# Bath Salts and K12



## xrsm002 (Sep 28, 2011)

I am a new Paramedic student and haven't had much pharmacology except in my intermediate class over NS, d50w, and Narcan, diphenhydramine, zofran, epinephrine 1,1000, and Lidocaine, IO, (which is what my agency allows us to administer) The pharmacology for my paramedic is coming up after Christmas.  

Anyways,

I was just wondering if anyone has any experience dealing with these two "new" designer drugs BATH SALTS AND K12 (which are now illegal in all states according to the DEA 
I was mainly interested in what treatment was given, I know the bath salts cause increased HR, and BP, along with anxiety, and irritability along with hallucinations and suicidal tendencies.  But what drugs seem to work well? I am  I mean I was thinking you could (if your service carries these) administer Amiodarone to slow the Heart down, labetolol, to decrease their BP, and maybe Narcan just to CYA?


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## 18G (Sep 28, 2011)

I've had one patient that took K12. It was a 19 year old female that presented with moderate nausea, vomiting, increased HR, chest tightness, and anxiety. Care was supportive. There is no specific treatment for K12. Care is directed at treating the symptoms. 

In this case, ECG, Zofran, IV, and monitored throughout transport.


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## jjesusfreak01 (Sep 29, 2011)

18G said:


> I've had one patient that took K12. It was a 19 year old female that presented with moderate nausea, vomiting, increased HR, chest tightness, and anxiety. Care was supportive. There is no specific treatment for K12. Care is directed at treating the symptoms.
> 
> In this case, ECG, Zofran, IV, and monitored throughout transport.



Expounding on 18Gs comment, almost all the care we do is based on treating the symptoms, because often the root causes of disease take far longer to treat than the amount of time we spend with patients in the back of the ambulance. Even a complicated or obscure medical issue can receive excellent pre-hospital care if we treat the symptoms correctly.


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## jpmedic21 (Sep 29, 2011)

ive had pts that needed to be sedated while on k12. A little versed goes a long way with theese pts.


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## tssemt2010 (Oct 3, 2011)

had a patient that smoked a bit of k12 last weekend, like said above, nausea and plenty of vomiting, walked in on scene and patient was laying on the floor staring at the ceiling refusing to respond to anyone because we were white while singing gangsters paradise by coolio, just hooked him up to some o2, 4 lead, started a line and transported


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## Jon (Oct 3, 2011)

I honestly HAVEN'T seen Spice/K12/Bath Salts toxicity yet. And I'm surprised. I supervise a college first-response squad, and have been looking for it for a year.

My medical director echos JPMedic, though. He's seen more than a few, several of which required copious amounts of Ativan and/or Versed in combination with hard restraints in the ED/ICU.


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## bigbaldguy (Oct 3, 2011)

Jon said:


> I honestly HAVEN'T seen Spice/K12/Bath Salts toxicity yet. And I'm surprised. I supervise a college first-response squad, and have been looking for it for a year.



I think the bath salt thing is mostly a high school and jr high thing. College kids can score better drugs it seems. Now that it is no longer sold in head shops and is more difficult to find online I suppose the craze will die off a bit.


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## imadriver (Oct 3, 2011)

K12 or "Kind" / "Spice" is mostly what they call it here, and We have a BAD problem with this. Bath Salts not too much. I've ran one respiratory arrest with on it, seems the kid aspirated it and just stopped breathing not long there after. Otherwise, it's caused a lot of rapid heart rates, extreme nausea, respiratory issues, panic attacks, and in one cause a bad cause of excited excited delirium (which we are pretty sure he was on something else too)


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## Trevor (Oct 3, 2011)

xrsm002 said:


> I am a new Paramedic student and haven't had much pharmacology except in my intermediate class over NS, d50w, and Narcan, diphenhydramine, zofran, epinephrine 1,1000, and Lidocaine, IO, (which is what my agency allows us to administer) The pharmacology for my paramedic is coming up after Christmas.
> 
> Anyways,
> 
> ...



