Laboratory Data

1. Intracranial Hemorrhage following Bath Salt use: A Case ReportAmber Widenski, DO, Josh Johnson, DO, Jamshid Mistry, DO, Michael Neeki, DO, and Anh Nguyen, MDDepartment of Emergency Medicine, Arrowhead Regional Medical Center, Colton, CA and 4th ventricle, causing an obstructive hydrocephalus requiring an emergent ventriculostomy that was placed by the neurosurgical team (Figure 1). The patient was subsequently admitted to the neurosurgical intensive care unit, and after 4 days was extubated. Upon reevaluation, the patient demonstrated a disconjugate gaze and speech impairment, later requiring a ventriculoperitoneal shunt 9 days after hospital admission. Fortunately, the patient continued to improve throughout the rest of his hospital stay and was later discharged into the care of his family with continued outpatient rehabilitation therapy. Although their exact mechanism of action is unclear, bath salts possess both direct agonist activity and re-uptake inhibition of norepinephrine, serotonin, and dopamine, resulting in a toxidrome similar to the effects of methamphetamine, cocaine, and ecstasy.2 The product is usually in powder or crystal form, white or tan brown in color, and often carries the label "not for human consumption" on its packaging to subvert government control (Figure 2). Most users will nasally insufflate the powder form or smoke the crystalline form, but oral ingestion, rectal suppository, intramuscular, and intravenous forms have also been reported. The usual dose is 50-300mg, with 300mg costing approximately $20. The “high” from bath salt use generally lasts 2 to 4 hours, and has been described as a feeling of euphoria, empathic mood, sexual stimulation, increased mental focus, and increased energy. Other common symptoms include hallucinations, paranoia, insomnia, agitation, and suicidal thoughts, often mimicking an acute psychosis.7,8 However, a prominent “letdown” effect that follows can last several hours, driving many users to re-dose the drug repetitively. The most significant complications reported are seizures, agitation, myocarditis, chest pain, and electrolyte abnormalities. Multiple case reports of death after mephedrone use have also been documented.2 Thus far, however, no prior reported cases of intracranial hemorrhage (ICH) due to bath salt abuse have ever been reported in the literature. In 2008, Pozzi et al suggested that methamphetamine and cocaine users are at increased risk for ICH secondary to vasospasm, cerebral vasculitis and enhanced platelet aggregation. In addition, hypertensive surges as a result of drug use also contributed to the higher rate of ICH in their study population.3 Other studies suggest that long-term use may contribute to vascular changes that eventually result in the development of aneurysms.4 Overall, most studies agree that transient elevations in blood pressure as a result of sympathomimetics likely place individuals at increased risk for ICH.3,4,5 Although their exact mechanism of action remains unclear, it seems reasonable to assume the risk of stroke and ICH due to bath salts is similar to that of methamphetamine and ecstasy, given their similar chemical structures. The clinical presentation after bath salt ingestion can vary greatly among individuals, making it difficult for the practitioner to recognize. Therefore, it is necessary for emergency physicians to have a high index of suspicion for bath salt ingestion when individuals show signs of a sympathomimetic toxidrome. Unfortunately, unlike amphetamines and other common illicit drugs, a rapid drug screen for detection of bath salt use does not exist currently. And despite sharing structural similarities, a negative toxicology screen for amphetamines does not rule out recent bath salt ingestion. More advanced testing for mephedrone and MDPV do exist, but data is limited on the accuracy of currently used immunoassays, making the clinical assessment more sensitive.2 Based on previous case reports and known adverse effects from similar drugs, standard medical management for bath salt ingestion includes establishing IV access, placing the patient on continuous cardiac monitoring, and obtaining a 12-lead ECG and basic labs, such as a CBC, BMP, and cardiac enzymes.2 In addition, based on this case report and multiple studies linking chemically similar drugs to increased rates of ICH, it is our recommendation that physicians also perform a detailed neurological exam, maintaining a low threshold for obtaining a Head CT scan, even if reported neurological deficits have appeared to resolve on initial evaluation. Treatment options consist mostly of conservative measures, including IV fluids, temperature control, and benzodiazepines for signs of agitation. Seizures will likely respond to benzodiazepines, barbiturates, or propofol. Additionally, as demonstrated in our case, airway compromise is also a potential complication that respects close monitoring, and may require advanced airway management .2 Despite multiple states recently placing bath salts on their banned substances list, the drugs are still widely available at gas stations and smoke shops nationwide, in addition to being easily purchased online from international retailers. In an effort to further “prevent an imminent threat to public safety” from bath salts, the U.S. Drug Enforcement