reported urological symptoms, most frequently hematuria and urinary frequency (n = 7 each). Imaging abnormalities were present in three cases. Withdrawal was managed with diazepam (5-20 mg/day) and multimodal analgesia for bladder pain. Median admission length was 7 days.ConclusionsInpatient ketamine detoxification is associated with complex psychiatric and multisystem morbidity. Benzodiazepine-assisted withdrawal, targeted analgesia and coordinated urological follow-up formed key components of management.

Ketamine, initially developed as a dissociative anaesthetic, has seen expanding therapeutic applications, in managing treatment-resistant depression and chronic pain. However, its psychoactive properties have also been associated with a significant rise in recreational use globally. Chronic, high-dose recreational ketamine use is associated with dependence potential and a spectrum of long-term complications affecting multiple organ systems. This narrative review details the major chronic urological, neurological, neuropsychiatric and hepatobiliary complications that clinicians may encounter in individuals with long-term ketamine use, along with an overview of the potential risk of dependence. This review highlights the importance of heightened awareness among clinicians of the issues related to long-term ketamine use, enabling early identification and prompt, appropriate investigation and management.

INTRODUCTION:The Clinical Toxicology Recommendations Collaborative was established by three international clinical toxicology societies and tasked to produce recommendations on the management of poisonings. The Activated Charcoal in Clinical Toxicology Workgroup (the Workgroup) was formed to provide recommendations on the administration of activated charcoal for gastrointestinal decontamination and enhanced elimination in poisoning. METHODS:Based on a systematic review of the literature, 43 poisons or poison categories were selected for appraisal. Voting statements were drafted using a predetermined format. Strength of consensus was measured using the Disagreement Index as defined by the RAND/University of California at Los Angeles Appropriateness Method. A two-round modified Delphi method was used to reach expert consensus. RESULTS:The Workgroup concluded that there is no role for activated charcoal in poisoning from arsenic, caesium, copper, ethanol, methanol, ethylene glycol, iron, lead, lithium, and metformin. Activated charcoal is appropriate after ingestion of antidysrhythmics (types I and III not discussed specifically), beta-adrenergic antagonists, bupropion, calcium-channel blockers, carbamazepine, cardiac glycosides, chloroquine, cocaine, colchicine, cyanide, dapsone, diphenhydramine, disopyramide, factor Xa inhibitors, ibuprofen, isoniazid, lamotrigine, methotrexate, moclobemide, opioids, organophosphorus insecticides, paracetamol (acetaminophen), paraquat, phenobarbital, phenytoin, quinidine and quinine, salicylates, selective serotonin reuptake inhibitors, sulfonylureas, thallium, theophylline, tricyclic antidepressants, valproic acid, venlafaxine, and warfarin. An additional dose of activated charcoal to complete gastrointestinal decontamination is appropriate after ingestion of carbamazepine, paracetamol, paraquat, phenobarbital, salicylates, thallium, theophylline, valproic acid and verapamil. The maximum time post-ingestion for which activated charcoal administration is recommended differs for each poison and different formulations. According to an individualized risk assessment, activated charcoal is appropriate up to 6 h post-ingestion for many poisons. If ongoing absorption is suspected, which may occur, for example, with pharmacobezoar formation, certain modified-release preparations, or when drug burden exceeds the limits of solubility, then activated charcoal can be administered beyond 6 h post-ingestion for gastrointestinal decontamination. Multiple-dose activated charcoal for enhanced elimination is appropriate in poisoning with carbamazepine, cardiac glycosides, colchicine, dapsone, phenobarbital, phenytoin, thallium and theophylline. Before deciding to perform endotracheal intubation to assist with the administration of activated charcoal, every clinician needs to weigh the potential complications and adverse effects of this procedure against the toxicity expected to be prevented by the administration of activated charcoal. This is a challenging decision, and a local poison centre and/or a bedside toxicology consultation can assist with this decision. Endotracheal intubation is not a benign procedure and is associated with a high rate of various adverse events, such as new haemodynamic instability, severe hypoxaemia, and cardiac arrest, which seem more common in children. In three studies that evaluated the risks of endotracheal intubation in over 2,200 poisoned patients, the rates of hypotension were between 1.5% and 11.8%, desaturation between 3.4% and 7.1%, and cardiac arrest in 0.4%. The risk of aspiration following administration of activated charcoal after endotracheal intubation is reported to be low (1-4%). Therefore, the decision to endotracheally intubate a patient to administer activated charcoal needs to carefully assess the patient's other comorbidities and the expected toxicity of the ingestion, which needs to be clinically significant to outweigh the risk of endotracheal intubation. Endotracheal intubation may also be considered if another treatment, such as haemodialysis or extracorporeal circulation, might be required or for transportation to another institution for ongoing clinical care. In these situations, for which endotracheal intubation has been performed for another indication, the risk-benefit will change in favour of activated charcoal administration. The following good practice statements were adopted to address the use of endotracheal intubation to facilitate the administration of activated charcoal. Endotracheal intubation should not be performed solely for the purpose of administration of activated charcoal in patients not anticipated to develop clinically significant complications of poisoning.In patients in whom endotracheal intubation is clinically indicated (e.g., compromised or unprotected airway, respiratory failure, significantly diminished level of consciousness, refractory seizures, hemodynamic instability), insertion of a nasogastric or orogastric tube is reasonable to facilitate gastrointestinal decontamination with activated charcoal.In patients with a clinically significant risk of developing life-threatening toxicity, endotracheal intubation is reasonable to safely facilitate gastrointestinal decontamination, especially if other treatment options are nonexistent or unavailable.Use of nasogastric or orogastric tube insertion without endotracheal intubation to facilitate the administration of activated charcoal: The following good practice statement was adopted: Nasogastric or orogastric tube insertion without endotracheal intubation should not be performed solely for the purpose of administration of AC. DISCUSSION:The decision to use activated charcoal is complex and depends primarily on the nature of the poison(s), the time since ingestion, the severity of the symptoms present at the time of decision or expected based on the dose ingested or patient comorbidities, and the availability of antidotes or other treatments. Although the existing level of evidence is primarily of low or very low quality, clinical decisions are still necessary. CONCLUSIONS:The Workgroup recommends the administration of a single-dose of activated charcoal beyond the traditional 1 h post-ingestion time point in selected poisons and introduces the concept of an additional dose of activated charcoal to prevent further absorption of poisons that may remain in the gastrointestinal tract for prolonged periods of time. Multiple-dose activated charcoal is also recommended to enhance elimination in selected clinical scenarios.

