Transcript Hey Dude! How Did I Get Here?

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

Melinda Lucas DOES NOT have a financial
interest/arrangement or affiliation with one or
more organizations that could be perceived as a
real or apparent conflict of interest in the
context of the subject of this presentation.
Conflict of Interest Disclosure


All individuals who participate in sponsored activities
are expected to disclose any significant financial
relationships that may pose a conflict with the
principles of balance and independence.
In the past 12 months neither Melinda Lucas nor any
member of her family has had a financial or beneficial
relationship with one or more of the following
commercial entities: grant/research support, other
remuneration (Speaker’s Bureau, honoraria, travel
expenses, etc.), Major Stock/share holder (not mutual
funds), Advisory Board; Ownership or Partnership.
Learning Objectives
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Develop a differential diagnosis for patients with
hallucinations and an altered state of
consciousness
Understand the impact of social media on illicit
drug usage
Become familiar with the toxidromes for 2
designer drugs.
Alice In Wonderland
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11 Year Old Female
Fever, cough, Coryza, & Myalgias for 3 days
Night-time Audio and Visual Hallucinations
Pictures Zoomed in and out which scared her
Alleged her parents were talking and moving in
very, very slow motion
Alice in Wonderland
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Negative PMH; No Migraines
Family History negative for Migraines,
Tamiflu (oseltamivir phosphate) for 24 hours
Vital Signs: Temp 36.8oC, Heart Rate 107 bpm, BP
92/68 mm Hg, Pulse Ox 98% Room Air
Physical Exam: no meningeal irritation; Cranial
Nerves 2-12 Normal, Cerebellar Function Normal
Motor and Sensory Systems Normal
Alice in Wonderland
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Labs:
CBC & diff Normal
 CMP Normal
 EBV Serology Negative
 H1N1 PCR Positive
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Clinical Course:
Flu symptoms resolved in 2 days
 Neurological symptoms resolved in 2 days
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Tamiflu stopped after 5 day course.
Alice in Wonderland
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First Described by John Todd, an English
psychiatrist, in 1955
Disorienting Neurological Condition
Temporary Condition
Alice in Wonderland
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Visual Distortions
Micropsia
 Macropsia
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Distorted Perception of other Sensory
modalities
Time
 Touch
 Sound
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Alice in Wonderland
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Associated with
Migraines
 Brain Tumors
 Psychoactive Drugs
 Initial Presentation of Epstein-Barr Virus
 Influenza
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Usually Influenza A
 Can be H1N1
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Alice in Wonderland
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Take Home Messages
Medical Illnesses can present with visual and
auditory changes or hallucinations
 Mental Health Problems can present with
hallucinations
 Psychotropic Drugs can also cause hallucinations
and/or visual & auditory changes
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The Spice Girl
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17 year old girl 11 weeks gestation
Bipolar Disorder and Depression History
Stayed at friend’s house until afternoon
Slept 2-6 p.m.
Awoke with Nausea, dizziness, thirst, heart
racing, unable to void
Visual and Auditory Hallucinations
Medications: Prenatal Vitamins
The Spice Girl
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PMH:
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Cutting Behaviors
2 Inpatient Psychiatric Admissions
Psychiatric Medications self-discontinued
Last Psychiatric Visit > 1 year ago
Prior user of Cocaine and Cannabis
Smoker
Prenatal Care started 2 weeks ago
SH
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Broke up with boyfriend recently
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(father of unborn child)
The Spice Girl
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PE:
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Denies suicidal & homicidal tendencies
Denies thoughts of wanting to hurt unborn child
Vital Signs: Temp 97oF; HR 150; BP 115/51 mm Hg; Pulse
Oximeter 100% Room Air
Alert, Anxious, awake
Warm, Dry Skin without flushing
PERRLA, No nystagmus, Pupils 3 mm
Dry Mouth
Normal Thyroid
Tachycardia without Murmur
Normal Neurological Exam except for visual and auditory
hallucinations
The Spice Girl
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Lab:
Normal Urine Drug Screen for amphetamines,
barbiturates, benzodiazepines, cocaine, opiates,
phencyclidine, cannabis using kinetic interactions of
micro particles technique
 Negative blood tests for ethanol, acetaminophen,
salicylates
 EKG with 130 beats per minute, QRS interval 86
milli seconds, QTc interval of 380 milliseconds, no
ischemia, NOT SVT
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The Spice Girl
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Treatment
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20 mL/kg Normal Saline IV
Ultrasound of Pelvis with single live intrauterine
pregnancy at 12 weeks 2 days
Admitted for Observation
2 Episodes of hypotension (70/30 mm Hg) treated with
IV NS – 20 mL/kg each
Hallucinations Resolved over 2 days
Confessed to ingestion of a powder from her
mother’s spike rack to get high
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instructions on T.V.
