The first synthetic cathinone-related death in the United States, described in the scientific literature, involved a year-old male who was found unresponsive and subsequently died at the receiving hospital. Blood and urine tested positive for mephedrone, heroin metabolites, codeine, and doxylamine. Electrocardiographic changes with greater than 3 mm ST-segment elevation in the anterolateral leads, and high T2 signal at the lateral left ventricle on cardiac magnetic resonance imaging, confirmed the diagnosis of myocarditis.
One additional case of documented 2-mm ST depression in a patient exposed to MDPV is reported, although this case did not result in death and resolved with only sublingual nitrates. Rising use patterns and cases of self-mutilation and suicide have garnered increasing media attention.
Incident usage of cathinone-derived sympathomimetic bath salts continues to increase in the United States. Data are limited, largely because unique surveillance coding of bath salt calls to poison centers was initiated only in mid Bailey, personal communication, April 25, Nationally, calls regarding bath salts were made to poison centers in ; by October 3, a total of 5, calls to poison centers had already been made in Bailey, personal communication, October 3, By contrast, poison center calls referencing synthetic cannabinoids have not seen the same increase in volume.
This is a comparison that may prove instructive for EPs: the designer synthetic marijuana movement is of similar scope, likely familiar to most EPs, and it seems to be on the decline, while bath salt use seems to be on the rise see Figure. US poison center calls for bath salts and synthetic cannabinoids, — Bailey, personal communication, October 3, On September 7, the US Drug Enforcement Agency DEA announced that it will exercise its emergency scheduling authority and temporarily control MDPV and mephedrone along with methylone, a similar compound , as schedule I substances for a minimum of 12 months.
At the time of the DEA's announcement, at least 33 states had independently taken measures to control the substances specifically in bath salts. One instructive example of this is the ban on mephedrone enacted in the United Kingdom on April 16, Specific recommendations for ED evaluation and management of isolated bath salts exposures, specifically for mephedrone or MDPV, would be difficult in most cases presenting to the ED, and interventions typically undertaken for more common sympathomimetic toxicities remain the first line of therapy.
A specific antidote does not exist, and few laboratories have the capacity to screen serum or urine for specific bath salts; to our knowledge, none on a timeline useful in the acute care setting. Features typical of the bath salt toxidrome include, but are not limited to, altered mentation and sensorium, agitation, tachycardia, hypertension, and hyperthermia, with other symptoms possible as well.
Such a presentation is not only common but also consistent with a wide range of disease states, both toxicologic and nontoxicologic. Even among patients with unequivocally toxicologic etiologies to explain these symptoms, bath salts are but one in a multitude of potential intoxicants and diagnoses, including serotonin syndrome, neuroleptic malignant syndrome, anticholinergic and sympathomimetic toxidromes, drug withdrawal syndrome, and exposure to older hallucinogens ie, lysergic acid diethylamine, phencyclidine or to a newer tryptamine or phenethylamine hallucinogen.
Clinical experience in the treatment of bath salt toxicity is limited, and stratifying risk for certain outcomes that draw concern with other sympathomimetics or with new independent concerning outcomes is difficult.
The risk for acute coronary syndrome, rhabdomyolysis, and serotonin syndrome, for example, remains unclear at this time, as does the subsequent need for laboratory testing and appropriate monitoring parameters. The case reports discussed above document important outcomes including death, myocarditis, agitated delirium, and hyponatremia, all of which merit considerable care in the management of documented or suspected bath salt toxicity.
It thus seems prudent to include in the ED workup several key monitoring and therapeutic interventions. Peripheral intravenous access and cardiac monitoring are essential starting points, as is obtaining full vital signs at the outset of the visit including temperature, and repeating those vital signs during the ED stay.
We recommend, at minimum, vital checks every 30 minutes until stable. Electrocardiograms and chest radiographs should be obtained for all patients presenting with tachycardia, chest pain, or shortness of breath. The specific role of cardiac markers in the evaluation of these patients has not been elucidated; however, given previously documented mephedrone cardiac toxicity 13 and well-known propensity of amphetamines to cause direct cardiac damage by way of vasospasm and ischemia, it is prudent to approach the treatment of patients with acute bath salt toxicity and chest pain with at least the same level of caution as nonintoxicated patients with cardiac chest pain.