INTRODUCTION:Paracetamol (acetaminophen) poisoning is common, and many publications describe various outcomes and treatments. As internationally agreed definitions are non-existent to describe patterns of paracetamol overdose (acute, repeated supratherapeutic, chronic, or staggered), it is difficult to analyze outcomes between studies. The Clinical Toxicology Recommendations Collaborative was tasked to provide guidance on the management of paracetamol poisoning and formed the Paracetamol Workgroup. The Workgroup concluded that an agreed set of terms was needed to perform the systematic review and categorize the evidence. METHODS:A modified Delphi process was employed to establish uniform definitions to categorize various patterns of paracetamol overdose. RESULTS:Group consensus was reached for each one of the following standard definitions for each pattern of poisoning: acute, staggered, repeated supratherapeutic ingestions, and chronic for use in their upcoming systematic review. "Acute" ingestion represents an excessive amount of paracetamol ingested over a total time (from first paracetamol dose ingested to last paracetamol dose ingested) of less than 8 h. "Staggered" ingestion involves an excessive amount of paracetamol ingested over a total time period of between 8 h and 24 h. "Repeated supratherapeutic ingestion" describes ingestions exceeding the recommended daily dose for more than 24 h, and "chronic" ingestion includes both staggered or repeated supratherapeutic ingestions. "High-risk overdoses" are defined by either an ingested dose, that is greater than 500 mg/kg or 30 g (whichever is less), or an initial serum or plasma paracetamol concentration of greater than 300 mg/L (1,985 µmol/L) at 4 h on the Rumack-Matthew nomogram line. DISCUSSION:The definitions established by the Paracetamol Workgroup will structure the upcoming systematic review, ensuring consistent categorization of studies within each ingestion pattern to enable clearer comparisons of treatments and outcomes. CONCLUSION:We encourage researchers to define overdose patterns and patients at increased risk of hepatotoxicity consistently and to include these definitions in publications to improve research reliability and comparability.