update in toxicology 2013 k2, spice, bath salts, & the new designer drugs k2, spice, bath salts, &...

Update in Toxicology 2013 K2, Spice, Bath Salts, & the New Designer Drugs K2, Spice, Bath Salts, & the New Designer Drugs William Hurley, MD FACEP William Hurley, MD FACEP Harborview Medical Center Harborview Medical Center Washington Poison Center Washington Poison Center [email protected] [email protected] (800) 222-1222 (800) 709-0911

Update in Toxicology 2013 Goal Goal Increase knowledge in management of the poisoned patient Objectives Objectives Describe manifestations & management of the stimulant syndrome List new designer drugs, their mechanisms, & their sources Designer Drugs

Tox Update 2012

Designer Drugs

Poisoning Case A 20 year-old female is found agitated & confused by family in her dormitory room. A 20 year-old female is found agitated & confused by family in her dormitory room. She has no significant past medical history, but the family suspects she has been experimenting with alcohol & marijuana since starting school. She has no significant past medical history, but the family suspects she has been experimenting with alcohol & marijuana since starting school. She is agitated & aggressively ordering care providers to leave her exam room. Family explains this is not like her at all. She is agitated & aggressively ordering care providers to leave her exam room. Family explains this is not like her at all. She is tachycardic, hypertensive, hot, & diaphoretic She is tachycardic, hypertensive, hot, & diaphoretic (P 128, BP 180/110) How would you manage this encounter? How would you manage this encounter?

20 Year Old Female Anxious & Agitated Initial Evaluation ? Initial Evaluation ? Designer Drugs

20 Year Old Female Anxious & Agitated Mental Status Mental Status A A B B C C D D E E Designer Drugs

20 Year Old Female Anxious & Agitated Mental Status Mental Status A Open & Protected ? A Open & Protected ? B Ventilating & Oxygenating ? B Ventilating & Oxygenating ? C Rhythm, Perfusion ? C Rhythm, Perfusion ? D - Disability / Seizures D - Disability / Seizures Decontamination, Dextrose ? Decontamination, Dextrose ? E Exposure, Elimination ? E Exposure, Elimination ? Poison Center 1-800-222-1222 Poison Center 1-800-222-1222 Designer Drugs

Initial Management WA Poison Center WA Poison Center 1-800-222-1222 1-800-222-1222 1-800-709-0911 1-800-709-0911 Airway Airway Breathing Breathing Circulation Circulation 80% of poisonings Disability/Decontamination Disability/Decontamination 90% of poisonings Exposure/Elimination Exposure/Elimination Antidotes 100% of poisonings Designer Drugs

20 Year Old Female Anxious & Agitated Agitated, responding to loud verbal Agitated, responding to loud verbal A Open with intact gag reflex A Open with intact gag reflex B - RR 20-24 / minute, clear lungs B - RR 20-24 / minute, clear lungs C - Tachycardic (Sinus - 130s) C - Tachycardic (Sinus - 130s) Hypertensive (180/110) Hypertensive (180/110) D - No Seizure, Glucose 108 D - No Seizure, Glucose 108 Decontamination? Decontamination? E Elimination? E Elimination? Designer Drugs

Poisoning Management ABCDE ABCDE Safety Net Safety Net IV, Monitors (ECG & O2) Focused History Focused History What, when, why, what has been done? What else is available? Focused Physical Examination Focused Physical Examination Toxicologic Syndrome? Designer Drugs

Toxicologic Syndromes Asphyxiant Asphyxiant Cholinergic Cholinergic Anticholinergic Anticholinergic Cyclic Antidepressant Cyclic Antidepressant Opiod Opiod Sedative Sedative Stimulant Stimulant Hallucinogenic Hallucinogenic Serotonergic Serotonergic Hepatotoxic Hepatotoxic Heavy Metal Heavy Metal Irritant gas Irritant gas Caustic Caustic Salicylates Salicylates Toxic Alcohols Toxic Alcohols Hydrocarbons Hydrocarbons Calcium antagonists Calcium antagonists Designer Drugs

Poisoning Management Physical Examination Toxicologic Syndrome Physical Examination Toxicologic Syndrome Designer Drugs

Poisoning Management Physical Examination Toxicologic Syndrome Physical Examination Toxicologic Syndrome Vital Signs Mental Status confused, stimulated, depressed confused, stimulated, depressed Pupils; small or large, reactive or not Mucus membranes; color, moisture Respiratory rate & depth, bronchospasm, pulmonary edema rate & depth, bronchospasm, pulmonary edema Gastrointestinal Tract; hyper- or hypoactive Skin; color, temperature, moisture Designer Drugs