Administration recently designated them as Schedule I, the most restrictive category under the Controlled Substances Act.6 However, as the trend has shown in recent years, their use is only rising, and physicians must be familiar with their effects and management. As this case highlights, intracranial hemorrhaging is one of the potential devastating consequences of bath salt use, and should be considered when evaluating these patients. History and Physical D.M. is a 42 year old male who arrived to the emergency department via ambulance at 9:35am for reported altered mental status, right sided weakness, slurred speech, blurry vision and dizziness. On evaluation in the emergency department, the patient complained of a persistent headache and dizziness, reporting resolution of any focal weakness or slurred speech prior to arrival. Upon questioning, the patient admitted to using “bath salts” via nasal insufflation multiple times prior to symptom onset, with his last use being a few hours prior to arrival. The patient has used bath salts on prior occasions, but denied any previous episodes of similar symptoms. He denied any past medical or surgical history, and had no known drug allergies. He reported habitual tobacco use and occasional alcohol ingestion. His family history was non-contributory. On physical exam, vitals were: temperature 97.8F, blood pressure 132/77, heart rate 81 beats per minute, respirations 22 breaths per minute, and an oxygen saturation of 100% on room air. He presented agitated, with a Glasgow Coma Scale (GCS) of 15, and was alert and oriented x 4. He was normocephalic, atraumatic, with pupils 3-2mm reactive bilaterally, and dry mucous membranes. His lungs were clear to auscultation bilaterally, and his heart was regular in rate and rhythm, with no murmurs noted. His abdomen was soft, non-distended and non-tender. There was no facial droop observed, and cranial nerves II-XII were grossly intact, but the patient did exhibit mild slurred speech. He moved all extremities equally with 5/5 motor strength bilaterally, with no pronator drift, sensory deficits, or ataxia noted. Figure 1: Non-contrast Head CT scan of D.M., showing an acute left thalamic hemorrhage Laboratory Data Discussion A random blood glucose on arrival was 145 mg/dL. Chemistry panel showed a sodium 136 mEq/l, potassium 2.9 mEq/l, chloride 98 mEq/l, bicarbonate 25 mmoles/l, blood urea nitrogen 16 mg/dl, and creatinine 1.0 mg/dl. A complete blood count, serum alcohol level, aspirin level, and acetaminophen level were all within normal limits. The urine drug screen was also negative for any opiates, barbiturates, amphetamines, cocaine or marijuana. An EKG obtained at the bedside showed a normal sinus rhythm with no ectopy, and a chest x-ray showed no abnormalities. With names such as White Ice, Ivory Wave, Ocean Snow, Lunar Wave, and Vanilla Sky, the dangerous consequences from the increasing use of bath salts are easily overshadowed. Reports of morbidity and mortality due to bath salts have sharply increased in recent years. In 2011, The American Association of Poison Control Centers (AAPCC) reported 6,138 calls for related bath salt use – a significant increase from 304 calls received in 2010. As of February 2012, the AAPCC had already received over 400 calls.1 For this reason, it is important for emergency physicians to be knowledgeable in how to approach patients who present after abusing these products. Bath salts contain derivatives of cathinone, isolated from the East African plant Catha edulis, which shares structural similarities to methamphetamine and ecstasy (3,4-methylenedioxy-methamphetamine; MDMA). Since the mid-2000s, unregulated cathinone derivatives have appeared in American and European drug markets. The most common compounds that comprise bath salts, and that are responsible for most of their effects, are MDPV (3,4–Methylenedioxypyrovalerone) and Mephedrone (4-Methylmethcathinone), also commonly referred to as “plant food.”2,6 Figure 2: Mephedrone (bath salt compound) commonly marketed as “plant food.” References The American Association of Poison Control Centers. Bath Salts Data. http://www.aapcc.com. Accessed April 16, 2012. Olives, T et al. Bath Salts: The Ivory Wave of Trouble. West J Emerg Med 2012;13(1):58-62. Pozzi, M et al. Drug abuse and intracranial hemorrhage. Neurol Sci 2008;29:S269-270. Ho, E et al. Cerebrovascular Complications of Methamphetamine Abuse. Neurocrit Care 2009;10:295-305. Martin-Schild, S et al. Intracerebral Hemorrhage in Cocaine Users. Stroke 2010;41:680-684. United States Drug Enforcement Administration. Chemicals Used in “Bath Salts” Now Under Federal Control and Regulation. http://www.justice.gov. Accessed April 16, 2012. Antonowicz, J et al. “Paranoid psychosis induced by consumption of methylenedioxypyrovalerone: two cases.” General Hospital Psychiatry 2011;33(6):640.e5-640.e6. Smith, C et al. “Bath salts as a ‘legal high.’” American Journal of Medicine 2011;124(11):e7-e8. Hospital Course A STAT non-contrast Head CT scan was obtained in the ER. Upon completion of the Head CT scan, the patient was re-evaluated and showed signs of rapidly declining mental status, with his GCS now 8. For this reason, the patient was then intubated for airway protection. The Head CT scan showed a left-sided thalamic intracranial hemorrhage with extension into the brainstem