The Spice Girl
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Nutmeg
Abortifacient by American & English women in late
19th & early 20th century.
 Euphoric and Hallucinogenic effects with low cost
and ease of availability
 Spice obtained by grating the kernel within the fruit
of the nutmeg tree.
 Mace is made from the red-laced membrane
surrounding the seed.
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The Spice Girl
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Nutmeg comes from the evergreen tree, Myristica
fragrans, & is a mixture of compounds:
Aromatic (myristicin, elemicin, and safrole)
 Terpene (eugenol and mace)
 Compositions vary with differences in quality,
storage, purifying and processing
 Elemicin chemically closely resembles mescaline
 Myristicin is closely related to 3-methoxy-4,5
methylenedioxyamphetamine.
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The Spice Girl
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Atropine-Like Syndrome or mistaken for pure
antichoinergic toxicity
Dry mouth
 Facial flushing
 Nausea
 Unsteadiness (dizzy)
 Epigastric Pain
 Urinary Retention
 Blurred Vision
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The Spice Girl
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Sympathomimetic and Serotonergic Effects
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Cardiovascular Effects
Sinus Tachycardia
 Palpitations
 Hypotension
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Central Nervous System Effects
Hallucinations - 14% of users
 Psychosis
 Anxiety
 Drowsiness
 Fear
 Paresthesias
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The Spice Girl
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Symptoms
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Ingestions of >10 g of nutmeg
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1-3 whole nuts or 1-2 TBSP ground nutmeg
Appear 3-6 hours after ingestion
 Duration of 24-48 hours
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Treatment
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Supportive care for agitation, hypotension, and
psychiatric symptoms
Legal Highs
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Nutmeg (Myristica fragrans)
Morning glory (Ipomoea violecea):
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Kava kava (Piper methysticum)
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mitragynine, a low dose stimulent & high dose narcotic
Jimson Weed (Datura stramonium)
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Kava lactones = sedation & hallucinations
Kratom (Mitragyna speciosa)
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lysergic acid amide, a hallucinogen
Belladonna alkaloids, atropine, scopolaine, hyoscyamine =
delerium, hallucinations, anticholinergic syndrome
Salvia divinorium
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Salvinorin A: subtle high to vivid psychedelic experience
The Spice Girl
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Take Home Message
Sources of information may be from unverified
sources such as T.V., online encyclopedias, You
Tube, online “trip reports”, tweets & blogs, and
“how-to” information on the Web
 Conventional intoxicants and “legal highs” are a
trend with adolescents.
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Reliable web sites:
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www.herbmed.org; www.mskcc.org/aboutherbs
Mountain Mike
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15 year old brought to ER by EMS for violence,
crazy behavior, and visual hallucinations.
15 minutes prior to calling EMS he took a Single
Bong Hit from a water pipe.
Prior History of being high before, but not like
this
Mountain Mike
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Physical Exam
Restless, anxious
 Oriented to person, place, time
 Complains legs feel numb and twitchy
 Vital Signs: HR 120 bpm; BP 135/85 mm Hg;
afebrile; pulse oximeter 98% room air
 PERRLA, EOMs intact, Pupils slightly dilated
 Moist Membranes
 Normal Thyroid
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Mountain Mike
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PE
Chest exam normal
 CV exam no murmur or gallop; otherwise normal
 Abdominal exam normal
 Skin: sweaty, no flushing of skin, no rash
 Neurological: Normal cranial nerves, no clonus,
normal strength and sensation in extremities;
fasciculations in quadricep muscles.
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Mountain Mike
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Lab
Glucose normal – not elevated or low
 CMP: Potassium 2.9 mEq/L; normal otherwise
 Ethanol negative
 Urine radioimmunoassay (RIA) for amphetamines,
barbiturates, benzodiazepines, cocaine, opiates , and
phencyclidine (PCP) is negative. Positive for
Tetrahydrocannabiol
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Mountain Mike
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Treatment
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Lorazepam 2 mg IV
HR decreases to 95 bpm
 Calmer
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Observation for 6 hours
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Confused as to how he got to hospital
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3 Friends taken to same hospital after trying a new
marijuana for the first time
Mountain Mike
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Acute Marijuana Intoxication
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Increase Heart Rate
Increase Blood Pressure
Euphoria and a Sense of Detachment
Unpleasurable experience rare
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inconsistent with patient’s prior history
Dysphoria with Large Doses and assosciated with panic,
