How many cases have been seen in Michigan? As of February 3, 2011, there have been 18 patients seen in emergency departments across Michigan for the recreational use of a new designer drug called “bath salts,” with 1 related death. Most were young adults in their 20’s to 30’s from three Michigan counties, with a large cluster occurring in northern Michigan. Similar reports have been seen in many states across the country. What are the signs/symptoms? Patients are presenting with extreme paranoia, psychotic features (reporting seeing demons, monsters, foreign soldiers, or aliens), and sometimes violent behavior. Other symptoms include tachycardia, chest pain, confusion, high blood pressure, sweating, hyper-alertness, sleep depravation, agitation, extreme anxiety, hallucinations, bruxism, compulsive water drinking, motor automatisms (compulsive repeated hand washing), tremors, and seizures. Symptoms may progress to rhabdomyolysis, renal failure, or liver failure. Several have remained symptomatic for 2-3 days. How do you evaluate and treat patients? Intoxication with this drug should be evaluated and treated as any other drug causing a sympathomimetic toxidrome (cocaine, methamphetamine etc.) Patients should be evaluated and screened for rhabdomyolysis with CK testing, watched for hyperthermia, markedly elevated BP and tachyarrhymias, agitated & violent behavior, paranoid behavior, potential harm to themselves or others. Treatments should include use of lorazepam for hypertension, agitation, hyperthermia, or seizures. Tepid lukewarm water sponging and fanning should be used to cool patients with temp over 104 F (40 C) in addition to lorazepam to control agitation. Avoid using beta-blockers to treat ANY degree of elevation in blood pressure as this may cause an unopposed peripheral alpha-adrenergic effect and dangerous, dramatic paradoxical surge in blood pressure. Any patient with a history of paranoia, violent behavior or signs of this in the ED should be treated with lorazapam at whatever dose it takes to calm them down in 2 to 4 mg increments each 10 to 15 minutes IV or IM. In addition, a Pathways psychological consult should also be obtained in such patients. Benzodiazepines in large doses may not be effective. This is still the primary agent of choice, with ziprasidone or haloperidol added if this is not effective. What are long term health effects? Psychiatric symptoms may persist. Five patients have been transferred to long term psychiatric facilities because their symptoms weren’t improving. How is it packaged and what does it contain? Bath salts are sold as crystalline powder in a small bag with names, such as White Rush, Ivory Wave, Blow, Red Dove, Vanilla Sky, Aura, Zeus 2, Zoom, Bliss, Blue Silk, White Lightning, Ocean, Charge, Cosmic Blast, Scarface, Hurricane Charlie, Red Dove, Cloud 9, Energy 1, White Dove, and others.
Regardless of the label, these can contain one of many “designer drugs”. The most likely one currently used is MDPV (methylenedioxy pyrovalerone) but they could also contain mephedrone (the Khat derivative that is a Schedule I drug in Michigan). The packets likely come from New Orleans and are distributed to head shops, gas stations, etc. They are not sold at normal outlets . Is it legal? The ingredient mephedrone is a Schedule I drug in Michigan if present. MDPV is not scheduled. The Drug Enforcement Agency (DEA) in the New Orleans area has confirmed that much of the supply is coming in from China. The DEA says that because MDPV is an analogue of a drug that is on Schedule I of the Controlled Substances Act (CSA), "law enforcement cases involving MDPV can be prosecuted under the Federal Analogue Act of the CSA." What is the pattern of abuse? Most patients are experienced drug users/abusers who describe the experience as horrible. Some binge for 3-4 days and come in crashed. Ages have ranged from 15-61. Bath salts are snorted, ingested mixed with water, injected, or inserted rectally or vaginally. There is craving for more once the binge is over. How should cases be reported? Hospitals are encouraged to report to the Poison Center by calling 1-800-222-1222 or e- mail [email protected].
MOHS SURGERY PRE-OP INSTRUCTIONS These instructions are to be followed before and after your surgery. Please call us if you have any questions or need further clarification. A. Aspirin Related Drugs (Stop taking 10-14 Days prior to your surgery) For a two-week period prior to and after the scheduled date of your surgery, please do not take any medication that contains aspirin or aspiri
SEDRAH SELECTIONS PARSHAS BO 5772 BS”D Ch. 7, v. 17: “Hi’nei onochi ma’keh” – Behold I will smite – Many commentators explain the appropriateness of smiting the Egyptians with specifically the ten plagues, as recorded in our and the following parshios. The Kli Yokor offers: 1) The Nile was smitten in response to Paroh’s saying that the Nile was his and he created himself (