hey dude! how did i get here? melinda lucas, m.s., m.d., f.a.a.p. southwest virginia pediatric...
TRANSCRIPT
Hey Dude! How Hey Dude! How Did I Get Here?Did I Get Here?
Melinda Lucas, M.S., M.D., Melinda Lucas, M.S., M.D., F.A.A.P.F.A.A.P.
SouthWest Virginia Pediatric SouthWest Virginia Pediatric Conference, August 4-5, 2012Conference, August 4-5, 2012
Disclosure Statement of Disclosure Statement of Financial InterestFinancial Interest
Melinda Lucas DOES NOT have a Melinda Lucas DOES NOT have a financial interest/arrangement or financial interest/arrangement or affiliation with one or more affiliation with one or more organizations that could be organizations that could be perceived as a real or apparent perceived as a real or apparent conflict of interest in the context of conflict of interest in the context of the subject of this presentation. the subject of this presentation.
Conflict of InteConflict of Interrest est DisclosureDisclosure
All individuals who participate in sponsored All individuals who participate in sponsored activities are expected to disclose any significant activities are expected to disclose any significant financial relationships that may pose a conflict financial relationships that may pose a conflict with the principles of balance and independence.with the principles of balance and independence.
In the past 12 months neither Melinda Lucas nor In the past 12 months neither Melinda Lucas nor any member of her family has had a financial or any member of her family has had a financial or beneficial relationship with one or more of the beneficial relationship with one or more of the following commercial entities: grant/research following commercial entities: grant/research support, other remuneration (Speaker’s Bureau, support, other remuneration (Speaker’s Bureau, honoraria, travel expenses, etc.), Major honoraria, travel expenses, etc.), Major Stock/share holder (not mutual funds), Advisory Stock/share holder (not mutual funds), Advisory Board; Ownership or PartnershipBoard; Ownership or Partnership. .
Learning ObjectivesLearning Objectives
Develop a differential diagnosis for Develop a differential diagnosis for patients with hallucinations and an patients with hallucinations and an altered state of consciousnessaltered state of consciousness
Understand the impact of social Understand the impact of social media on illicit drug usagemedia on illicit drug usage
Become familiar with the toxidromes Become familiar with the toxidromes for 2 designer drugs. for 2 designer drugs.
Alice In WonderlandAlice In Wonderland
11 Year Old Female11 Year Old Female Fever, cough, Coryza, & Myalgias for Fever, cough, Coryza, & Myalgias for
3 days3 days Night-time Audio and Visual Night-time Audio and Visual
HallucinationsHallucinations Pictures Zoomed in and out which Pictures Zoomed in and out which
scared her scared her Alleged her parents were talking and Alleged her parents were talking and
moving in very, very slow motionmoving in very, very slow motion
Alice in WonderlandAlice in Wonderland
Negative PMH; No MigrainesNegative PMH; No Migraines Family History negative for Migraines, Family History negative for Migraines, Tamiflu (oseltamivir phosphate) for 24 hoursTamiflu (oseltamivir phosphate) for 24 hours Vital Signs: Temp 36.8Vital Signs: Temp 36.8ooC, Heart Rate 107 C, Heart Rate 107
bpm, BP 92/68 mm Hg, Pulse Ox 98% Room bpm, BP 92/68 mm Hg, Pulse Ox 98% Room AirAir
Physical Exam: no meningeal irritation; Physical Exam: no meningeal irritation; Cranial Nerves 2-12 Normal, Cerebellar Cranial Nerves 2-12 Normal, Cerebellar Function Normal Motor and Sensory Function Normal Motor and Sensory Systems NormalSystems Normal
Alice in WonderlandAlice in Wonderland
Labs:Labs: CBC & diff NormalCBC & diff Normal CMP NormalCMP Normal EBV Serology NegativeEBV Serology Negative H1N1 PCR PositiveH1N1 PCR Positive
Clinical Course: Clinical Course: Flu symptoms resolved in 2 daysFlu symptoms resolved in 2 days Neurological symptoms resolved in 2 Neurological symptoms resolved in 2
daysdays Tamiflu stopped after 5 day course.Tamiflu stopped after 5 day course.