anxiety or depression – Not agitation
Agitation NOT TYPICAL
Hypokalemia NOT TYPICAL unless malnourished in a
habitual drug user
Mountain Mike
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New Marijuana
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? Grown with advanced horticultural techniques which have increased
psychoactive potency
? Marijuana with addition of another psychoactive substance such as
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? Different botanical entity being smoked
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Ecstasy
Clenbuterol : B-adrenergic agonist
PCP: cyrstal joint, supergrass, dipper, illy, fry, wet
Freebase or Powdered Cocaine: dusting, snowcapping
Salvia divinorum: legal marijuana, herbal smoke, herbal marijuana
Mephedrone derived from khat plan (catha edulis)
? Chemical entity being smoked
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Herbal incense, herbal smoke
Potpourri
Incense
Mixture of 1 or more synthetic cannabinoids
Mountain Mike
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Synthetic Cannabinoids
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Different chemical structure than 11-nor-9carboxytetrahydrocannabinol
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Most common molecule tested in UDS
Gas chromatography-mass spectrometry in highly
specialized laboratories
4 Selected synthetic cannabinoids
JWH-018
 JWH-073
 CP-47,497
 HU-210
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Mountain Mike
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Synthetic Cannabinoids
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Brand Names
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K 2 after second highest mountain on earth
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(28,251 ft
Deadly to inexperienced climbers
Spice after spice from Frank Herbert’s book Dune
 JWH-018
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Sold over the Internet to a private residence for research
laboratory purposes only and comes with a disclaimer
Sold at certain “convenience” stores
Sold at “head shops” or drug paraphenalia shops
Mountain Mike
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K-2 or Spice Toxidrome
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Hypokalemia
Tremors
Agitation
Hallucinations
Anxiety
Tachycardia
Elevated Blood Pressure
Pallor
Vomiting
Mountain Mike
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Take Home Message
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Anticipatory Guidance
Manufacture not regulated
 Full range of immediate adverse effects unknown
 Long-term consequences of synthetic cannabinoids and the
derivatives are unknown
 Tolerance and physiological withdrawal have been reported
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If the symptoms do not add up, suspect “incense”
State-specific guidelines about possession exist
FDA bans sale and importation
Aggressive Andy
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14 year old with ADHD brought to ED for a
mental status exam by police
Police called to residence by mother because patient
threatening to kill her and destroying walls and
furniture
Mother states patient was in bedroom and emerged
with intermittent confusion and aggression
May have been hallucinating for several days, and
seems to be hiding from someone, but no one
around
Aggressive Andy
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Patient uncomfortable and complains of chest
pain and his heart racing
Intermittent racing of heart for several days
Thoughts race through his brain
Panicking as thoughts race
Very hungry but cannot eat
Aggressive Andy
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No medications
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Self-stopped medications for ADHD years ago because
they were costly
SH denies substance abuse initially but later admits
to alcohol (three 12 packs each weekend), cigarettes
(1 ppd), K-2 or Spice if horticultural marijuana not
available (2-4 joints 2 times a day), mother’s Xanax,
tried meth and cocaine recently
Admits to taking mother’s Xanax tonight and also
the “white powder” she uses when upset and needs
to laugh
Aggressive Andy
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Physical Exam
HR 250
 BP 161/110 mm Hg
o
 Temp 37.6 C
 RR 22-30/minute
 Restless - hands & feet in constant motion
 No eye Contact
 Very short attention span
 Exasperated with all questions
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Aggressive Andy
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PE
Dilated, reactive pupils without nystagmus
 Normal nares, nasal septum, oral pharynx
 No goiter
 Chest clear
 CV with tachycardia, but normal pulses and
perfusion and warm pink extremities
 No liver or spleen enlargement
 Sweaty skin
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Aggressive Andy
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PE
Cranial Nerves 2-12 intact, Motor strength and tone
normal, normal DTR, alert and able to answer
questions but concerned about chest pain,
 Tremor in outstretched hands
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Aggressive Andy
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Lab
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CMP normal
Glucose Normal
Ethanol Not detected
Commercial radioimmunoassay of urine for
amphetamines, benzodiazepines, barbiturates, cannabis,
cocaine, opoids was negative
CXR Normal
CT head Normal
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EKG: SVT
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Aggressive Andy
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Treatment
IVF with 20 mL/kg Normal saline bolus
