Four Loko

[HERBIE1]

Just had my first experience with a patient on this alcohol/caffeine drink. I heard bits and pieces about it, about OD's and deaths associated with it, but never- to my knowledge- dealt with someone under the influence of it. To be honest, I had to do some homework on it. For those unfamiliar, let my explain what this stuff is.

Generally sold in 24oz cans, in multiple fruity flavors

the "Four" comes from the original 4 ingredients:

12% alcohol(a fortified malt liquor) by volume- roughly 3 times the ETOH content of a typical beer.

caffeine- the equivalent to 4-6 cups of coffee

guarana(a stimulant similar to, but far more potent than caffeine)

Taurine- an amino acid type chemical- also a stimulant

There have also been accusations the drink contains wormwood, which is the intoxicant found in absinthe

So- 3 stimulants, plus one depressant.

Apparently after the deaths and OD's the FDA forced the company to reformulate the product late last year, and allegedly the removed everything except the alcohol. So- it's now essentially a fruit drink with booze. But-this article claims the original version of the product is still being sold illegally in many stores- at least in the Virginia area as late as July:

http://www.nbc12.com/story/13784441/banned-four-loko-still-being-sold?redirected=true

Our patient: 36 year old female, approximately 150lbs, found unresponsive by boyfriend when he came home from work. He tried the usual ghetto tricks to wake her up- dumping her in a bathtub, dumping ice down her pants- no luck. So- he pulled her out, dried her off, dressed her(nice of him) and placed her sitting up on the couch where we found her. Minimal response to pain- appeared to be very intoxicated, flacid. BF found 2 empty cans of Four Loko- no other alcohol or other drugs present on scene. PMH of HTN- Lisinopril and Flagyl were the meds, NKDA. Also a PMH of IVDA- heroin- last used allegedly 3 months ago. Boyfriend strenuously denied she could be using again, and there was no evidence of fresh needle marks, no drug paraphernalia found by police or crew, no trauma. ALS established.

BP- 140/90, IV established- Blood sugar 137, Sinus Tach at 108, RR 14 but shallow- occasionally snoring respirations. Pupils midrange, equal, reactive but sluggish. Pulse ox 98% initially on room air- 100% with nonrebreather mask. Skin pale, warm, dry. Lungs clear/equal. Nasopharyngeal airway- tolerated well respiratory rate and effort improved. Administered 2mg Naloxone IVP.

Response- repeat vitals after medication- essentially unchanged. After approximately 5-7 minutes, Pt pulled nasal airway, began to be verbal, very slurred and difficult to understand, admitted to the 4 Loko, but denied drug use. Became increasingly more restless and uncooperative, and upon arrival at ER was placed in restraints by staff. Talking now, still highly intoxicated, but denying drug use, stating all she had was the 2 cans of Loko, and was actually singing the praises of the stuff, and actually wished she had more of it. LOL

Hospital was not familiar with similar cases and was doing homework on this as well. I will follow up on this case ASAP and get the results of a toxicology screen, more information, etc.

So- our thoughts- likely heroin use combined with ETOH intoxication. Too coincidental that she became more responsive after the Naloxone. BUT- being unfamiliar with this product, not knowing whether this was the new or old formula, and wondering about the combined physiological effects of these compounds, we simply did not know for certain.

What say you guys? Any familiarity with this stuff?

[DwayneEMTP]

I've not used that stuff, but I once ended up in that exact same condition after reading one of Crotchity's post about his pure soul and love of the Black community....Probably isn't related to this incident..but..does she get on EMTCity?

Dwayne

Edit. Sorry brother, was trying to be funny but then realized that I was just being an ass and didn't answer your question.

I've not treated any of these patients, but I do hear the crew talking about it sometimes. It seems, or seemed at least, to be all the rage. I too will be interested to hear the experiences of others.

Edited September 27, 2011 by DwayneEMTP

[uglyEMT]

Hi Herbie. I have ALOT of experience with this product and some of its variants. Everything you described sounds spot on to our experience. For some reason this crap puts folks on their ass and it gets scary for realitives and bystandards.

I am assuming Naloxone is the same pharma as Narcan. I have seen the turn around after a push of Narcan and the hostility as well. I would love to hear the toxic screen, not because I suspect drug use but would love to see what "other" ingrediants are in Four Loko that are not listed.

[Just Plain Ruff]

Other ingredients not listed, that's the Proprietary blend that so many products have these days.

They can use proprietary blend and not put any of their ingredients because if they told what they had, there woudl be knock off products all over the place.

sounds like some pretty powerful stuff, maybe I'll go get a couple of cans and do a self initiated experiment.

[uglyEMT]

Other ingredients not listed, that's the Proprietary blend that so many products have these days.

They can use proprietary blend and not put any of their ingredients because if they told what they had, there woudl be knock off products all over the place.

sounds like some pretty powerful stuff, maybe I'll go get a couple of cans and do a self initiated experiment.

Exactly my point on the tox screen. I have seen too many of the same reaction and from "drinkers" as well that says to me something else is in there causing this reaction. I look at it this way I haven't seen this reaction from RedBull and Vodka drinkers at parties from just one or two drinks yet most of my Loco patient either finished one started number 2 or didn't even get through the first one.