Alice in WonderlandAlice in Wonderland
First Described by John Todd, an First Described by John Todd, an English psychiatrist, in 1955English psychiatrist, in 1955
Disorienting Neurological ConditionDisorienting Neurological Condition Temporary ConditionTemporary Condition
Alice in WonderlandAlice in Wonderland
Visual Distortions Visual Distortions MicropsiaMicropsia MacropsiaMacropsia
Distorted Perception of other Distorted Perception of other Sensory modalitiesSensory modalities TimeTime TouchTouch SoundSound
Alice in WonderlandAlice in Wonderland
Associated withAssociated with MigrainesMigraines Brain TumorsBrain Tumors Psychoactive DrugsPsychoactive Drugs Initial Presentation of Epstein-Barr Initial Presentation of Epstein-Barr
VirusVirus InfluenzaInfluenza
Usually Influenza AUsually Influenza A Can be H1N1Can be H1N1
Alice in WonderlandAlice in Wonderland
Take Home MessagesTake Home Messages Medical Illnesses can present with Medical Illnesses can present with
visual and auditory changes or visual and auditory changes or hallucinationshallucinations
Mental Health Problems can present Mental Health Problems can present with hallucinationswith hallucinations
Psychotropic Drugs can also cause Psychotropic Drugs can also cause hallucinations and/or visual & auditory hallucinations and/or visual & auditory changeschanges
The Spice GirlThe Spice Girl
17 year old girl 11 weeks gestation17 year old girl 11 weeks gestation Bipolar Disorder and Depression Bipolar Disorder and Depression
HistoryHistory Stayed at friend’s house until afternoonStayed at friend’s house until afternoon Slept 2-6 p.m. Slept 2-6 p.m. Awoke with Nausea, dizziness, thirst, Awoke with Nausea, dizziness, thirst,
heart racing, unable to void heart racing, unable to void Visual and Auditory HallucinationsVisual and Auditory Hallucinations Medications: Prenatal VitaminsMedications: Prenatal Vitamins
The Spice GirlThe Spice Girl PMH: PMH:
Cutting BehaviorsCutting Behaviors 2 Inpatient Psychiatric Admissions2 Inpatient Psychiatric Admissions Psychiatric Medications self-discontinuedPsychiatric Medications self-discontinued Last Psychiatric Visit > 1 year agoLast Psychiatric Visit > 1 year ago Prior user of Cocaine and CannabisPrior user of Cocaine and Cannabis SmokerSmoker Prenatal Care started 2 weeks ago Prenatal Care started 2 weeks ago
SH SH Broke up with boyfriend recently Broke up with boyfriend recently
(father of unborn child)(father of unborn child)
The Spice GirlThe Spice Girl PE:PE:
Denies suicidal & homicidal tendenciesDenies suicidal & homicidal tendencies Denies thoughts of wanting to hurt unborn childDenies thoughts of wanting to hurt unborn child Vital Signs: Temp 97Vital Signs: Temp 97ooF; HR 150; BP 115/51 mm F; HR 150; BP 115/51 mm
Hg; Pulse Oximeter 100% Room AirHg; Pulse Oximeter 100% Room Air Alert, Anxious, awakeAlert, Anxious, awake Warm, Dry Skin without flushingWarm, Dry Skin without flushing PERRLA, No nystagmus, Pupils 3 mmPERRLA, No nystagmus, Pupils 3 mm Dry MouthDry Mouth Normal ThyroidNormal Thyroid Tachycardia without MurmurTachycardia without Murmur Normal Neurological Exam except for visual and Normal Neurological Exam except for visual and
auditory hallucinationsauditory hallucinations
The Spice GirlThe Spice Girl
Lab:Lab: Normal Urine Drug Screen for Normal Urine Drug Screen for
amphetamines, barbiturates, amphetamines, barbiturates, benzodiazepines, cocaine, opiates, benzodiazepines, cocaine, opiates, phencyclidine, cannabis using kinetic phencyclidine, cannabis using kinetic interactions of micro particles techniqueinteractions of micro particles technique
Negative blood tests for ethanol, Negative blood tests for ethanol, acetaminophen, salicylatesacetaminophen, salicylates
EKG with 130 beats per minute, QRS EKG with 130 beats per minute, QRS interval 86 milli seconds, QTc interval of interval 86 milli seconds, QTc interval of 380 milliseconds, no ischemia, 380 milliseconds, no ischemia, NOT SVTNOT SVT
The Spice GirlThe Spice Girl TreatmentTreatment
20 mL/kg Normal Saline IV20 mL/kg Normal Saline IV Ultrasound of Pelvis with single live Ultrasound of Pelvis with single live
intrauterine pregnancy at 12 weeks 2 daysintrauterine pregnancy at 12 weeks 2 days Admitted for ObservationAdmitted for Observation 2 Episodes of hypotension (70/30 mm Hg) 2 Episodes of hypotension (70/30 mm Hg)
treated with IV NS – 20 mL/kg eachtreated with IV NS – 20 mL/kg each Hallucinations Resolved over 2 daysHallucinations Resolved over 2 days
Confessed to ingestion of a powder Confessed to ingestion of a powder from her mother’s spike rack to get from her mother’s spike rack to get high high instructions on T.V. instructions on T.V.
The Spice GirlThe Spice Girl
NutmegNutmeg Abortifacient by American & English Abortifacient by American & English
women in late 19women in late 19thth & early 20 & early 20thth century. century. Euphoric and Hallucinogenic effects Euphoric and Hallucinogenic effects
with low cost and ease of availabilitywith low cost and ease of availability Spice obtained by grating the kernel Spice obtained by grating the kernel
within the fruit of the nutmeg tree.within the fruit of the nutmeg tree. Mace is made from the red-laced Mace is made from the red-laced
membrane surrounding the seed.membrane surrounding the seed.
The Spice GirlThe Spice Girl Nutmeg comes from the evergreen tree, Nutmeg comes from the evergreen tree,
Myristica fragransMyristica fragrans, & is a mixture of , & is a mixture of compounds:compounds: Aromatic (myristicin, elemicin, and safrole)Aromatic (myristicin, elemicin, and safrole) Terpene (eugenol and mace)Terpene (eugenol and mace) Compositions vary with differences in Compositions vary with differences in
quality, storage, purifying and processingquality, storage, purifying and processing Elemicin chemically closely resembles Elemicin chemically closely resembles
mescalinemescaline Myristicin is closely related to 3-methoxy-Myristicin is closely related to 3-methoxy-
4,5 methylenedioxyamphetamine.4,5 methylenedioxyamphetamine.
