Bath Salts: What the EMS Provider Needs to Know

   There has been increasing law enforcement and media interest in a new product that is currently unregulated, but is causing significant medical issues for emergency providers. With this new group of drugs hitting the streets across the United States, there is a high level of alarm with law enforcement, poison control centers, lawmakers and physicians alike.

   The drugs, referred to as "bath salts," were never intended for the tub, and you won't find them at Bath and Body Works. These salts, with names like "Ivory Wave," "White Lightning" and "Vanilla Sky," seem harmless, though they are anything but, having been blamed for up to four deaths in the U.S. Unbelievably, this product is legally available and can be easily purchased at convenience stores, head shops and online for about $20-$40 per gram. It is sold as a powder in sealed envelopes and can be purchased by consumers of any age. There are no limitations on quantity and no need to register the purchases.

   In Louisiana, after the state poison center received more than 125 calls in the last three months of 2010 involving exposure to the chemicals, they alerted the appropriate authorities. In response, the state legislature issued a Declaration of Emergency and enacted a temporary order on January 6, 2011, banning the sale of bath salts and placing these toxic chemicals on the state's Controlled Dangerous Substances list. In addition to Louisiana, lawmakers in Texas, Mississippi, North Carolina and Kentucky are considering proposals to ban the sale of the powder. The DEA has weighed in recently, calling them a "drug of concern."

BATH SALTS: THE SCIENCE

   So what is this new drug? What are the active chemicals in it, and what effects do they have on the human body? How should you manage the patient who has ingested a bath salt?

   Bath salts contain the active ingredients methylenedioxypyrovalerone (MDPV) and mephedrone. MDPV is a synthetic psychoactive drug with stimulant properties that have been likened to ecstasy. Mephedrone is a synthetic stimulant with amphetamine-like or cocaine-like effects. These molecules are very similar to amphetamines, cocaine and other stimulants. The substances have been described as a white or off-white powder that can be smoked, snorted, injected, or wrapped in pieces of paper and ingested (bombed). Both are considered analogs of illegal substances that are prohibited by the Federal Analog Act, a section of the United States Controlled Substances Act. However, since this act only applies to drugs sold for human consumption, they can be sold legally in products labeled as "bath salts." The appearance is similar to cocaine and other illicit substances, so law enforcement may or may not be able to do field testing to identify them.

EFFECTS ON HUMANS

   The drugs have profound effects on the central nervous and cardiovascular systems, similar to other stimulants. To date, complications have been reported at three levels. With small quantities, users report feelings of euphoria, increased alertness and awareness, diminished need for food and sleep, and overall feeling of well-being.

   At higher doses, the substances can cause hallucinations, anxiety, agitation, paranoia and erratic behavior. In one case that was well-publicized in the national media, an abuser used his skinning knife to slice his face and stomach repeatedly. Effects on the cardiovascular system include tachycardia and hypertension, increasing the risk of stroke and acute myocardial infarction. Increased activity and metabolism common with use of the drugs can lead to renal failure secondary to rhabdomyolysis and hyperthermia. Rhabdomyolysis is the breakdown of muscle fibers that results in the release of myoglobin into the bloodstream, which damages kidneys and can result in renal failure.

   With frequent use, persons report insatiable cravings for the drug, and have been reported to engage in days-long binges. Almost nothing is known of the long-term, but users can be expected to experience the compulsive use and psychological and physical dependence that are characteristic of amphetamine-type drugs. There have been cases of severe depression after "coming down" from a bath salt high, as well as reports of suicide attempts and success during these episodes.

PREHOSPITAL EMERGENCY CARE

   Management of the patient presenting with acute bath salt toxicity is driven by the symptoms exhibited, and the spectrum of possible presentations is quite varied. A patient may present with simple depression after a bath salt binge, or with an altered mental status, hyperthermia and renal failure. As with any patient, the airway, breathing and circulation should be evaluated and any immediate life threats promptly corrected.

   EMS providers must be prepared to protect the patient and themselves related to the use or overuse of these substances. Patients who present with depression after a binge episode will require reassurance, support and basic monitoring. The EMS crew should attempt to create an environment that reduces stimulation. For example, turning down the lights, avoiding unnecessary use of the siren and driving smoothly can help prevent a patient from becoming more agitated and complicating the situation. A patient who is agitated, combative or in some other way dangerous to himself or you may require soft restraints. The use of soft restraints is not without risk, however, as hyperthermia or rhabdomyolysis can result secondary to the patient struggling against them. For the paramedic, chemical sedation with a benzodiazepine (lorazepam, midazolam, Valium) or a barbiturate (phenobarbital) can be considered, but medical control should be consulted prior to administration.

   Any patient presenting with an altered mental status, altered level of consciousness, tachycardia or hypertension should be administered oxygen via the appropriate delivery device to assure a SpO₂ above 95%. The hyperthermic patient should be cooled in accordance with your local protocol. Possible methods include misting with tepid (59°F) water and application of cold packs to the axillae, groin and anterior neck.

   EMS providers should stay informed regarding this class of substances, with cooperative efforts involving local law enforcement, poison control centers, emergency departments and medical control. Information regarding bath salts is still evolving and may change with intervention by federal authorities.

   Scott R. Snyder, BS, NREMT-P, is the EMS education manager for the San Francisco Paramedic Association in San Francisco, CA, where he is responsible for the original and continuing education of EMTs and paramedics. Scott has worked on numerous publications as an editor, contributing author and author, and enjoys presenting on both clinical and EMS educator topics. Contact him at scottrsnyder@me.com.