hey dude! how did i get here?
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Hey Dude! How Did I Get Here?. Melinda Lucas, M.S., M.D., F.A.A.P. SouthWest Virginia Pediatric Conference, August 4-5, 2012. Disclosure Statement of Financial Interest. - PowerPoint PPT PresentationTRANSCRIPT
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 3 Fever, cough, Coryza, & Myalgias for 3
daysdays 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 daysNeurological symptoms resolved in 2 days
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 from Confessed to ingestion of a powder from her mother’s spike rack to get high her mother’s spike rack to get 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-4,5 Myristicin is closely related to 3-methoxy-4,5
methylenedioxyamphetamine.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, hyoscyamine Belladonna alkaloids, atropine, scopolaine, hyoscyamine = delerium, hallucinations, anticholinergic syndrome= delerium, hallucinations, anticholinergic 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 unverified Sources of information may be from unverified sources such as T.V., sources such as T.V., online encyclopediasonline encyclopedias, , You Tube, online “trip reports”, tweets & You Tube, online “trip reports”, tweets & blogs, and “how-to” information on the Webblogs, and “how-to” information on the Web
Conventional intoxicants and “legal highs” are Conventional intoxicants and “legal highs” are a trend with adolescents.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 marijuana: legal marijuana, herbal smoke, herbal marijuana 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 and Long-term consequences of synthetic cannabinoids and
the derivatives are unknownthe derivatives are unknown Tolerance and physiological withdrawal have been Tolerance and physiological withdrawal have been
reportedreported If the symptoms do not add up, suspect “incense”If the symptoms do not add up, suspect “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 each later admits to alcohol (three 12 packs each weekend), cigarettes (1 ppd), K-2 or Spice weekend), cigarettes (1 ppd), K-2 or Spice if horticultural marijuana not available (2-4 if horticultural marijuana not available (2-4 joints 2 times a day), mother’s Xanax, tried joints 2 times a day), mother’s Xanax, tried meth and cocaine recentlymeth and cocaine recently
Admits to taking mother’s Xanax tonight Admits to taking mother’s Xanax tonight and also the “white powder” she uses when and also the “white powder” she uses when upset and needs to laughupset 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 motion Restless - hands & feet in constant 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 CV with tachycardia, but normal pulses
and perfusion and warm pink extremitiesand perfusion 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 was barbiturates, cannabis, cocaine, opoids was negativenegative
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 bath Illegal to possess or sell the chemicals in bath
salts or products containing them in the U.S. salts or products containing them in the U.S. for 1 yearfor 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 (LSD) (heroin and lysergic acid diethylamide (LSD) ) or Schedule II (methadone and injectable ) or Schedule II (methadone and injectable methamphetamine) to be treated as if it is methamphetamine) to be treated as if it is also a controlled substance, with the caveat also a controlled substance, with the caveat that the chemical has to be intended for that the chemical has to be intended for human consumption.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 bath Internet English – Language sites selling bath saltssalts
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 Psychiatric Greatest Risk for Adverse Psychiatric
ReactionsReactions Underlying Neurological ConditionsUnderlying Neurological Conditions Underlying Psychiatric ConditionsUnderlying Psychiatric Conditions
Greatest Risk for Healthcare-directed Greatest Risk for Healthcare-directed ViolenceViolence 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 Todd J. The syndrome of Alice in Wonderland, Todd J. The syndrome of Alice in Wonderland,
Can Med Assoc JCan Med Assoc J. 1955; 73:701-704l. 1955; 73:701-704l Cinbis M, Aysun S. Alice in Wonderland Cinbis M, Aysun S. Alice in Wonderland
syndrome as an initial manifestation of syndrome as an initial manifestation of Epstein-Barr virus infection. Epstein-Barr virus infection. Br J Ophthalmol. Br J Ophthalmol. 1992; 76:316.1992; 76:316.
Morishima T, Togashi T, Yokota S, et al. Morishima T, Togashi T, Yokota S, et al. Encephalitis and encephalopathy associated Encephalitis and encephalopathy associated with an influenza epidemic in Japan. with an influenza epidemic in Japan. Clin Clin Infect Dis. Infect Dis. 2002; 35:512-517.2002; 35:512-517.
ReferencesReferences Wade T, Morishima T, Okumura A, et al. Wade T, Morishima T, Okumura A, et al.
Differences in clinical manifestations of Differences in clinical manifestations of influenze-associated encephalopathy by age. influenze-associated encephalopathy by age. Microbiol Immunol. Microbiol Immunol. 2009; 53:83-88.2009; 53:83-88.