The Spice GirlThe Spice Girl
Atropine-Like Syndrome or mistaken Atropine-Like Syndrome or mistaken for pure antichoinergic toxicityfor pure antichoinergic toxicity Dry mouthDry mouth Facial flushingFacial flushing NauseaNausea Unsteadiness (dizzy)Unsteadiness (dizzy) Epigastric PainEpigastric Pain Urinary RetentionUrinary Retention Blurred VisionBlurred Vision
The Spice GirlThe Spice Girl Sympathomimetic and Serotonergic Sympathomimetic and Serotonergic
EffectsEffects Cardiovascular EffectsCardiovascular Effects
Sinus TachycardiaSinus Tachycardia PalpitationsPalpitations HypotensionHypotension
Central Nervous System EffectsCentral Nervous System Effects Hallucinations - 14% of usersHallucinations - 14% of users PsychosisPsychosis AnxietyAnxiety DrowsinessDrowsiness FearFear ParesthesiasParesthesias
The Spice GirlThe Spice Girl SymptomsSymptoms
Ingestions of >10 g of nutmegIngestions of >10 g of nutmeg 1-3 whole nuts or 1-2 TBSP ground nutmeg1-3 whole nuts or 1-2 TBSP ground nutmeg
Appear 3-6 hours after ingestionAppear 3-6 hours after ingestion Duration of 24-48 hoursDuration of 24-48 hours
TreatmentTreatment Supportive care for agitation, Supportive care for agitation,
hypotension, and psychiatric symptomshypotension, and psychiatric symptoms
Legal HighsLegal Highs Nutmeg Nutmeg (Myristica fragrans)(Myristica fragrans) Morning glory Morning glory (Ipomoea violecea): (Ipomoea violecea):
lysergic acid amide, a hallucinogenlysergic acid amide, a hallucinogen Kava kava Kava kava (Piper methysticum(Piper methysticum))
Kava lactones = sedation & hallucinations Kava lactones = sedation & hallucinations Kratom Kratom (Mitragyna speciosa)(Mitragyna speciosa)
mitragynine, a low dose stimulent & high dose narcoticmitragynine, a low dose stimulent & high dose narcotic Jimson Weed Jimson Weed (Datura stramonium)(Datura stramonium)
Belladonna alkaloids, atropine, scopolaine, Belladonna alkaloids, atropine, scopolaine, hyoscyamine = delerium, hallucinations, hyoscyamine = delerium, hallucinations, anticholinergic syndromeanticholinergic syndrome
Salvia divinoriumSalvia divinorium Salvinorin A: subtle high to vivid psychedelic Salvinorin A: subtle high to vivid psychedelic
experienceexperience
The Spice GirlThe Spice Girl
Take Home MessageTake Home Message Sources of information may be from Sources of information may be from
unverified sources such as T.V., unverified sources such as T.V., online online encyclopediasencyclopedias, You Tube, online “trip , You Tube, online “trip reports”, tweets & blogs, and “how-to” reports”, tweets & blogs, and “how-to” information on the Webinformation on the Web
Conventional intoxicants and “legal highs” Conventional intoxicants and “legal highs” are a trend with adolescents.are a trend with adolescents.
Reliable web sites:Reliable web sites: www.herbmed.org; ;
www.mskcc.org/aboutherbswww.mskcc.org/aboutherbs
Mountain Mike Mountain Mike
15 year old brought to ER by EMS 15 year old brought to ER by EMS for violence, crazy behavior, and for violence, crazy behavior, and visual hallucinations.visual hallucinations.
15 minutes prior to calling EMS he 15 minutes prior to calling EMS he took a Single Bong Hit from a water took a Single Bong Hit from a water pipe.pipe.
Prior History of being high before, Prior History of being high before, but not like thisbut not like this
Mountain MikeMountain Mike
Physical ExamPhysical Exam Restless, anxiousRestless, anxious Oriented to person, place, timeOriented to person, place, time Complains legs feel numb and twitchy Complains legs feel numb and twitchy Vital Signs: HR 120 bpm; BP 135/85 mm Vital Signs: HR 120 bpm; BP 135/85 mm
Hg; afebrile; pulse oximeter 98% room airHg; afebrile; pulse oximeter 98% room air PERRLA, EOMs intact, Pupils slightly PERRLA, EOMs intact, Pupils slightly
dilateddilated Moist MembranesMoist Membranes Normal ThyroidNormal Thyroid
Mountain MikeMountain Mike
PEPE Chest exam normalChest exam normal CV exam no murmur or gallop; otherwise CV exam no murmur or gallop; otherwise
normalnormal Abdominal exam normalAbdominal exam normal Skin: sweaty, no flushing of skin, no rashSkin: sweaty, no flushing of skin, no rash Neurological: Normal cranial nerves, no Neurological: Normal cranial nerves, no
clonus, normal strength and sensation in clonus, normal strength and sensation in extremities; extremities; fasciculationsfasciculations in quadricep in quadricep muscles.muscles.