 Adenosine X 2 with HR converting for 20 seconds
 Response to Cardizem (diltiazem) with HR 220.
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Aggressive Andy
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Impression:
Compensated SVT
 Hypertension unusual for SVT
 Agitation and Aggression Worrisome for Safety of
Health Care Providers, safety of patient
 Overdose/Ingestion of ? Bath Salts or K-2
 Binge Drinking and habitual substance abuse
 ADHD
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Aggressive Andy
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Transfer to PICU requested - utilizing Helicopter
Patient refused stretcher and restraints and became aggressive
and threatening
Helicopter Pilot refuses to fly uncooperative patient
Ativan 4 mg IV given X 2 and patient settles
Ground transport with EMS and helicopter crew transports
patient to PICU
Patient restrained and cooperative in SVT with talk down
2-4 hours later patient converts from “stable SVT” to NSR
after maximum dose of cardizem bolus and drip used.
Admits to snorting some salt
Leaves AMA 2 days later with Mother and GF’s assistance
Aggressive Andy
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Diagnosis of Exclusion
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Urine Toxicology for PCP, Cocaine, Amphetamines
Serum Alcohol Level
BMP for Electrolyte Imbalances
Bedside Glucose
ABG as metabolic acidosis seen with sympathomimetic
toxicology
CBC & Diff for infection or severe anemia
CT head for subarachnoid hemorrhage or hydrocephalus
12 – Lead EKG for arythmia or ischemia
Consider Troponin, CPK-MB, Myoglobin
Aggressive Andy
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Definitive Diagnosis
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Specific high performance liquid
chromatography/tandem mass spectroscopy of the
urine for MDPV and Mephedrone
Aggressive Andy
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Other Complications
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Cardiac (up to 2 weeks later)
Tachycardia
 Hypertension
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Hyperthermia
 Renal:
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Respiratory
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Rhabdomyolysis
Aspiration Pneumonia
Delerium
Aggressive Andy
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Other Complications:
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Neurological:
Seizures
 Intracerebral Hemorrhage
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Myopathy
 Critical Illness Myopathy/Polyneuropathy
 GI: intestinal infarction/ischemia
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Other polydrug usage
complications/contaminants
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Manganism from potassium permanganate exposure
Aggressive Andy
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Contaminants/
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Levamisole:
agranulocytosis/thrombotic events
Hallucinations
Prolonged Anxiety
Seizures
Panic Attacks
Deaths
Aggressive Andy
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Bath Salts
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Not Epsom salts or spa-type bath salts
Drugs of abuse marketed with an innocent name
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Bypass current U.S. drug laws
Known as White Rush Bath Salts
Sold as “plant food”
Sold as “insect repellant”
Sold over the internet
Sold at small convenience gas station markets
Sold at selective stores like “head shops”
Aggressive Andy
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Other Names for the bath salts
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Bliss
Blue Silk
Down2Earth White Horse
Energizing Aromatherapy
Ivory Wave
Kamikaze
Purple Wave
Red Dove
Vanilla Sky
White Lightning
Aggressive Andy
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Bath Salts
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White, tan, or brown powder
Usually “clumpy”
Encapsulated or crystal
Packages of 50-200 mg or large vials of 500 mg of
“cathinone”
Pharmacological Effect depends on purity,
concentration, and filler properties
PO, Rectal insertion, Snorted (insufflated), Injected or
Smoked
Onset of action, Peak, and Duration depends on route
of administration
Aggressive Andy
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Sympathomimetic Toxidrome
Insomnia
 Agitation
 Tachycardia/ SVT
 Hypertension
 Mydriasis
 Diaphoresis
 Tremor
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Aggressive Andy
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Other Substances Causing Sympathomimetic
Toxidromes
Amphetamine
 Methamphetamine
 Cocaine
 Prescription Drugs for ADHD
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Aggressive Andy
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DEA
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Schedule 1
Ecstasy (MDMA)
 Mushrooms (psilocybin)
 LSD
 Mescaline (peyote active ingredient)
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October 2011
Illegal to possess or sell the chemicals in bath salts or
products containing them in the U.S. for 1 year
Studies to be done to weigh whether they should be
permanently banned
Aggressive Andy
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Federal Analog Act: Any chemical “substantially
similar” to a Schedule I (heroin and lysergic acid
diethylamide (LSD) ) or Schedule II (methadone
and injectable methamphetamine) to be treated as if
it is also a controlled substance, with the caveat that
the chemical has to be intended for human
consumption.
Marketed with the label “NOT FOR HUMAN
CONSUMPTION”
Aggressive Andy
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Bath Salts