Poisoning Case A 20 year-old female crazy A 20 year-old female crazy Tachycardic, hypertensive, warm, & wet Tachycardic, hypertensive, warm, & wet (P 130, BP 185/110) Synthetic marijuana? Synthetic marijuana? Designer Drugs

Poisoning Case A 20 year-old female crazy A 20 year-old female crazy Tachycardic, hypertensive, warm, & wet Tachycardic, hypertensive, warm, & wet (P 130, BP 185/110) Synthetic marijuana? Synthetic marijuana? Toxicologic Syndrome? Toxicologic Syndrome? Designer Drugs

Physical Examination Stimulant Syndrome Vital Signs Vital Signs Mental Status Mental Status Pupils Pupils Mucus membranes Mucus membranes Respiratory Respiratory Gastrointestinal Gastrointestinal Skin Skin T, P, R, BP T, P, R, BP Seizures Seizures Dilated & reactive Dilated & reactive Moist Moist Rate, depth Rate, depth Motility Motility Pink, warm, moist Pink, warm, moist Designer Drugs

Spice Case Roomate produces packets of incense purchased at a local head shop. Roomate produces packets of incense purchased at a local head shop. Designer Drugs

Spice Case A 20 year-old female crazy A 20 year-old female crazy Begins screaming & struggling Begins screaming & struggling Attempting IV Has 3 minute seizure Management? Management? Designer Drugs

Stimulant Agents - ? Designer Drugs

Stimulant Agents Cocaine Cocaine Amphetamines Amphetamines Methamphetamine, Ecstasy, methylphenidate, phentermine Decongestants Decongestants Ephedrine, Pseudo-ephedrine Beta Stimulators Beta Stimulators Albuterol, caffeine, theophylline Withdrawal States Withdrawal States EtOH, benzodizepine, GHB Designer Drugs

Cannabinoids

Cannabinoids Spice products - Europe in 2004 Spice products - Europe in 2004 Herbal smoking blend Herbal smoking blend Not for Human Consumption Not for Human Consumption Synthetic agents, created to simulate effects of cannabis Synthetic agents, created to simulate effects of cannabis CNS cannabinoid receptors CNS cannabinoid receptors Derived from cathinones (Khat) Derived from cathinones (Khat) Designer Drugs

Cannabinoids Sold in small packets Sold in small packets Variety of names Variety of names K2, Spice Gold, Spice Diamond, Spice Silver, Spice of Life Retail U. S. $25-$40 Retail U. S. $25-$40 Designer Drugs

Plant & Herbal Blends Marketed as incense Marketed as incense Desire for legal high Desire for legal high Ability to avoid detection on drugs- of-abuse testing (THC) Ability to avoid detection on drugs- of-abuse testing (THC) Designer Drugs

Whats up with the Eye? Designer Drugs

Whats up with the Eye? Wide-open-eye imprint Wide-open-eye imprint Allusion to Dune Allusion to Dune Fictional drug Melange Fictional drug Melange Called the spice Called the spice Excessive use caused blue sclera Excessive use caused blue sclera Designer Drugs

Cannabinoids Heterogeneous structured compounds Heterogeneous structured compounds Agonize endogenous cannabinoid receptors Include phytocannabinoids derived from Cannabis sativa (delta 9-THC) Endogenous cannabinoids Synthetics Designer Drugs

Synthetic Cannabinoids Synthesized 1960s at Hebrew University (HU) Synthesized 1960s at Hebrew University (HU) HU-210 Pfizer 1970s; Cyclohexylphenol series Pfizer 1970s; Cyclohexylphenol series J W Huffman (JWH) 80s J W Huffman (JWH) 80s JWH-018, JWH-073, JWH-200 Designer Drugs

Cannabinoids Signs & Symptoms Tachycardia Tachycardia Hypertension Hypertension Hyperthermia Hyperthermia Anxiety Anxiety Seizures Seizures Paranoia & hallucinations Paranoia & hallucinations Designer Drugs

European Experience Within weeks of regulatory control Within weeks of regulatory control Non-prohibited cannabinoids found in products Non-prohibited cannabinoids found in products Structures heterogeneous Structures heterogeneous No THC rxn Designer Drugs