Mountain MikeMountain Mike
LabLab Glucose normal – not elevated or lowGlucose normal – not elevated or low CMP: CMP: Potassium 2.9 mEq/Potassium 2.9 mEq/L; normal L; normal
otherwiseotherwise Ethanol negativeEthanol negative Urine radioimmunoassay (RIA) for Urine radioimmunoassay (RIA) for
amphetamines, barbiturates, amphetamines, barbiturates, benzodiazepines, cocaine, opiates , and benzodiazepines, cocaine, opiates , and phencyclidine (PCP) is negative. phencyclidine (PCP) is negative. Positive Positive for Tetrahydrocannabiolfor Tetrahydrocannabiol
Mountain MikeMountain Mike TreatmentTreatment
Lorazepam 2 mg IVLorazepam 2 mg IV HR decreases to 95 bpmHR decreases to 95 bpm CalmerCalmer
Observation for 6 hoursObservation for 6 hours Confused as to how he got to hospitalConfused as to how he got to hospital
3 Friends taken to same hospital after 3 Friends taken to same hospital after trying a new marijuana for the first trying a new marijuana for the first timetime
Mountain MikeMountain Mike Acute Marijuana IntoxicationAcute Marijuana Intoxication
Increase Heart RateIncrease Heart Rate Increase Blood PressureIncrease Blood Pressure Euphoria and a Sense of DetachmentEuphoria and a Sense of Detachment Unpleasurable experience rare Unpleasurable experience rare
inconsistent with patient’s prior historyinconsistent with patient’s prior history Dysphoria with Large Doses and Dysphoria with Large Doses and
assosciated with panic, anxiety or assosciated with panic, anxiety or depression – Not agitationdepression – Not agitation
Agitation NOT TYPICALAgitation NOT TYPICAL Hypokalemia NOT TYPICAL unless Hypokalemia NOT TYPICAL unless
malnourished in a habitual drug usermalnourished in a habitual drug user
Mountain MikeMountain Mike New MarijuanaNew Marijuana
? Grown with advanced horticultural techniques which ? Grown with advanced horticultural techniques which have increased psychoactive potencyhave increased psychoactive potency
? Marijuana with addition of another psychoactive ? Marijuana with addition of another psychoactive substance such as substance such as
EcstasyEcstasy Clenbuterol : B-adrenergic agonistClenbuterol : B-adrenergic agonist PCP: cyrstal joint, supergrass, dipper, illy, fry, wetPCP: cyrstal joint, supergrass, dipper, illy, fry, wet Freebase or Powdered Cocaine: dusting, snowcappingFreebase or Powdered Cocaine: dusting, snowcapping
? Different botanical entity being smoked? Different botanical entity being smoked Salvia divinorumSalvia divinorum: legal marijuana, herbal smoke, herbal : legal marijuana, herbal smoke, herbal
marijuanamarijuana Mephedrone derived from khat plan (Mephedrone derived from khat plan (catha eduliscatha edulis))
? Chemical entity being smoked? Chemical entity being smoked Herbal incense, herbal smoke Herbal incense, herbal smoke PotpourriPotpourri IncenseIncense Mixture of 1 or more synthetic cannabinoids Mixture of 1 or more synthetic cannabinoids
Mountain MikeMountain Mike
Synthetic CannabinoidsSynthetic Cannabinoids Different chemical structure than 11-nor-9-Different chemical structure than 11-nor-9-
carboxytetrahydrocannabinolcarboxytetrahydrocannabinol Most common molecule tested in UDSMost common molecule tested in UDS
Gas chromatography-mass spectrometry in Gas chromatography-mass spectrometry in highly specialized laboratorieshighly specialized laboratories
4 Selected synthetic cannabinoids4 Selected synthetic cannabinoids JWH-018 JWH-018 JWH-073JWH-073 CP-47,497CP-47,497 HU-210HU-210
Mountain MikeMountain Mike Synthetic CannabinoidsSynthetic Cannabinoids
Brand NamesBrand Names K 2 after second highest mountain on earthK 2 after second highest mountain on earth
(28,251 ft (28,251 ft Deadly to inexperienced climbersDeadly to inexperienced climbers
Spice after spice from Frank Herbert’s book Spice after spice from Frank Herbert’s book DuneDune JWH-018JWH-018
Sold over the Internet to a private residence Sold over the Internet to a private residence for research laboratory purposes only and for research laboratory purposes only and comes with a disclaimercomes with a disclaimer
Sold at certain “convenience” storesSold at certain “convenience” stores Sold at “head shops” or drug paraphenalia Sold at “head shops” or drug paraphenalia
shopsshops
Mountain MikeMountain Mike
K-2 or Spice ToxidromeK-2 or Spice Toxidrome HypokalemiaHypokalemia TremorsTremors AgitationAgitation HallucinationsHallucinations AnxietyAnxiety TachycardiaTachycardia Elevated Blood PressureElevated Blood Pressure PallorPallor VomitingVomiting
Mountain MikeMountain Mike
Take Home MessageTake Home Message Anticipatory GuidanceAnticipatory Guidance
Manufacture not regulatedManufacture not regulated Full range of immediate adverse effects unknownFull range of immediate adverse effects unknown Long-term consequences of synthetic cannabinoids Long-term consequences of synthetic cannabinoids
and the derivatives are unknownand the derivatives are unknown Tolerance and physiological withdrawal have been Tolerance and physiological withdrawal have been
reportedreported If the symptoms do not add up, suspect If the symptoms do not add up, suspect
“incense”“incense” State-specific guidelines about possession existState-specific guidelines about possession exist FDA bans sale and importation FDA bans sale and importation
Aggressive AndyAggressive Andy 14 year old with ADHD brought to ED 14 year old with ADHD brought to ED