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Stimulant derivatives of Schedule I chemical
cathinone (bata-ketoamphetamine) from the Khat
shrub, Catha edulis
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Mephedrone = 4-methylmethcathinone: popular
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Structurally like cocaine, amphetamine, & MDMA (ectasy)
MDPV = 3,4-methylenedioxypyrovalerone: potent
Inhibit reuptake of norepinephrine and dopamine
 Promote release of dopamine, noradrenalin, &
serotonin
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Aggressive Andy
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Six Chemicals
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MDPV
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Mephedrone, 4-MMC
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4-fluoromethcathinone
3-FMC
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3,4-methylenedioxymethcathinone
Flephedrone, 4-FMC
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4-methylmethcathinone
Methylone, MDMC
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3,4-methylenedioxypyrovalerone
3-fluoromethcathinone
Methedrone, BK-PMMA, PMMC
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4-methoxymethcathinone
Aggressive Andy
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European Club Scene in 2010
40% of 2,000 clubbers had used bath salts
 30% of 2,000 clubbers used them in past month
 Use of ecstasy declined
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MDMA unavailable
Instability of ecstasy market
Internet English – Language sites selling bath salts
30 in 12/2009
 70 in 3/2010
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Poison Control Centers in U.S.
2009: No calls
 2010: 303 Calls
 July 31, 2011: 4,100 calls
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Aggressive Andy
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Recreational Users report
Euphoria
 Empathy
 Increased Alertness
 Improved Concentration and ability to focus
 Higher energy levels
 Sense of well-being (decreased hostility?)
 No hangover, or comedown or depression like
amphetamines, cocaine, and ecstasy
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Aggressive Andy
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Health Care Providers Report
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Severe Paranoia
Severe Anxiety
Severe psychosis
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Severe Agitation
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Bizarre Behavior
Tremors
Delusions
Persecutory Hallucinations
Signs and Symptoms last for several DAYS
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Aggressive Andy
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Health Care Providers Report
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Palpitations
Shortness of Breath
Diaphoresis
Hot Flashes
Headaches
Hyperthermia
Overwhelming Thirst
Polydipsia
Jaw pain from bruxism (ecstasy & amphetamines)
Signs & Symptoms like Amphetamine & Cocaine
Intoxication – sympathetic nervous system stimulation
Aggressive Andy
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Health Care Providers Notice Initially
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Combative
Self-Destructive
Suicidal
Homicidal
Violent Behavior without Warning
Health Care Providers Notice Finally
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Suicidal Thoughts & Actions
Extreme Sadness
Depression
Aggressive Andy
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Greatest Risk for Adverse Psychiatric Reactions
Underlying Neurological Conditions
 Underlying Psychiatric Conditions
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Greatest Risk for Healthcare-directed Violence
Male
 History of Violent Behavior, Psychiatric Illness,
and/or drug or alcohol abuse
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Aggressive Andy
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Warning Signs for Patients at High Risk for
Acting Out
Speaking increasingly Loudly
 Abusive Language
 Clenched Fists
 Avoidance of eye contact
 Tense Posturing
 Pacing
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Aggressive Andy
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Successful Management
Verbal Deescalating Techniques may not be
successful if patient psychotic
 Sedation and nonrestrictive methods of restraint
should be tried first
 Physical restraints probably needed
 POLICE USE TAZERS!!
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Aggressive Andy
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Management
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Sedatives in large doses & intubate to maintain airway
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Antipsychotic Medications
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Diazepam = Valium
Lorazepam = Ativan
Haloperidol = Haldol
Ziprasidone = Geodon
Monitor temperature
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Fatal Hyperthermia (Mephedrone)
Serotonin Syndrome-Induced Hyperthermia
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Rhabdomyolysis
RenalFailure
Metabolic Acidosis
DDIC – disseminated intravascular coagulation
Coma
Death
Aggressive Andy
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Management:
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Protect Caregivers
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50% ED staff become victims of patient violence
5% violent patient possess a concealed weapon
Emergency Psychiatric Evaluation As Soon As Possible
 Body & Possession Search to remove objects of potential
harm
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


