| Issue Info |
Authors: Rahul Shah, MD; Carl R. Baum, MD, FAAP, FACMT
Peer Reviewers: Michael Levine, MD; Dan Quan, DO
Publication Date: May 1, 2018
CME Expiration Date: May 1, 2021
CME Credits: 4 AMA PRA Category 1 CreditsTM, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME credits also include 2 hours Pharmacology credit.
PubMed ID: 29697923
1. “The patient’s urine toxicology screen was negative, so his presentation cannot be related to drug abuse.”
Synthetic drugs are rarely covered in a conventional urine toxicology screen, which adds to their abuse appeal. While mass spectrometry is, technically, an option for testing compounds or bodily fluids, this technology is not available to most emergency clinicians. Correlating clinical presentation with a thorough history is currently the best strategy to assess for possible synthetic drug exposure.
2. “I figured the boy’s chest pain was from anxiety that the K2 induced. Children rarely have truly cardiogenic chest pain.”
While the second statement is objectively true, in the context of suspected drug exposure—particularly synthetic cannabinoids—further evaluation is almost always necessary. A number of myocardial infarctions have been noted, even in the pediatric patient population.56 An electrocardiogram would be an appropriate first step in management.
3. “I identified synthetic cannabinoid use in several patients tonight and treated their symptoms. My work is done.”
Prompt reporting of severe symptoms to the Department of Health and your local Poison Control Center is recommended. This allows these agencies to track adverse-effect profiles in your area and permits public health workers to assess whether especially potent strains of drugs are prevalent. Multiple clusters of especially remarkable presentations have been noted in various cities. If workflow in the ED makes completing this task difficult, this should be explicitly passed along to the inpatient team.
4. “This patient already admitted taking MDMA earlier in the day. She was a bit anxious, but looked fine. It was a hot day, and I wanted to keep her hydrated, so I told her to drink plenty of water and sent her home.”
While this patient may appear to be doing well, MDMA is known to increase antidiuretic hormone release and can lead to hyponatremia. Multiple reports have found significant morbidity and mortality secondary to cerebral edema in patients who consumed MDMA, and this is thought to be secondary to low serum sodium levels. A basic metabolic panel should be ordered for any patient suspected of presenting with acute MDMA intoxication. Having the patient drink fluids containing electrolytes or administering a normal saline bolus would be more appropriate courses of management and can help prevent worsening electrolyte disturbances.
5. “My patient stated she had taken a small pill of ecstasy a few weeks ago; there is no way her current psychosis is related to that small quantity.”
This pitfall highlights 2 points. First, it is effectively impossible for patients to accurately know how much MDMA (or other substance, for that matter) they are ingesting when they take ecstasy. Studies have shown that the amount of psychoactive substances in such pills has increased dramatically compared to the drug’s introduction. The “small” size of the pill is meaningless. Second, cases of delayed psychosis secondary to MDMA use have been reported.107,108
6. “While her parents admitted to the use of marijuana at their home, there is no way that this 18-month-old child could have been exposed to a toxic level.”
Children are adventurous explorers when they become mobile, and continuously place items in their mouths. Synthetic drugs are often packaged in shiny, colorful packaging, and may be especially enticing to young children. Oral ingestion of K2 by a 10-month-old child has been documented,30 and such cases are likely to recur.
7. “This was his third visit related to MDMA intoxication. He was hypertensive and tachycardic, but had some response to benzodiazepines and fluids. He developed some chest pain, a stomachache, and had some loose stool several hours later. I recommended that he follow up with his pediatrician for the stomach bug that has been going around.”
Hypertension can sometimes precipitate aortic dissection. In this scenario, the patient’s diarrhea may be secondary to bowel ischemia from aortic dissection; this diagnosis should be considered prior to discharge.
8. “The patient’s temperature when he first came in was pretty high. I administered some acetaminophen and figured that this would take care of any form of drug-induced hyperthermia.”
The pathophysiology of hyperthermia is independent of the hypothalamic temperature set-point, and antipyretics will not reduce a patient’s body temperature sufficiently. Monitoring motor agitation and aggressive lowering of the body temperature with evaporative measures (cooling blankets, wet sheets, and fans) are most appropriate.
9. “I wanted to know if my patient was taking any drugs, so I did a HEADSS screen and asked if he ever tried pot or cocaine. He said no, and I believed him.”