for a mental status exam by policefor a mental status exam by police Police called to residence by mother Police called to residence by mother
because patient threatening to kill her because patient threatening to kill her and destroying walls and furnitureand destroying walls and furniture
Mother states patient was in bedroom Mother states patient was in bedroom and emerged with intermittent and emerged with intermittent confusion and aggressionconfusion and aggression
May have been hallucinating for May have been hallucinating for several days, and seems to be hiding several days, and seems to be hiding from someone, but no one aroundfrom someone, but no one around
Aggressive AndyAggressive Andy
Patient uncomfortable and Patient uncomfortable and complains of chest pain and his complains of chest pain and his heart racingheart racing
Intermittent racing of heart for Intermittent racing of heart for several daysseveral days
Thoughts race through his brainThoughts race through his brain Panicking as thoughts racePanicking as thoughts race Very hungry but cannot eat Very hungry but cannot eat
Aggressive AndyAggressive Andy No medicationsNo medications
Self-stopped medications for ADHD years ago Self-stopped medications for ADHD years ago because they were costlybecause they were costly
SH denies substance abuse initially but SH denies substance abuse initially but later admits to alcohol (three 12 packs later admits to alcohol (three 12 packs each weekend), cigarettes (1 ppd), K-2 or each weekend), cigarettes (1 ppd), K-2 or Spice if horticultural marijuana not Spice if horticultural marijuana not available (2-4 joints 2 times a day), available (2-4 joints 2 times a day), mother’s Xanax, tried meth and cocaine mother’s Xanax, tried meth and cocaine recentlyrecently
Admits to taking mother’s Xanax tonight Admits to taking mother’s Xanax tonight and also the “white powder” she uses and also the “white powder” she uses when upset and needs to laughwhen upset and needs to laugh
Aggressive AndyAggressive Andy
Physical ExamPhysical Exam HR 250HR 250 BP 161/110 mm HgBP 161/110 mm Hg Temp 37.6Temp 37.6ooCC RR 22-30/minuteRR 22-30/minute Restless - hands & feet in constant Restless - hands & feet in constant
motion motion No eye ContactNo eye Contact Very short attention spanVery short attention span Exasperated with all questionsExasperated with all questions
Aggressive AndyAggressive Andy PEPE
Dilated, reactive pupils without nystagmusDilated, reactive pupils without nystagmus Normal nares, nasal septum, oral pharynxNormal nares, nasal septum, oral pharynx No goiterNo goiter Chest clearChest clear CV with tachycardia, but normal pulses and CV with tachycardia, but normal pulses and
perfusion and warm pink extremitiesperfusion and warm pink extremities No liver or spleen enlargement No liver or spleen enlargement Sweaty skinSweaty skin
Aggressive AndyAggressive Andy
PEPE Cranial Nerves 2-12 intact, Motor Cranial Nerves 2-12 intact, Motor
strength and tone normal, normal DTR, strength and tone normal, normal DTR, alert and able to answer questions but alert and able to answer questions but concerned about chest pain, concerned about chest pain,
Tremor in outstretched handsTremor in outstretched hands
Aggressive AndyAggressive Andy LabLab
CMP normalCMP normal Glucose NormalGlucose Normal Ethanol Not detectedEthanol Not detected Commercial radioimmunoassay of urine for Commercial radioimmunoassay of urine for
amphetamines, benzodiazepines, amphetamines, benzodiazepines, barbiturates, cannabis, cocaine, opoids barbiturates, cannabis, cocaine, opoids was negativewas negative
CXR NormalCXR Normal CT head NormalCT head Normal
EKG: SVTEKG: SVT
Aggressive AndyAggressive Andy
TreatmentTreatment IVF with 20 mL/kg Normal saline bolusIVF with 20 mL/kg Normal saline bolus Adenosine X 2 with HR converting for Adenosine X 2 with HR converting for
20 seconds 20 seconds Response to Cardizem (diltiazem) with Response to Cardizem (diltiazem) with
HR 220.HR 220.
Aggressive AndyAggressive Andy
Impression:Impression: Compensated SVTCompensated SVT Hypertension unusual for SVTHypertension unusual for SVT Agitation and Aggression Worrisome for Agitation and Aggression Worrisome for
Safety of Health Care Providers, safety of Safety of Health Care Providers, safety of patientpatient
Overdose/Ingestion of ? Bath Salts or K-2Overdose/Ingestion of ? Bath Salts or K-2 Binge Drinking and habitual substance Binge Drinking and habitual substance
abuseabuse ADHDADHD
Aggressive AndyAggressive Andy Transfer to PICU requested - utilizing HelicopterTransfer to PICU requested - utilizing Helicopter Patient refused stretcher and restraints and became Patient refused stretcher and restraints and became
aggressive and threateningaggressive and threatening Helicopter Pilot refuses to fly uncooperative patientHelicopter Pilot refuses to fly uncooperative patient Ativan 4 mg IV given X 2 and patient settlesAtivan 4 mg IV given X 2 and patient settles Ground transport with EMS and helicopter crew Ground transport with EMS and helicopter crew
transports patient to PICUtransports patient to PICU Patient restrained and cooperative in SVT with talk Patient restrained and cooperative in SVT with talk
downdown 2-4 hours later patient converts from “stable SVT” to 2-4 hours later patient converts from “stable SVT” to
NSR after maximum dose of cardizem bolus and drip NSR after maximum dose of cardizem bolus and drip used.used.