Something tells me some ingediant is making the ETOH to metabalize in the system much faster then normal. Just as Herbie's patient didn't have vitals too out of wack 140/90, Sinus at 108 (there is your caffine/guarana mix ), sugar at 137 (taurine plus the sugar content) yet this person was unresponsive but reacted to the Naloxone push. Would like to see the BAC that turns up too. If it isn't too bad then something in these drinks are causing an overdose like effect without the person realizing it till it happens.

Best example I can think of is one of my FFs that I know can clean a bottle of Vodka straight and still function tried ONE of these and won a trip to the ED. Looked at us when he came around and said never again and what the hell was in that thing LOL I for one think it plus its variants should be pulled from the shelves, nothing good comes from these things.

[HERBIE1]

The thing that was so frustrating was that like many folks who mix their pharmaceuticals and based on their vitals and exam, you never know exactly what they have ingested. Obviously a straight opiate will constrict pupils, but a stimulant will dilate them. Our patient had midrange- although sluggish pupils. Opiates- and alcohol- depress respirations, but the stimulants do the opposite.

From what I read about this stuff- and other similar formulas I guess- is that the stimulants mask the depressant effects of the alcohol, so even though you may have consumed more than enough alcohol to get drunk, until the stimulants wear off, you don't feel it. Thus, you drink more than you normally would, and as soon as the stimulants are gone, the ETOH hits you like a ton of bricks- the "knock out".

I'm an old fart, so this stuff never existed when I was doing the party scene and out clubbing. I've never had a Red Bull and Vodlka or anything similar, nor do I care to. I don't do energy drinks-good, strong coffee is my stimulant of choice.

When I do get a chance to indulge, I enjoy my premium and hand crafted beers, and an occasional top shelf vodka or gin drink.

Hi Herbie. I have ALOT of experience with this product and some of its variants. Everything you described sounds spot on to our experience. For some reason this crap puts folks on their ass and it gets scary for realitives and bystandards.

I am assuming Naloxone is the same pharma as Narcan. I have seen the turn around after a push of Narcan and the hostility as well. I would love to hear the toxic screen, not because I suspect drug use but would love to see what "other" ingrediants are in Four Loko that are not listed.

Yes- Naloxone is Narcan.

Like I said, allegedly those ingredients are no longer in this drink, but the old stuff is apparently readily available.

I wonder about the wormwood claim. After reading about it, this seems like a pretty serious chemical. Major stimulant, and the reason absinthe is banned in many places is a component in the herb called thujone. Apparently wormwood is found in many things- with low concentrations of the thujone.

Interesting read here:

http://www.webmd.com/vitamins-supplements/ingredientmono-729-WORMWOOD.aspx?activeIngredientId=729&activeIngredientName=WORMWOOD

[DFIB]

Did the patient present nausea or vomiting. I would expect some sort of gastric discomfort from the Flagyl and ETOH mix. Has she been puking a lot and was she possibly dehydrated?

It seems that this drink is bad for the body, I would wonder what effect the metronidazole might have had in her overall condition.

[ERDoc]

Good pickup on the disulfram like reaction, dfib. It can produce the tachycardia and can easily be missed by someone who doesn't think knowing what medications a pt is taking is important. You won't get the lethargy though, but I'd be curious what her alcohol level is. Four Loko looks like it is 12 or 24 proof, so it's a little weak, but when it comes in 23.5oz cans, it is still quite a bit of alcohol.

[DFIB]

Thanks ERDoc I am an amateur at drug interactions but think they are pretty important from a clinical perspective. Not wanting to encroach into your expertise but dehydration could possibly contribute to lethargy. Then again we don't know if she was dehydrated but if so I would expect her condition to improve with IV fluids.

This could be a question and statement in one, Would IV fluids without Narcan be useful in the differential diagnosis or would waiting to observe the effect of fluids alone be considered dangerous in this case?

Caffeine and alcohol also contribute to dehydration but captopril will help retain fluids so this case raises more questions than answers for me.

I am interested in your thoughts.

[Vorenus]

As far as I know, Naloxon or Narcan does only antagonize opiates - I can`t really imagine opiates to be in that drink (never heard of it, though).

There are of course possibilities to produce fluid opiates (i.e. laudanum), though I can`t really imagine that they use opium poppy in that drink.

All the more mysterious, why your patients seem to respond to narcanti - could be coincidence though.

The ingredients that gave Absinth the "kick" in previous times were for the most part absinthin and thujon. Thujon especially triggers hallucinations (can lead to epileptic fits, too). Because of that hallucination aspect, Absinth is also called The Green Fairy (referring to its green colour [at least in the past it was mainly green, there is also black and I think red absinth] and the hallucinations you could get).

In Europe, the amount of Thujon in todays Absinth is confined to 35mg/kg. Don`t know wether such a regulation exists in the US.

I guess you would taste wormwood though, it`s a pretty obvious and characteristic taste and I can`t imagine it mixed with fruit flavours, so I guess there is no wormwood in that drink.