Basics
Description
"Bath salts"�: �
- General term for "designer drugs"� containing synthetic cathinones:
- 3,4 methylenedioxypyrovalerone (MDPV) is most common in US
- Also mephedrone, methylone, and many others
- Sold under numerous names including
- Aura, Bliss, Bolivian Bath, Cloud 9, Ivory Snow, Ivory Wave, Vanilla Sky, White Dove, White Rush
- Labeled "not for human consumption"� to evade regulatory control
- Falsely marketed as plant food, insect repellents, "bath salts"�
- Substances may be powders, tablets, or crystals:
- Ranging in color from white, yellow, brown, or gray
- May be ingested, snorted, smoked, injected
- Highly addictive CNS stimulant, often with hallucinogenic properties:
- Many effects similar to cocaine, methamphetamine, or ecstasy
- Severe delirium, psychosis, violence, multiorgan failure, DIC, myocardial infarction, stroke, and deaths have been reported
Epidemiology
Incidence and Prevalence Estimates
- 1st use in US reported in 2010
- MDPV and mephedrone noted in Europe since 2004
- Called "Americas new drug problem"� in 2011
- Thousands of cases reported to poison control centers nationwide
- Immediate temporary classification (Fall 2011) as a DEA schedule I controlled substance
- Still available at retail shops or through the internet
Etiology
- MDPV is structurally similar to cathinone, an alkaloid derived from the khat plant (chewed socially and abused for centuries in East Africa and Arabian Peninsula)
- Drug chemical formulas change regularly to evade detection, compound identification, and classification as "illegal"�
- Principal toxicity derives from effects on dopamine, norepinephrine, and serotonin receptors
- Effects from potential adulterants and contaminants in the drugs remain unknown
Diagnosis
Signs and Symptoms
History
- Often unobtainable or incomplete
- Friends, family, bystanders may provide information about patient behavior
- High index of suspicion when signs and symptoms are present with no satisfactory alternative explanation
Physical Exam
- No pathognomonic signs or symptoms
- Sympathomimetic toxidrome:
- Hyperthermia
- Tachycardia
- Hypertension
- Dysrhythmias
- Diaphoresis
- Mydriasis
- Rhabdomyolysis
- Respiratory distress
- Hyperreflexia
- Seizures
- Mental status and behavioral effects:
- Psychomotor agitation
- Hallucinations
- Physical aggression
- Psychosis
- Paranoia
- Excited delirium
- Suicidal ideation
- Panic attacks
- Insomnia
Essential Workup
Primarily focused on assessing severity of intoxication and excluding other medical or toxicologic causes of altered mental status �
Diagnosis Tests & Interpretation
Lab
- No tests in current routine ED use to detect MDPV:
- Samples of ingested substance, serum, or urine can be sent to reference labs
- Results not available in ED setting
- Labs:
- Urine and serum toxicology screens may detect coingestants
- CBC, BMP, liver profile, PT/PTT
- Lactate, pH
- Total CK
- Blood/urine culture if infectious process suspected
- Imaging:
- Consider CT head if appropriate (e.g., trauma)
- ECG:
- Evaluate QRS/QT intervals, dysrhythmias
Differential Diagnosis
- Other intoxications:
- Cocaine
- Amphetamines
- Anticholinergic agents
- Ecstasy
- Ethanol
- Acute psychosis
- Serotonin syndrome
- Delirium from infectious or metabolic process
Treatment
Pre-Hospital
- Stabilize airway
- Vital signs
- IV access
- Fingerstick glucose
- Oxygen administration if needed
Initial Stabilization/Therapy
- Stabilize airway, establish IV, vital signs, cardiac monitoring
- Benzodiazepines are 1st-line medications
- Judicious use of physical restraints, if necessary, for prevention of harm to patient and staff
Ed Treatment/Procedures
- Supportive care is mainstay of treatment with continuous cardiac and temperature monitoring:
- Fluid resuscitation
- Oxygen
- Benzodiazepines are 1st-line medications
- Aggressive cooling measures for hyperthermia:
- Ice packs, cool mists, fans, cooling blankets, cool intravenous fluids
- Severe symptoms may necessitate intubation in rare cases:
- Caution with antipsychotic administration which may lower seizure threshold, cause extrapyramidal symptoms, and dysrhythmias
- Poison Control Center/toxicology guidance (1-800-222-1222)
Medication
- (Ativan) 2-4 mg increments IM or IV
- Valium 10-30 mg increments IM or IV
Follow-Up
Disposition
Admission Criteria
- All patients with symptoms should be admitted for monitoring
- Severe symptoms including uncontrollable hypertension, altered mental status, cardiovascular instability, and hyperthermia require ICU monitoring
Discharge Criteria
Only asymptomatic patients who remain asymptomatic after an adequate observation period (half-life of MDPV estimated at 1.88 hr with 6-8 hr duration of action) may be discharged; exact timing will vary on each case (consult your poison control center) �
Followup Recommendations
Follow up with primary care after discharge �
Pearls and Pitfalls
- A sympathomimetic toxidrome with delirium/psychosis should arouse suspicion for "bath salts"� intoxication
- Severe hyperthermia should be aggressively controlled
- Focused supportive care is the mainstay of treatment, with benzodiazepines as initial therapy
Additional Reading
- Borek �HA, Holstege �CP. Hyperthermia and multiorgan failure after abuse of "bath salts"� containing 3,4 methylenedioxypyrovalerone. Ann Emerg Med. 2012;60(1):103-105.
- Hill �SL, Thomas �SH. Clinical toxicology of newer recreational drugs. Clin Toxicol (Phila). 2011;49:705-719.
- Prosser �JM, Nelson �LS. The toxicology of bath salts: A review of synthetic cathinones. J Med Toxicol. 2012;8:33-42.
- Ross �EA, Reisfield �GM, Watson �MC, et al. Psychoactive "bath salts"� intoxication with methylenedioxypyrovalerone. Amer J Med. 2012;125:854-858.
- Spiller �HA, Ryan �ML, Weston �RG, et al. Clinical experience with and analytical confirmation of "bath salts"� and "legal highs"� (synthetic cathinones) in the United States. Clin Toxicol (Phila). 2011;49:499-505.
Codes
ICD9
969.6 Poisoning by psychodysleptics (hallucinogens) �
ICD10
- T43.8X1A Poisoning by oth psychotropic drugs, accidental, init
- T43.8X4A Poisoning by oth psychotropic drugs, undetermined, init
SNOMED
- 61438005 Poisoning by psychotropic agent (disorder)
- 85975005 Poisoning by psychodysleptic (disorder)
- 216550002 Accidental poisoning by hallucinogens (disorder)