Admits to snorting some saltAdmits to snorting some salt Leaves AMA 2 days later with Mother and GF’s Leaves AMA 2 days later with Mother and GF’s
assistanceassistance
Aggressive AndyAggressive Andy Diagnosis of ExclusionDiagnosis of Exclusion
Urine Toxicology for PCP, Cocaine, AmphetaminesUrine Toxicology for PCP, Cocaine, Amphetamines Serum Alcohol LevelSerum Alcohol Level BMP for Electrolyte ImbalancesBMP for Electrolyte Imbalances Bedside GlucoseBedside Glucose ABG as metabolic acidosis seen with ABG as metabolic acidosis seen with
sympathomimetic toxicologysympathomimetic toxicology CBC & Diff for infection or severe anemiaCBC & Diff for infection or severe anemia CT head for subarachnoid hemorrhage or CT head for subarachnoid hemorrhage or
hydrocephalushydrocephalus 12 – Lead EKG for arythmia or ischemia12 – Lead EKG for arythmia or ischemia Consider Troponin, CPK-MB, MyoglobinConsider Troponin, CPK-MB, Myoglobin
Aggressive AndyAggressive Andy
Definitive DiagnosisDefinitive Diagnosis Specific high performance liquid Specific high performance liquid
chromatography/tandem mass chromatography/tandem mass spectroscopy of the urine for MDPV and spectroscopy of the urine for MDPV and MephedroneMephedrone
Aggressive AndyAggressive Andy
Other ComplicationsOther Complications Cardiac (up to 2 weeks later)Cardiac (up to 2 weeks later)
TachycardiaTachycardia Hypertension Hypertension
HyperthermiaHyperthermia Renal: Renal:
RhabdomyolysisRhabdomyolysis RespiratoryRespiratory
Aspiration PneumoniaAspiration Pneumonia Delerium Delerium
Aggressive AndyAggressive Andy
Other Complications:Other Complications: Neurological: Neurological:
SeizuresSeizures Intracerebral HemorrhageIntracerebral Hemorrhage
MyopathyMyopathy Critical Illness Myopathy/PolyneuropathyCritical Illness Myopathy/Polyneuropathy GI: intestinal GI: intestinal infarction/ischemiainfarction/ischemia
Other polydrug usage complications/contaminants Manganism from potassium permanganate
exposure
Aggressive AndyAggressive Andy
Contaminants/Contaminants/ Levamisole: Levamisole:
agranulocytosis/thrombotic eventsagranulocytosis/thrombotic events Hallucinations Hallucinations Prolonged AnxietyProlonged Anxiety SeizuresSeizures Panic AttacksPanic Attacks Deaths Deaths
Aggressive AndyAggressive Andy Bath SaltsBath Salts
Not Epsom salts or spa-type bath saltsNot Epsom salts or spa-type bath salts Drugs of abuse marketed with an innocent Drugs of abuse marketed with an innocent
namename Bypass current U.S. drug laws Bypass current U.S. drug laws
Known as White Rush Bath SaltsKnown as White Rush Bath Salts Sold as “plant food”Sold as “plant food” Sold as “insect repellant”Sold as “insect repellant” Sold over the internetSold over the internet Sold at small convenience gas station marketsSold at small convenience gas station markets Sold at selective stores like “head shops”Sold at selective stores like “head shops”
Aggressive AndyAggressive Andy Other Names for the bath saltsOther Names for the bath salts
BlissBliss Blue SilkBlue Silk Down2Earth White HorseDown2Earth White Horse Energizing AromatherapyEnergizing Aromatherapy Ivory WaveIvory Wave KamikazeKamikaze Purple WavePurple Wave Red DoveRed Dove Vanilla SkyVanilla Sky White LightningWhite Lightning
Aggressive AndyAggressive Andy Bath SaltsBath Salts
White, tan, or brown powderWhite, tan, or brown powder Usually “clumpy”Usually “clumpy” Encapsulated or crystalEncapsulated or crystal Packages of 50-200 mg or large vials of Packages of 50-200 mg or large vials of
500 mg of “cathinone”500 mg of “cathinone” Pharmacological Effect depends on purity, Pharmacological Effect depends on purity,
concentration, and filler propertiesconcentration, and filler properties POPO, Rectal insertion, , Rectal insertion, SnortedSnorted
(insufflated), Injected or Smoked (insufflated), Injected or Smoked Onset of action, Peak, and Duration Onset of action, Peak, and Duration
depends on route of administrationdepends on route of administration
Aggressive AndyAggressive Andy
Sympathomimetic ToxidromeSympathomimetic Toxidrome InsomniaInsomnia AgitationAgitation Tachycardia/ SVTTachycardia/ SVT HypertensionHypertension MydriasisMydriasis DiaphoresisDiaphoresis TremorTremor
Aggressive AndyAggressive Andy
Other Substances Causing Other Substances Causing Sympathomimetic ToxidromesSympathomimetic Toxidromes AmphetamineAmphetamine MethamphetamineMethamphetamine CocaineCocaine Prescription Drugs for ADHDPrescription Drugs for ADHD
Aggressive AndyAggressive Andy DEA DEA
Schedule 1Schedule 1 Ecstasy (MDMA)Ecstasy (MDMA) Mushrooms (psilocybin)Mushrooms (psilocybin) LSDLSD Mescaline (peyote active ingredient)Mescaline (peyote active ingredient)
October 2011October 2011 Illegal to possess or sell the chemicals in Illegal to possess or sell the chemicals in
bath salts or products containing them in bath salts or products containing them in the U.S. for 1 yearthe U.S. for 1 year
Studies to be done to weigh whether they Studies to be done to weigh whether they should be permanently bannedshould be permanently banned
Aggressive AndyAggressive Andy
Federal Analog Act: Any chemical Federal Analog Act: Any chemical “substantially similar” to a Schedule I “substantially similar” to a Schedule I (heroin and lysergic acid diethylamide (heroin and lysergic acid diethylamide (LSD) ) or Schedule II (methadone and (LSD) ) or Schedule II (methadone and injectable methamphetamine) to be treated injectable methamphetamine) to be treated as if it is also a controlled substance, with as if it is also a controlled substance, with the caveat that the chemical has to be the caveat that the chemical has to be intended for human consumption.intended for human consumption.
