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Bath Salts – Synthetic Cathinones Poisoning, Emergency Medicine

Basics

Description

- 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"пїЅ to evade regulatory control - Falsely marketed as plant food, insect repellents, "bath salts"пїЅ

- 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

- 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

"Bath salts"пїЅ: пїЅ

  • General term for "designer drugs"пїЅ containing synthetic cathinones:3,4 methylenedioxypyrovalerone (MDPV) is most common in USAlso mephedrone, methylone, and many others
  • Sold under numerous names includingAura, Bliss, Bolivian Bath, Cloud 9, Ivory Snow, Ivory Wave, Vanilla Sky, White Dove, White RushLabeled "not for human consumption"пїЅ to evade regulatory controlFalsely marketed as plant food, insect repellents, "bath salts"пїЅ
  • 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 ecstasySevere 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 2010MDPV and mephedrone noted in Europe since 2004
  • Called "Americas new drug problem"пїЅ in 2011Thousands 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"пїЅ
  • 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 incompleteFriends, family, bystanders may provide information about patient behaviorHigh index of suspicion when signs and symptoms are present with no satisfactory alternative explanation

Physical Exam

  • No pathognomonic signs or symptoms
  • Sympathomimetic toxidrome:HyperthermiaTachycardiaHypertensionDysrhythmiasDiaphoresisMydriasisRhabdomyolysisRespiratory distressHyperreflexiaSeizures
  • Mental status and behavioral effects:Psychomotor agitationHallucinationsPhysical aggressionPsychosisParanoiaExcited deliriumSuicidal ideationPanic attacksInsomnia

Essential Workup

Primarily focused on assessing severity of intoxication and excluding other medical or toxicologic causes of altered mental status пїЅ

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 labsResults not available in ED setting
  • Labs:Urine and serum toxicology screens may detect coingestantsCBC, BMP, liver profile, PT/PTTLactate, pHTotal CKBlood/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:CocaineAmphetaminesAnticholinergic agentsEcstasyEthanol
  • 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 resuscitationOxygen
  • 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) пїЅ

Followup Recommendations

Follow up with primary care after discharge пїЅ

Pearls and Pitfalls

  • A sympathomimetic toxidrome with delirium/psychosis should arouse suspicion for "bath salts"пїЅ intoxication
  • Severe hyperthermia should be aggressively controlled
  • Focused supportive care is the mainstay of treatment, with benzodiazepines as initial therapy

Additional Reading

  • Borek пїЅHA, Holstege пїЅCP. Hyperthermia and multiorgan failure after abuse of "bath salts"пїЅ containing 3,4 methylenedioxypyrovalerone. Ann Emerg Med. 2012;60(1):103-105.
  • Hill пїЅSL, Thomas пїЅSH. Clinical toxicology of newer recreational drugs. Clin Toxicol (Phila). 2011;49:705-719.
  • Prosser пїЅJM, Nelson пїЅLS. The toxicology of bath salts: A review of synthetic cathinones. J Med Toxicol. 2012;8:33-42.
  • Ross пїЅEA, Reisfield пїЅGM, Watson пїЅMC, et al. Psychoactive "bath salts"пїЅ intoxication with methylenedioxypyrovalerone. Amer J Med. 2012;125:854-858.
  • Spiller пїЅHA, Ryan пїЅML, Weston пїЅRG, et al. Clinical experience with and analytical confirmation of "bath salts"пїЅ and "legal highs"пїЅ (synthetic cathinones) in the United States. Clin Toxicol (Phila). 2011;49:499-505.

Codes

ICD9

969.6 Poisoning by psychodysleptics (hallucinogens) пїЅ

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)