serotonin (5-hydroxytryptamine) This class of drugs is often used orally or sublingually either in powder form or on blotter paper Clinical Considerations For LSD, the somatic symptoms of dizziness, weakness, drowsiness, nausea, and paresthesias may be observed after one oral dose of 0.5 to mcg/kg Between the dose range of and 16 mcg/kg, the intensity of LSD’s psychoactive effects is proportional to the dose A typical LSD “hit” is 200 to 400 mcg A high degree of tolerance develops after three to four daily doses, with sensitivity returning after a drug-free interval In general, the somatic effects of hallucinogens are sympathomimetic and serotonergic and include pupillary dilation, hypertension, tachycardia, hyperreflexia, and hyperpyrexia Doses of LSD as low as 20 to 25 mcg can produce CNS effects such as euphoria, visual perceptual distortions, alteration of subjective time so time passes slowly, lability of mood, or even an acute panic episode Hallucinations and psychosis with hyperalertness are commonly seen The clinical duration of action of LSD is somewhat dose dependent but averages to 12 hours The psychedelic state includes a heightened awareness of sensory input, often accompanied by an enhanced sense of clarity but a diminished control over what is experienced There is often a feeling that one part of the self is a passive observer while another part receives vivid sensory input The ability to separate one object from another or to separate self from the environment is diminished There is an enhanced sense of oneness with humanity Some of the LSD analogs and 2C drugs may cause more significant clinical toxicity, including seizures, serotonin syndrome, rhabdomyolysis, and acute kidney injury Pay specific attention to mental status and vital signs, including temperature Because LSD is ingested in minuscule doses and onset of symptoms occurs hours after ingestion, GI decontamination is unnecessary, unless coingestion is suspected In cases of significant clinical toxicity, consider laboratory testing for creatine kinase and renal function LSD and analogs are not typically included on standard urine toxicology screens and ongoing evolution of emerging compounds limits detection even on more comprehensive testing Management is thus based on history of exposure, suspicion of exposure based on assessment, and clinical severity of presentation Clinical management involves placing the patient in a quiet room Someone who knows the patient may be able to quietly “talk down” and reassure the patient The patient’s loss of boundaries and fear of fragmentation or selfdisintegration create a need for a structuring or a supportive environment