Bath salts toxicity

Background

• Found in herbal products sold under guise of "not for human consumption"
  • May be found under brand name Aura, Ivory wave, Vanilla sky
• Active ingredients vary; often contain methylenedioxyprovalerone (MDPV) or mephedrone
• Similar effects to Ecstasy (MDMA), cocaine, methamphetamines

Clinical features

Sympathomimetic toxicity + Psychomotor agitation + Hallucinations

• Sympathomimetic toxidrome
  • Tachycardia
  • Hypertension
  • Agitation
  • Paranoia
  • Hyperthermia
• Hallucinogenic

Differential Diagnosis

Sympathomimetics

• Cocaine
• Amphetamines
  • Synthetic cathinones (khat)
• Ketamine
• Ecstasy (MDMA)
• Synthetic cannabinoids
• Bath salts

Evaluation

Work-Up

• Fingerstick glucose
• Complete metabolic panel
• LFTs
• Coags
• Total CK
• Utox not helpful, usually negative

Diagnosis

• Diagnosis is based on history and physical exam

Management

• Benzodiazepines for agitation
• Rapid cooling for hyperthermia
• Paralyze if hyperthermia uncontrolled (avoid Succinylcholine due to hyperkalemia)
• IV hydration
• Monitor urine output

Contra-indicated

• Do not use butyrophenones (e.g. Haldol) or second gen antipsychotic (e.g. Geodon) as first line agents
  • They interfere with heat dissipation, lower seizure threshold, may prolong QTc

Disposition

• Discharge if AMS and sympathomimetic symptoms resolve with out end-organ damage
• Admit for lab abnormalities or persistent AMS

Complications

• Rhabdomyolysis
• Cardiomyopathy
• Valvular heart disease
• Cardiac arrhythmias
• Pulmonary hypertension
• Aortic dissection
• Acute tubular necrosis

See Also

• Sympathomimetic toxicity
• Altered Mental Status (AMS)