Synthetic Cannabinoids 2010 U.S. DEA, Office of Diversion Control JWH 73 11% JWH 250 13%

U.S. DEA Activity March, 2011 March, 2011 Temporary Schedule I Temporary Schedule I unsafe, highly abused, no medical usage Five synthetic cannabinoids Five synthetic cannabinoids JWH-018, JWH-073, JWH-200 CP-47,497 & Cannabicyclohexanol HU-210 all ready Schedule I Designer Drugs

Synthetic Cannabinoids 2011 U.S. DEA, Office of Diversion Control JWH 250 12% JWH 210 9% JWH-122 12% JWH-18 14% AM-2201 29%

Synthetic Drug Abuse Prevention Act of 2012 Signed into law July 9, 2012 Signed into law July 9, 2012 Adds certain classes of synthetic cannabinoids & two substituted cathinonesmephedrone and MDPV to the federal controlled substances act. Adds certain classes of synthetic cannabinoids & two substituted cathinonesmephedrone and MDPV to the federal controlled substances act. Designer Drugs

Stimulant Agents Cocaine Cocaine Amphetamines Amphetamines Decongestants Decongestants Beta Stimulators Beta Stimulators Withdrawal States Withdrawal States Cannabinoids Cannabinoids JWH-018, JWH-073, JWH-200 CP-47,497, Cannabicyclohexanol HU-210 Designer Drugs

Stimulant Agents Mechanisms of Action - ? Designer Drugs

Stimulant Agents Mechanisms of Action

Central inhibition of catecholamine reuptake Central inhibition of catecholamine reuptake Epinephrine, norepinephrine Peripheral stimulation of alpha & beta receptors Peripheral stimulation of alpha & beta receptors Additional effects (nuances) Additional effects (nuances) Na channel / local anesthetic (cocaine) Serotonin reuptake inhibition (MDMA) Designer Drugs

Stimulant Toxicity Clinical Management - ? Designer Drugs

Stimulant Toxicity Clinical Management Central inhibition of catecholamine reuptake Central inhibition of catecholamine reuptake Benzodiazepines (GABA receptor agonists) 0.1-0.2 mg/kg Diazepam IV (5-10 mg) 0.1-0.2 mg/kg Diazepam IV (5-10 mg) 0.05 mg/kg Lorazepam or Midazolam IV or IM (2-5 mg) 0.05 mg/kg Lorazepam or Midazolam IV or IM (2-5 mg) Repeat every 5-10 minutes for seizures, every 10 minutes until calm Repeat every 5-10 minutes for seizures, every 10 minutes until calm Neuroleptics (monitor the QT interval) 2-5 mg IM or slow IV Haloperidol or Droperidol 2-5 mg IM or slow IV Haloperidol or Droperidol Designer Drugs

Stimulant Toxicity Management Peripheral stimulation of alpha & beta receptors Peripheral stimulation of alpha & beta receptors Benzodiazepines (cardiac receptors) Vasodilators; phentolamine, nitroprusside Cardiac monitoring Additional effects Additional effects Benzodiazepines Hydration, Cooling, Neuromuscular paralysis Designer Drugs

Spice Case A 20 year-old female crazy A 20 year-old female crazy Tachycardic, hypertensive, warm, & wet Tachycardic, hypertensive, warm, & wet (P 140, BP 185/110) Diazepam 5 mg IV X 2 Diazepam 5 mg IV X 2 Temp 104.4 o Temp 104.4 o Urine reddish brown IV NS with 2 amps NaHCO 3 Designer Drugs

Spice Case CT head negative CT head negative Urine Tox negative Urine Tox negative Admitted ICU Admitted ICU Continuous EEG monitoring Awakens next morning Awakens next morning Admits binge of Spice Peak CPK 14,000 No renal failure Discharged home intact day #3 Designer Drugs

Smoking Bath Salts 26 y.o. male agitated & confused 26 y.o. male agitated & confused 3 day binge 3 day binge Smoking Bolivian Bath Salts Roomate found him face-down on floor Roomate found him face-down on floor Designer Drugs

26 Year Old Male Agitated & Confused Management? Management? Designer Drugs

Initial Management WA Poison Center WA Poison Center 1-800-222-1222 1-800-222-1222 1-800-709-0911 1-800-709-0911 Airway Airway Breathing Breathing Circulation Circulation 80% of poisonings Disability/Decontamination Disability/Decontamination 90% of poisonings Exposure/Elimination Exposure/Elimination Antidotes 100% of poisonings Designer Drugs