A basic metabolic panel should be drawn for all patients to seek out hyponatremia and metabolic acidosis. The risk of rhabdomyolysis is uncertain, but in the setting of persistent agitation, obtaining a baseline creatine kinase would be reasonable. A complete blood count is unlikely to aid in the workup of bath salt toxicity, although in the setting of altered mental status, agitation, and hyperthermia of unclear etiology, it may be improper to ignore.
Agitation can be controlled with benzodiazepines as first-line therapy. Other supportive measures, including fluid management and temperature control, may play significant roles in individual cases. More advanced fluid management techniques may be required for cases complicated by hyponatremia or rhabdomyolysis. Airway compromise, extreme sedation needs, seizures evolving to status epilepticus, and uncontrolled agitation all suggest the need for advanced airway management.
The first isolated mephedrone-related case report stated that the substance was not identified by routine toxicologic analysis, but subsequent reports had success with more advanced testing. As with many emerging substances of abuse, little data are available to describe the sensitivity of currently used immunoassays in broad terms, and at this time it is likely that the clinical assessment of the patient who has ingested bath salts will be more sensitive for the diagnosis than a toxicologic screen.
There is a limited but building body of literature consisting largely of case reports, case series, surveys, media releases, and poison center data regarding mephedrone and MDPV toxicity. Chemical structure, case reports, popular media, user forums, and the sparse provider data that exist all support the notion that both compounds act to create a sympathomimetic toxidrome akin to that of cocaine and certain amphetamines.
Proposed evaluation and management arise from experience and case reports only, but are likely congruous with standard proposed management of more well-known drugs such as cocaine, methamphetamine, and MDMA. Epidemiologic data are suggestive of a growing disease burden stemming from markedly increasing popularity of these so-called legal highs.
Even in areas in which they have been banned, the problem of their acute toxicity persists and should be recognized by the well-prepared EP. Volume 13, no. Supervising Section Editor: Jeffrey R.
Suchard, MD. Conflicts of Interest: By the West JEM article submission agreement, all authors are required to disclose all affiliations, funding, sources, and financial or management relationships that could be perceived as potential sources of bias.
The authors disclosed none. National Center for Biotechnology Information , U. West J Emerg Med. Author information Article notes Copyright and License information Disclaimer. Address for Correspondence: Travis D. E-mail: moc. As the list of controlled substances grows, so does the market for so-called designer drugs that elude statutory control. Mephedrone 4-methylmethcathinone, 4-MMC and MDPV 3,4-methylenedioxypyrovalerone have been increasingly implicated as the offending active substances in bath salts.
Copyright the authors. This article has been cited by other articles in PMC. Open in a separate window. Footnotes Volume 13, no. Suchard, MD Conflicts of Interest: By the West JEM article submission agreement, all authors are required to disclose all affiliations, funding, sources, and financial or management relationships that could be perceived as potential sources of bias. Psychopharmacology Berl ; — Recreational use of mephedrone 4-methylmethcathinone, 4-MMC with associated sympathomimetic toxicity.
J Med Toxicol. Drugnet Europe. Accessed April 25, Inhibition of plasma membrane monoamine transporters by beta-ketoamphetamines. Eur J Pharmacol. The effects of non-medically used psychoactive drugs on monoamine neurotransmission in rat brain. Emerg Med J. MDPV effects. Accessed February 19, A web-based survey on mephedrone. Drug Alcohol Depend. Durham M. Ivory Wave: the next mephedrone. Case series of individuals with analytically confirmed acute mephedrone toxicity.
Clin Toxicol Phila ; 48 — Karila L, Reynaud M. GHB and synthetic cathinones: clinical effects and potential consequences. Drug Test Anal. Multiple-drug toxicity caused by the coadministration of 4-methylmethcathinone mephedrone and heroin. J Anal Toxicol. Gussow L. The Poison Review Web site.
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