Marketed with the label “NOT FOR HUMAN Marketed with the label “NOT FOR HUMAN CONSUMPTION”CONSUMPTION”
Aggressive AndyAggressive Andy
Bath SaltsBath Salts Stimulant derivatives of Schedule I chemical Stimulant derivatives of Schedule I chemical
cathinone (bata-ketoamphetamine) from the cathinone (bata-ketoamphetamine) from the Khat shrub, Khat shrub, Catha edulis Catha edulis
Mephedrone = 4-methylmethcathinone: popularMephedrone = 4-methylmethcathinone: popular Structurally like cocaine, amphetamine, & MDMA (ectasy)Structurally like cocaine, amphetamine, & MDMA (ectasy)
MDPV = 3,4-methylenedioxypyrovalerone: potentMDPV = 3,4-methylenedioxypyrovalerone: potent Inhibit reuptake of norepinephrine and Inhibit reuptake of norepinephrine and
dopaminedopamine Promote release of dopamine, noradrenalin, & Promote release of dopamine, noradrenalin, &
serotoninserotonin
Aggressive AndyAggressive Andy Six ChemicalsSix Chemicals
MDPV MDPV 3,4-methylenedioxypyrovalerone3,4-methylenedioxypyrovalerone
Mephedrone, 4-MMCMephedrone, 4-MMC 4-methylmethcathinone4-methylmethcathinone
Methylone, MDMCMethylone, MDMC 3,4-methylenedioxymethcathinone3,4-methylenedioxymethcathinone
Flephedrone, 4-FMCFlephedrone, 4-FMC 4-fluoromethcathinone4-fluoromethcathinone
3-FMC3-FMC 3-fluoromethcathinone3-fluoromethcathinone
Methedrone, BK-PMMA, PMMCMethedrone, BK-PMMA, PMMC 4-methoxymethcathinone4-methoxymethcathinone
Aggressive AndyAggressive Andy European Club Scene in 2010European Club Scene in 2010
40% of 2,000 clubbers had used bath salts40% of 2,000 clubbers had used bath salts 30% of 2,000 clubbers used them in past month30% of 2,000 clubbers used them in past month Use of ecstasy declinedUse of ecstasy declined
MDMA unavailableMDMA unavailable Instability of ecstasy marketInstability of ecstasy market
Internet English – Language sites selling Internet English – Language sites selling bath saltsbath salts
30 in 12/200930 in 12/2009 70 in 3/201070 in 3/2010
Poison Control Centers in U.S. Poison Control Centers in U.S. 2009: No calls2009: No calls 2010: 303 Calls2010: 303 Calls July 31, 2011: 4,100 callsJuly 31, 2011: 4,100 calls
Aggressive AndyAggressive Andy Recreational Users reportRecreational Users report
EuphoriaEuphoria EmpathyEmpathy Increased AlertnessIncreased Alertness Improved Concentration and ability to focusImproved Concentration and ability to focus Higher energy levelsHigher energy levels Sense of well-being (decreased hostility?)Sense of well-being (decreased hostility?) No hangover, or comedown or depression No hangover, or comedown or depression
like amphetamines, cocaine, and ecstasylike amphetamines, cocaine, and ecstasy
Aggressive AndyAggressive Andy
Health Care Providers Report Health Care Providers Report Severe ParanoiaSevere Paranoia Severe AnxietySevere Anxiety Severe psychosisSevere psychosis Severe AgitationSevere Agitation Bizarre BehaviorBizarre Behavior TremorsTremors DelusionsDelusions Persecutory HallucinationsPersecutory Hallucinations Signs and Symptoms last for several DAYS Signs and Symptoms last for several DAYS
Aggressive AndyAggressive Andy Health Care Providers Report Health Care Providers Report
PalpitationsPalpitations Shortness of BreathShortness of Breath DiaphoresisDiaphoresis Hot FlashesHot Flashes HeadachesHeadaches HyperthermiaHyperthermia Overwhelming ThirstOverwhelming Thirst PolydipsiaPolydipsia Jaw pain from bruxism (ecstasy & amphetamines)Jaw pain from bruxism (ecstasy & amphetamines) Signs & Symptoms like Amphetamine & Cocaine Signs & Symptoms like Amphetamine & Cocaine
Intoxication – sympathetic nervous system Intoxication – sympathetic nervous system stimulationstimulation
Aggressive AndyAggressive Andy
Health Care Providers Notice InitiallyHealth Care Providers Notice Initially CombativeCombative Self-DestructiveSelf-Destructive SuicidalSuicidal HomicidalHomicidal Violent Behavior without WarningViolent Behavior without Warning
Health Care Providers Notice FinallyHealth Care Providers Notice Finally Suicidal Thoughts & ActionsSuicidal Thoughts & Actions Extreme SadnessExtreme Sadness DepressionDepression
Aggressive AndyAggressive Andy
Greatest Risk for Adverse Greatest Risk for Adverse Psychiatric ReactionsPsychiatric Reactions Underlying Neurological ConditionsUnderlying Neurological Conditions Underlying Psychiatric ConditionsUnderlying Psychiatric Conditions
Greatest Risk for Healthcare-Greatest Risk for Healthcare-directed Violencedirected Violence MaleMale History of Violent Behavior, Psychiatric History of Violent Behavior, Psychiatric
Illness, and/or drug or alcohol abuseIllness, and/or drug or alcohol abuse
Aggressive AndyAggressive Andy
Warning Signs for Patients at High Warning Signs for Patients at High Risk for Acting OutRisk for Acting Out Speaking increasingly LoudlySpeaking increasingly Loudly Abusive LanguageAbusive Language Clenched FistsClenched Fists Avoidance of eye contactAvoidance of eye contact Tense PosturingTense Posturing Pacing Pacing
Aggressive AndyAggressive Andy
Successful ManagementSuccessful Management Verbal Deescalating Techniques may Verbal Deescalating Techniques may
not be successful if patient psychoticnot be successful if patient psychotic Sedation and nonrestrictive methods of Sedation and nonrestrictive methods of
restraint should be tried firstrestraint should be tried first Physical restraints probably needed Physical restraints probably needed POLICE USE TAZERS!!POLICE USE TAZERS!!