26 Year Old Male Agitated & Confused Agitated, responding to loud verbal Agitated, responding to loud verbal A Open with intact gag reflex A Open with intact gag reflex B - RR 28 / minute, clear lungs B - RR 28 / minute, clear lungs C - Tachycardic (Sinus - 130s) C - Tachycardic (Sinus - 130s) Hypertensive (160/100) Hypertensive (160/100) D - No Seizure, Glucose 120 D - No Seizure, Glucose 120 Decontamination? Decontamination? E Elimination? E Elimination? Designer Drugs

Bath Salts Case Agitated, responds to loud verbal stimuli Agitated, responds to loud verbal stimuli No trauma No trauma Pupils 6 mm Pupils 6 mm P 130 BP 160/100 P 130 BP 160/100 Diaphoretic & Hot Diaphoretic & Hot Designer Drugs

Physical Examination Stimulant Syndrome Vital Signs Vital Signs Mental Status Mental Status Pupils Pupils Mucus membranes Mucus membranes Respiratory Respiratory Gastrointestinal Gastrointestinal Skin Skin T, P, R, BP T, P, R, BP Seizures Seizures Dilated & reactive Dilated & reactive Moist Moist Rate, depth Rate, depth Motility Motility Pink, warm, moist Pink, warm, moist Designer Drugs

Bath Salts White Ice, Ocean Snow, Lunar Wave, Purple Wave, Ivory Wave, Ivory Soft, Vanilla Sky, Bliss White Ice, Ocean Snow, Lunar Wave, Purple Wave, Ivory Wave, Ivory Soft, Vanilla Sky, Bliss $20 packets from convenience stores, truck stops & via Internet $20 packets from convenience stores, truck stops & via Internet Designer Drugs

Bath Salts - Compounds Very similar to amphetamines Very similar to amphetamines Side effects largely the same we see with amphetamines in large dose Side effects largely the same we see with amphetamines in large dose Jeffrey Baldwin, University of Nebraska Medical Center Typically snorted, smoked, injected Typically snorted, smoked, injected Can be mixed with water as a beverage Can be mixed with water as a beverage Designer Drugs

Snorting & Smoking Bath Salts Designer Drugs

Bath Salts - Contents Mephedrone Mephedrone MDPV (3,4-methylenedioxypyrovalerone) MDPV (3,4-methylenedioxypyrovalerone) Designer Drugs

Mephedrone - Europe Cathinone derivative Cathinone derivative Marketed as plant feeder not for human consumption Marketed as plant feeder not for human consumption Potentially addictive & Potentially addictive & Increasingly popular legal substitute for cocaine & ecstasy Increasingly popular legal substitute for cocaine & ecstasy Designer Drugs

MDPV 3,4 methylendioxypyrovalerone Epinephrine & Nor- epinephrine re-uptake inhibitor Epinephrine & Nor- epinephrine re-uptake inhibitor Designer Drugs

MDPV 3,4 methylendioxypyrovalerone Epinephrine & Norepinephrine re-uptake inhibitor Epinephrine & Norepinephrine re-uptake inhibitor Beta ketone research chemical Beta ketone research chemical Intake (Dose 5-15 mg); Intake (Dose 5-15 mg); Oral (capsule, bombing, beverage) Rectal, Insufflation, Smoking, IV Onset 1 hr, Peak 1.5 hr, Duration 3-12 hrs Designer Drugs

MDPV Toxicity -? Designer Drugs

Bath Salts Toxicity 35 patients, Michigan EDs 35 patients, Michigan EDs Agitation - 23 patients (66%) Agitation - 23 patients (66%) Tachycardia - 22 (63%) Tachycardia - 22 (63%) Delusions/hallucinations - 14 (40%) Delusions/hallucinations - 14 (40%) 17 patients hospitalized, 1 DOA 17 patients hospitalized, 1 DOA MDPV Identified MMWR / May 20, 2011 / Vol. 60 / No. 19 MMWR / May 20, 2011 / Vol. 60 / No. 19 Designer Drugs

Bath Salts Case Agitated for 18 hours at hospital Agitated for 18 hours at hospital Tachycardia resolves with IV benzos & fluids Tachycardia resolves with IV benzos & fluids Temp 104.1 Temp 104.1 Urine (+) benzos only Urine (+) benzos only CK Peak 6500 CK Peak 6500 Designer Drugs

Cannabinoids & Bath Salts 2010 - 2011 Designer Drugs Olives TD, et al. Bath salts: the ivory wave of trouble. West J Emerg Med. 2012 Feb;13(1):58-62.