Maricich SM, Neul JL, Lotze TE et al. Maricich SM, Neul JL, Lotze TE et al. Neurological complications associated with Neurological complications associated with influenze A in children during the 2003-2004 influenze A in children during the 2003-2004 influenza season in Houston, Texas. influenza season in Houston, Texas. Pediatrics Pediatrics. . 2004; 114: e626-e633. 2004; 114: e626-e633.
Brock e, Varghese A, Rowe C, et al. Neurologic Brock e, Varghese A, Rowe C, et al. Neurologic complications associated with novel influenza A complications associated with novel influenza A (H1N1) virus infections in children – Dallas, (H1N1) virus infections in children – Dallas, Texas, May 2009. Texas, May 2009. MMWRMMWR 2009;58(28):773- 2009;58(28):773-778.778.
ReferencesReferences Augarten A, Aderka D. Alice in Augarten A, Aderka D. Alice in
Wonderland Syndrome in H1N1 Influenza: Wonderland Syndrome in H1N1 Influenza: Case Report. Case Report. PECPEC. 2011; 27(2):120. . 2011; 27(2):120.
Green RC. Nutmeg poisoning. Green RC. Nutmeg poisoning. JAMAJAMA. . 1959;171:1342-1344.1959;171:1342-1344.
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.
ReferencesReferences Sangalli BC, Chiang W. Toxicology of Sangalli BC, Chiang W. Toxicology of
nutmeg abuse. nutmeg abuse. Clin Toxicol. Clin Toxicol. 2000;38:671-2000;38:671-678.678.
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;49:177-180.2011;49:177-180.
Forrester MB. Nutmeg intoxication in Forrester MB. Nutmeg intoxication in Texas, 1998-2004. Texas, 1998-2004. Hum Exp ToxicolHum Exp Toxicol. . 2005;24:563-566.2005;24:563-566.
ReferencesReferences Demetriades AK, Wallman PD, McGuiness Demetriades AK, Wallman PD, McGuiness
A, et al. Low cost, high risk: accidental A, et al. Low cost, high risk: accidental nutmeg intoxication. nutmeg intoxication. Emerg Med J. Emerg 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.
Winstock AR, Mitcheson LR, Deluca P, et Winstock AR, Mitcheson LR, Deluca P, et al. Mephedrone, new kid for the chop? al. Mephedrone, new kid for the chop? Addiction. Addiction. 2010;106:154-161.2010;106:154-161.
ReferencesReferences Wood DM, Davies S, Greene Sl, et al. Wood DM, Davies S, Greene Sl, et al.
Case series of individuals with Case series of individuals with analytically confirmed acute mephedrone analytically confirmed acute mephedrone toxicity. toxicity. Clin Toxicol. Clin Toxicol. 2010;48:924-927.2010;48:924-927.
Maskell PD, De Paoli g, Seneviratne C, et Maskell PD, De Paoli g, Seneviratne C, et al. Mephedrone-related deathsal. Mephedrone-related deaths. J Anal . J Anal ToxicolToxicol. 2011;35:188-191.. 2011;35:188-191.
Paynter B. Big business of synthetic Paynter B. Big business of synthetic highs. Businessweek. highs. Businessweek. http://www.businesswekk.com/magazine/http://www.businesswekk.com/magazine/content/11_26/b4234058348635.htm.content/11_26/b4234058348635.htm.
ReferencesReferences www.justice.gov/dea/pubs/pressrel/pr1021
11.html..
Wood DM, Greene SL, Dargan PI. Clinical Wood DM, Greene SL, Dargan PI. Clinical pattern of toxicity associated with the pattern of toxicity associated with the novel synthetic cathinone mephedrone. novel synthetic cathinone mephedrone. Emerg Med J. Emerg Med J. 2010;28(4):280-282.2010;28(4):280-282.
American Association of Poison Control American Association of Poison Control Centers. Bath Salts Data. Centers. Bath Salts Data.
McGraw MM. Is your patient high on McGraw MM. Is your patient high on “bath salts”. “bath salts”. NursingNursing 2012; 26-32. 2012; 26-32.
ReferencesReferences Osterhoudt K. A Teenager with Osterhoudt K. A Teenager with
Agitation. Agitation. Ped Emerg CarePed Emerg Care. . 2010;26(6);462-465.2010;26(6);462-465.
American Association of Poison American Association of Poison Control Centers. Marijuana and Control Centers. Marijuana and Synthetic Marijuana Data.Synthetic Marijuana Data.
American Association of Poison American Association of Poison Control Centers. Nutmeg Data. Control Centers. Nutmeg Data.