Sunday, November 20, 2016

Tox Talks: Bath Salts

Author: Meaghan Mercer, MSIV
Western University of Health Sciences
AAEM/RSA Medical Student Council President '11-'12

Originally Published: Modern Resident October/November 2011

Walking onto my shift a few days ago, I heard shrieking coming from my pod, and I knew this would be an interesting night. I rushed over to find a female restrained by four police officers screaming that demons were out to get her. Witnesses reported that after snorting an unknown substance, the patient began running down the street, topless, yelling that something was after her. It required all four officers to control her and get her to the ED. She was agitated and combative, unwilling to answer questions, with a HR: 130, RR: 20, BP: 190/115, temp: 103, and an O2 saturation of 95% on room air. This was it, what I have been hearing so much about ... a bath salt ingestion.

There has been a recent insurgency of patients presenting to emergency departments across the country in an agitated delirium caused by a new designer drug called bath salts. On October 21st, the DEA issued a temporary one-year ban on methylenedioxypyrovalerone (MDPV), the main component of bath salts, classifying it as a schedule 1 substance. Manufacturers evade the restriction with minor alterations in the chemical structure, and bath salts are still available in gas stations, head shops and online.[1]

MDPV is a sympathomimetic that inhibits dopamine and norepinephrine reuptake causing a toxidrome similar to a PCP. The effects of this drug include hyperthermia, diaphoresis, mydriasis, tachycardia, HTN, arrhythmias, rhabdomyolysis and possibly cardiovascular collapse; more prominently though, they cause anxiety, agitation, paranoid delusions and combativeness, and self-destructive behavior is the predominate cause of death.[2]

There is no specific antidote for bath salts, and the treatment is supportive. After the ABC's have been addressed, the cornerstone of management is aggressive benzodiazepines to dampen the sympathetic effects and reverse life-threatening tachycardia and hyperthermia. If the tachycardia persists, consider an alpha-blocker, but avoid unopposed beta blockade.[3] Patients often require aggressive intravenous fluid administration to prevent kidney damage from rhabdomyolysis. Hyperthermia is common, with temperatures reportedly reaching 107 degrees, and cooling measures should be initiated.[4] Finally, keeping these patients in a dark, quiet area can help decrease agitation.


  1. Gussow, Leon MD. Toxicology Rounds: Giving New Meaning to 'Bed, Bath, and Beyond.' Emergency Medicine News: March 2011.
  2. United States Drug Enforcement Administration. Methylenedioxypyrovalerone, December 2010.
  3. Emergency department visits after use of a drug sold as "bath salts" -- Michigan, November 13, 2010-March 31, 2011. Morb Mortal Wkly Rep 2011.
  4. Scott Weingart: Bath Salts with Leon Gussow - EMCrit podcasts October 25, 2011.

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