Bath Salts - Banned DEA Temporary Schedule I (Oct 2011) DEA Temporary Schedule I (Oct 2011) Up to 12 months for permanent Louisiana, Florida, North Dakota, WA Louisiana, Florida, North Dakota, WA New York, Kentucky, Mississippi - Pending PC calls fell with Louisiana ban PC calls fell with Louisiana ban Now ordering by Internet Shipping to Mississippi Executive Health February 04, 2011 Executive Health February 04, 2011 Designer Drugs

Stimulant Agents Cocaine Cocaine Amphetamines Amphetamines Decongestants Decongestants Beta Stimulators Beta Stimulators Withdrawal States Withdrawal States Cannabinoids Cannabinoids Bath Salts Bath Salts Mephedrone MDPV Designer Drugs

New Rave (2 C agents) Minneapolis, MN 17 March 2011 Minneapolis, MN 17 March 2011 Eleven hospitalized (16-21 y.o.) 2 critical, 1 dead Konawa, OK 7 May 2011 Konawa, OK 7 May 2011 Seven hospitalized (19-20 y.o.) 2 critical, 1 dead 2,5-dimethoxy-4-ethyl-phenethylamine 2,5-dimethoxy-4-ethyl-phenethylamine Designer Drugs

2, 5, I-NBOMe Deaths Erowid.org (Extracts) March 2012 Adult male South Australia March 2012 Adult male South Australia 2C-I-NBOMe & 2C-B-NBOMe (MVC) June 2012 17 & 18 yo males MN June 2012 17 & 18 yo males MN Mixed 25i with chocolate candy July 2012 - 25 yo female, NC July 2012 - 25 yo female, NC 25i pills, died >12 hours after ingestion Designer Drugs 2011

2 Ci Blotter Paper Designer Drugs

2 C-I Designer Drugs

Phenethylamines Chemical NameStreet Name 3,4,5-trimethoxy- phenethylamine Mescaline 2C-E 2,5-dimethoxy-4-ethyl- phenethylamine Europa 2C-B 2,5-dimethoxy-4-bromo- phenethylamine Bees, Bromo, Bromo mescaline, Nexus, Spectrum, Toonies, Venus 2C-I 2,5-dimethoxy-4-iodo- phenethylamine N-Bomb 2C-T7 2,5-dimethoxy-4- propylthio-phenethylamine Blue Mystic, Vanilla Aroma Designer Drugs

Phenethylamines Agonist/antagonist 5-HT receptor Agonist/antagonist 5-HT receptor Hallucinations Over-stimulation & agitation (amphetamines) Multiple forms Multiple forms Tablets, capsules, powder for insufflation Kinetics Kinetics Onset 20 min, peak 2 hrs, duration 6-12 hrs Designer Drugs

Phenethylamines Clinical Effects Hallucinations, agitation, seizures Hyperthermia, tachycardia, hypertension, tachypnea Extreme/rapid cycling emotions Mydriasis, flushing, diaphoresis Nausea, vomiting, Facial dystonia (teeth grinding, grimacing) Rhabdomyolysis Designer Drugs

Phenethylamines (cont) Insufflation - immediate pain nasal mucosa Law enforcement officers Phenethylamine laboratories Phenethylamine laboratories Mucous membrane & respiratory symptoms Mucous membrane & respiratory symptoms Designer Drugs

Phenethylamines Legal control Legal control 2C-B & 2C-T7 Schedule I 2C-E & 2C-I - not scheduled controlled substance analogs controlled substance analogs Bad trips ?alleviated by SSRIs? Bad trips ?alleviated by SSRIs? Not studied nor recommended Designer Drugs

Stimulant Agents Cocaine Cocaine Amphetamines Amphetamines Decongestants Decongestants Beta Stimulators Beta Stimulators Withdrawal States Withdrawal States Cannabinoids Cannabinoids Bath Salts Bath Salts Phenethylamines Phenethylamines 2 CE & 2 CI Designer Drugs