Notify Security
Keep Exit to room available for providers
“safety sitter”
Aggressive Andy

Treatment

Anticipatory Guidance
Unclear as to effects of metabolites
 Unclear as to chemicals included in “bath salts”
 No quality-control scrutiny
 Variable Potency leading to unintentional overdose
 Long-term consequences on brain function unknown

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Psychiatric Referral
Consider Alcohol and Drug Withdrawal Program
Law Enforcement: Charges for possession or for assault
Aggressive Andy

Increasing Concerns

Parents
Flashbacks
 Addiction


Healthcare Workers

Personal Safety
Government Officials
 Legal System

Schedule I
 Criminal Activity

Aggressive Andy

Take Home Message
Designer Drugs are distributed in different ways
 The Internet makes the distribution of designer
drugs spread more rapidly.
 The web makes alterations in drugs “easy” and
readily available for the “chemist”
 Bath Salts are not benign but are readily available
and can be deadly
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
Web Site: www.erowid.org

Thank you

Any Questions?
References
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Todd J. The syndrome of Alice in Wonderland,
Can Med Assoc J. 1955; 73:701-704l
Cinbis M, Aysun S. Alice in Wonderland syndrome
as an initial manifestation of Epstein-Barr virus
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Morishima T, Togashi T, Yokota S, et al.
Encephalitis and encephalopathy associated with an
influenza epidemic in Japan. Clin Infect Dis. 2002;
35:512-517.
References
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Wade T, Morishima T, Okumura A, et al. Differences in
clinical manifestations of influenze-associated
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complications associated with influenze A in children
during the 2003-2004 influenza season in Houston,
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complications associated with novel influenza A (H1N1)
virus infections in children – Dallas, Texas, May 2009.
MMWR 2009;58(28):773-778.
References
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Augarten A, Aderka D. Alice in Wonderland
Syndrome in H1N1 Influenza: Case Report. PEC.
2011; 27(2):120.
Green RC. Nutmeg poisoning. JAMA.
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References
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Sangalli BC, Chiang W. Toxicology of nutmeg
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References
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Demetriades AK, Wallman PD, McGuiness A, et al.
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Emerg Med J. 2005; ;22:223-225.
CDC. Emergency department visits after use of a
drug sold as bath salts” – Michigan, November 13,
2010 to March 31, 2011. MMWR. 2011;60:1-4.
Winstock AR, Mitcheson LR, Deluca P, et al.
Mephedrone, new kid for the chop? Addiction.
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References
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Wood DM, Davies S, Greene Sl, et al. Case series
of individuals with analytically confirmed acute
mephedrone toxicity. Clin Toxicol. 2010;48:924927.
Maskell PD, De Paoli g, Seneviratne C, et al.
Mephedrone-related deaths. J Anal Toxicol.
2011;35:188-191.
Paynter B. Big business of synthetic highs.
Businessweek.
http://www.businesswekk.com/magazine/content
/11_26/b4234058348635.htm.
References
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www.justice.gov/dea/pubs/pressrel/pr102111.html
.
Wood DM, Greene SL, Dargan PI. Clinical pattern
of toxicity associated with the novel synthetic
cathinone mephedrone. Emerg Med J.
2010;28(4):280-282.
American Association of Poison Control Centers.
Bath Salts Data.
McGraw MM. Is your patient high on “bath salts”.
Nursing 2012; 26-32.
References
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Osterhoudt K. A Teenager with Agitation. Ped
Emerg Care. 2010;26(6);462-465.
American Association of Poison Control
Centers. Marijuana and Synthetic Marijuana
Data.
American Association of Poison Control
Centers. Nutmeg Data.