Public perception about synthetic drugs, including synthetic cannabinoids, remains mixed. Many individuals believe such substances are either safe, legal, or both, and may not admit to the use of any drugs. Emergency clinicians are encouraged to ask broader questions regarding drugs of abuse, particularly if suspicion exists. Questions may include, “Have you ever smoked anything you purchased on the Internet?” or “Have you ever taken a pill of any type that wasn’t prescribed to you?”
10. “I noticed that his alanine transaminase was bumped, and he was complaining of right upper quadrant pain, but that seemed to fit with bath salt ingestion, which he already reported.”
As with all drug intoxications, the presence of one ingestion does not preclude the presence of others. Rather, it makes a second ingestion more likely. Emergency clinicians are encouraged to have a high index of suspicion for additional ingestions for any patient who admits to self-harm. Acetaminophen overdose remains among the most common in the United States, and can often go unnoticed—leading to preventable sequelae—and should be evaluated as well.
| About this Issue |
| Issue Features |
Synthetic cannabinoids, cathinones, and phenethylamines have gained popularity due to a public perception that they were relatively safe to consume and that they were legal. In 2011, a temporary ban was placed by the United States Drug Enforcement Administration on some synthetic cannabinoids, and in 2012, federal legislation was passed that covered all synthetic cannabimimetic agents. Other nations have also worked to close legal loopholes and target synthetic cannabinoids. One study from New Zealand demonstrated that legislation that reduced the availability of synthetic cannabinoids was correlated with a decrease in psychiatric ED visits associated with synthetic cannabinoid use.1 Another study conducted in New Zealand found a 52% reduction in patient utilization of emergency psychiatric services after the enactment of legislation that sought to curb the supply of synthetic cannabinoids.2 Today, however, new formulations have been developed to skirt restrictions, and synthetic cannabinoids remain the second most commonly used drugs of abuse, after conventional marijuana. Moreover, synthetic cannabinoids continue to be available for sale online and in many stores.3-5 Additionally, as Mathai et al found in the city of Houston, Texas, use may continue to increase despite legislative attention given to synthetic cannabinoids.6
Many emergency clinicians remain unfamiliar with terminology regarding synthetic drugs. In a 2013 study that surveyed 83 physicians (88% response rate), most providers reported that they gathered a significant amount of their knowledge on this subject from nonmedical sources. The study found that 80% of respondents admitted to feeling uneasy about managing a patient with synthetic cannabinoid intoxication. Additionally, clinicians appeared less likely to ask about synthetic drug use compared to conventional drug use.7 Vazirian et al surveyed 124 emergency clinicians connected to the Cleveland Clinic health system. While analysis of this study’s results may be scrutinized for low participation (34% completion rate), approximately two-thirds of respondents reported having managed, in the prior 2 years, a patient with suspected synthetic cathinone intoxication. Despite this exposure, 77% of surveyed emergency clinicians did not ask about synthetic cathinone use.8 It is imperative that emergency clinicians include acute intoxication and synthetic drug abuse in their differential diagnosis for a wide variety of presentations. Most commonly, these patients will present with agitation or with changes in mental status; however, maintaining a high index of suspicion for complaints of chest or abdominal pain is necessary to detect some of the more serious sequelae.
In recent years, synthetic drugs have made their mark in the United States. While ascertaining the true prevalence of these synthetic drugs has been challenging because of underreporting, experts believe that their use has been on the rise.9 Emergency clinicians must be prepared to identify and manage exposures to synthetic drugs in a diverse range of ages within the pediatric population. This issue of Pediatric Emergency Medicine Practice will guide emergency clinicians through the diagnosis, management, and disposition of children who present with synthetic drug intoxication.
| CME Information |
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 2 Pharmacology CME credits, subject to your state and institutional approval.
Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Shah, Dr. Baum, Dr. Levine, Dr. Claudius, Dr. Horeczko, Dr. Mishler, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Dr. Quan made the following disclosures: compensated or uncompensated service for the sponsor or any commercial entity: BTG and Pfizer. Dr. Jagoda made the following disclosures: Consultant, Daiichi Sankyo Inc; Consultant, Pfizer Inc; Consultant, Banyan Biomarkers Inc; Consulting fees, EB Medicine.
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