Stimulant Agents Mechanisms of Action Central inhibition of catecholamine reuptake Central inhibition of catecholamine reuptake Epinephrine, norepinephrine Peripheral stimulation of alpha & beta receptors Peripheral stimulation of alpha & beta receptors Additional effects (nuances) Additional effects (nuances) Na channel / local anesthetic (cocaine) Serotonin reuptake inhibition (MDMA) Designer Drugs

Poisoning Management ABCDE Poison Center (1-800-222-1222) ABCDE Poison Center (1-800-222-1222) Safety Net Safety Net IV, Monitors (ECG & O2) Focused History Focused History What, when, why, what has been done? What else is available? Focused Physical Examination Focused Physical Examination Toxicologic Syndrome? Laboratory Studies? Laboratory Studies? Designer Drugs

Bath Salts and Stimulants Designer Drugs - Expanded, Urine Test (8756U) Methamphetamine, Amphetamine, O-Desmethyltramadol MDMA, MDEA, MDA, DOM Mephedrone, MDPV, Pyrovalerone,, Ethylone, Flephedrone, Buphedrone, Methedrone, Methylone, Cathinone, Methcathinone 2C-B 2C-C 2C-E 2C-H 2C-I 2C-N 2C-P 2C-T-2 2C-T-7 Synthetic Cannabinoid Metabolites Screen - Expanded, Urine (Forensic) Test (9562U) AM-2201, JWH-018, JWH-019, JWH-073, JWH-081, JWH-122, JWH-210, JWH-250, & RCS-4 metabolites Tox Update 2012

Stimulant Toxicity - Key Points Central & Peripheral catecholamine surge Central & Peripheral catecholamine surge Characteristic clinical toxicological syndrome Specific agents Specific agents Cocaine, amphetamines, decongestants, cannabinoids, Mephedrone, MDPV, phenethylamines Often unavailable for decontamination & detection Treat the patient, not the agent Importance - reduce severity of poisoning (avoid complications) Importance - reduce severity of poisoning (avoid complications) Benzodiazepines & Hyperthermia prevention Designer Drugs

Spice References Gunderson EW, et al. "Spice" and "K2" herbal highs: a case series and systematic review of the clinical effects and biopsychosocial implications of synthetic cannabinoid use in humans. Am J Addict. 2012 Jul-Aug;21(4):320-6. Simmons JR, et al. Intoxication from smoking "spice. Ann Emerg Med. 2011 Feb;57(2):187-8. Vardakou I, et al. Spice drugs as a new trend: mode of action, identification & legislation. Toxicol Lett 2010 Sep 1;197(3):157-62. Schneir AB, et al. "Spice" Girls: Synthetic Cannabinoid Intoxication. J Emerg Med 2010 Dec 15. Designer Drugs

Bath Salts - References Designer Drugs o Borek HA, et al. Hyperthermia and multiorgan failure after abuse of "bath salts" containing 3,4-methylenedioxypyrovalerone. Ann Emerg Med. 2012 Jul;60(1):103-5. o Prosser JM, Nelson LS. The toxicology of bath salts: a review of synthetic cathinones. J Med Toxicol. 2012 Mar;8(1):33-42. o Murray BL, et al. Death following recreational use of designer drug "bath salts" containing 3,4-Methylenedioxypyrovalerone (MDPV). J Med Toxicol. 2012 Mar;8(1):69-75. o Kasick DP, et al. "Bath salt" ingestion leading to severe intoxication delirium: two cases and a brief review of the emergence of mephedrone use. Am J Drug Alc Abuse. 2012 Mar;38(2):176-80. o Emergency department visits after use of a drug sold as "bath salts"--Michigan, November 13, 2010-March 31, 2011. MMWR 2011 May 20;60(19):624-7. o Psychonaut WebMapping Research Group, Mephedrone Report, Institute of Psychiatry, King's College London, London, UK (2009).

Update in Toxicology 2013 Goal Goal Increase knowledge in management of the poisoned patient Objectives Objectives Describe manifestations & management of the stimulant syndrome List new designer drugs, their mechanisms, & their sources Designer Drugs

Update in Toxicology 2013 K2, Spice, Bath Salts, & the New Designer Drugs K2, Spice, Bath Salts, & the New Designer Drugs William Hurley, MD FACEP William Hurley, MD FACEP Harborview Medical Center Harborview Medical Center Washington Poison Center Washington Poison Center [email protected] [email protected] (800) 222-1222 (800) 709-0911

update in toxicology 2013 k2, spice, bath salts, & the new designer drugs k2, spice, bath salts, &...

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b ventilating oxygenating