Rosen & Barkin's 5-Minute Emergency Medicine Consult (96 page)

• Treatment of Chlamydia
  
• Treatment of Gonococcal Disease
  

CODES

• 098.0 Gonococcal infection (acute) of lower genitourinary tract
  
• 616.3 Abscess of Bartholin’s gland
  

BASICS

“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
    

• 1st use in US reported in 2010
  
  • MDPV and mephedrone noted in Europe since 2004
    
• Called “America’s 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
  

• 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

• 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
    

• 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
    

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

• 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
    

• Other intoxications:
  
  • Cocaine
    
  • Amphetamines
    
  • Anticholinergic agents
    
  • Ecstasy
    
  • Ethanol
    
• Acute psychosis
  
• Serotonin syndrome
  
• Delirium from infectious or metabolic process
  

TREATMENT

• Stabilize airway
  
• Vital signs
  
• IV access
  
• Fingerstick glucose
  
• Oxygen administration if needed
  

• 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
  

• 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:
  
  • Propofol for sedation
    
• Caution with antipsychotic administration which may lower seizure threshold, cause extrapyramidal symptoms, and dysrhythmias
  
• Poison Control Center/toxicology guidance (1-800-222-1222)
  

• Ativan 2–4 mg increments IM or IV
  
• Valium 10–30 mg increments IM or IV
  

FOLLOW-UP

• All patients with symptoms should be admitted for monitoring
  
• Severe symptoms including uncontrollable hypertension, altered mental status, cardiovascular instability, and hyperthermia require ICU monitoring
  

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)

Follow up with primary care after discharge

• 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
  

• 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