Aggressive AndyAggressive Andy ManagementManagement
Sedatives in large doses & intubate to maintain airwaySedatives in large doses & intubate to maintain airway Diazepam = ValiumDiazepam = Valium Lorazepam = AtivanLorazepam = Ativan
Antipsychotic Medications Antipsychotic Medications Haloperidol = HaldolHaloperidol = Haldol Ziprasidone = GeodonZiprasidone = Geodon
Monitor temperatureMonitor temperature Fatal Hyperthermia (Mephedrone)Fatal Hyperthermia (Mephedrone) Serotonin Syndrome-Induced Hyperthermia Serotonin Syndrome-Induced Hyperthermia
RhabdomyolysisRhabdomyolysis RenalFailureRenalFailure Metabolic AcidosisMetabolic Acidosis DDIC – disseminated intravascular coagulationDDIC – disseminated intravascular coagulation ComaComa DeathDeath
Aggressive AndyAggressive Andy
Management: Management: Protect CaregiversProtect Caregivers
50% ED staff become victims of patient violence50% ED staff become victims of patient violence 5% violent patient possess a concealed weapon5% violent patient possess a concealed weapon
Emergency Psychiatric Evaluation As Soon Emergency Psychiatric Evaluation As Soon As PossibleAs Possible
Body & Possession Search to remove Body & Possession Search to remove objects of potential harmobjects of potential harm
Notify SecurityNotify Security Keep Exit to room available for providersKeep Exit to room available for providers
““safety sitter” safety sitter”
Aggressive AndyAggressive Andy TreatmentTreatment
Anticipatory GuidanceAnticipatory Guidance Unclear as to effects of metabolitesUnclear as to effects of metabolites Unclear as to chemicals included in “bath salts”Unclear as to chemicals included in “bath salts” No quality-control scrutinyNo quality-control scrutiny Variable Potency leading to unintentional overdoseVariable Potency leading to unintentional overdose Long-term consequences on brain function unknown Long-term consequences on brain function unknown
Psychiatric ReferralPsychiatric Referral Consider Alcohol and Drug Withdrawal Consider Alcohol and Drug Withdrawal
ProgramProgram Law Enforcement: Charges for possession or Law Enforcement: Charges for possession or
for assault for assault
Aggressive AndyAggressive Andy
Increasing ConcernsIncreasing Concerns ParentsParents
FlashbacksFlashbacks AddictionAddiction
Healthcare WorkersHealthcare Workers Personal SafetyPersonal Safety
Government OfficialsGovernment Officials Legal SystemLegal System
Schedule I Schedule I Criminal ActivityCriminal Activity
Aggressive AndyAggressive Andy
Take Home MessageTake Home Message Designer Drugs are distributed in different Designer Drugs are distributed in different
waysways The Internet makes the distribution of The Internet makes the distribution of
designer drugs spread more rapidly.designer drugs spread more rapidly. The web makes alterations in drugs “easy” The web makes alterations in drugs “easy”
and readily available for the “chemist”and readily available for the “chemist” Bath Salts are not benign but are readily Bath Salts are not benign but are readily
available and can be deadlyavailable and can be deadly Web Site: www.erowid.orgWeb Site: www.erowid.org
Thank youThank you
Any Questions?Any Questions?
ReferencesReferences
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Stein U, Grier H, Hentshel H. Nutmeg Stein U, Grier H, Hentshel H. Nutmeg (myristicin) poisoning-report on a fatal (myristicin) poisoning-report on a fatal case and a series of cases recorded by a case and a series of cases recorded by a poison information centre. poison information centre. Forensic Sci Forensic Sci IntInt. 2001;118:87-90.. 2001;118:87-90.
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Carstairs SC, Cantrell PL. The spice of Carstairs SC, Cantrell PL. The spice of life: an analysis of nutmeg exposures in life: an analysis of nutmeg exposures in California. California. Clin Toxicol. Clin Toxicol. 2011;49:177-2011;49:177-180.180.
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McGuiness A, et al. Low cost, high risk: McGuiness A, et al. Low cost, high risk: accidental nutmeg intoxication. accidental nutmeg intoxication. Emerg Emerg Med J. Med J. 2005; ;22:223-225.2005; ;22:223-225.
CDC. Emergency department visits after CDC. Emergency department visits after use of a drug sold as bath salts” – use of a drug sold as bath salts” – Michigan, November 13, 2010 to March Michigan, November 13, 2010 to March 31, 2011. 31, 2011. MMWR.MMWR. 2011;60:1-4. 2011;60:1-4.
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Maskell PD, De Paoli g, Seneviratne C, Maskell PD, De Paoli g, Seneviratne C, et al. Mephedrone-related deathset al. Mephedrone-related deaths. J . J Anal ToxicolAnal Toxicol. 2011;35:188-191.. 2011;35:188-191.
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American Association of Poison American Association of Poison Control Centers. Nutmeg Data. Control Centers. Nutmeg Data.