Bath Salts are very similar to other stimulants, and patient's symptoms are close as well. You can expect tachycardia, tachypnea, anxiety and or paranoia/combativeness, hyperthermia/profuse diaphoresis, and generally a hypermetabolic state. I would be VERY hesitant to administer ANY cardiac drugs to these patients. The goal of treatment should be, like stated above, managing symptoms. Treatment should be at decreasing the hypermetabolic state (with valium/Ativan {if you have an IV}, or versed {if you dont have an IV}. That, coupled with IV fluid, should help with the tachycardia. If your patient is extemely hyperthermic, then cooling him down, would be beneficial as well. 

As far as the Narcan?!?!?!?! Why do we give Narcan???? Not for any type of overdose, but for only OPIATE overdoses... And not just Opiate Overdoses, but Opiate Overdoses with respiratory depression... So I wouldnt give Narcan either.


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## xrsm002 (Oct 5, 2011)

Narcan is just a cover my butt kinda thing.


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## STXmedic (Oct 5, 2011)

xrsm002 said:


> Narcan is just a cover my butt kinda thing.



/facepalm


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## FFEMT427 (Oct 6, 2011)

xrsm002 said:


> Narcan is just a cover my butt kinda thing.



Just a comment to help you to think alittle more on CYA narcan. If you have a PT. with either an expected bathsalt OD (or any stimulant overdose for that matter) and that patient is tachy(this has nothing to do with what he is wearing), warm dialated pupils muscle spasms rapid resp rate why would you want to give him narcan? he is already really excited right. so even if he is on a narcotic that may be the only thing keeping him down alittle. Now if he has resp supression or other signs and symptoms of narc OD and you give narcan and he goes into excited delirium("speed ballin"this is why we titrate our narcan anyway) thats just how it happens. Either way ativan will be your best friend


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## Jon (Oct 6, 2011)

xrsm002 said:


> Narcan is just a cover my butt kinda thing.


Ahhh... I love cookbook paramedics.



I concur - if the problem is stimulant OD... why take away any downers that are there.


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## rescuepoppy (Oct 24, 2011)

The long term effects of these things are the scary part. I know of a few that have had their lives completely ruined by K-2. Gone from good students and athletes to needing help with the basics of self care. I dont see wher Narcan is going to have any benefit in treatment. The best we can do is give good supportive care and get them to  a facility for advanced and long term care. More than likely if the patient presents with an altered LOC they are going to be altered for a long period of time,possibly for months maybe years and from what I have seen this could be permanent. I have not had any experience with these in the field but have seen them in a hospital setting after the acute phase is over.


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## NineLine (Oct 28, 2011)

The one I ever came in contact with we gave versed and O2. Thankfully it didn't get to the point of restraints. Giving Narcan for a non-opiate is pointless, the goal is to give as little medication as possible.


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## ah2388 (Oct 28, 2011)

I hope that this is not breaking any rules, if it is then I will delete immediately.

http://emcrit.org/podcasts/bath-salts/

Dr. Gussow advocates "healthy" dosing of benzodiazepines along with other supportive care as needed.


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## Handsome Robb (Oct 28, 2011)

The only thing we can really do is provide supportive care and protect the patient from themselves if it comes to that point. It's been running rampant here, we've used quite a bit of versed in the last couple of months.


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## usalsfyre (Oct 28, 2011)

If my limited research of the subject is correct, and both drugs have stimulant effects similar cocaine and methamphetamine , benzo the ever-loving crap out of these people. I prefer midazolam myself for rapid onset. 

Avoid beta-blockers. Unopposed alpha stimulation is a bad thing.


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## DT4EMS (Oct 28, 2011)

We were having a real problem with it here in Missouri. Both K2 (never heard of K12) and K-3 when they made K-2 illegal. Then the bath salts hit. Now they are all illegal and it has slowed a little.

I had one guy in 5 point restraints that had snorted the bath salts 4 days prior. He was still tripping.

I had a guy in his 50's at the bus station that had smoked K-3. Pupils dilated, temp elevated, pulse and B/P through the roof c/o syncope and chest pain.

Last was a 14 y/o female that ended up on propofol and intubated (in the ER)

haven't had any in the last couple of weeks.......... we were just starting to joke about the good ole days where people just used meth


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## systemet (Nov 3, 2011)

Another link here:

http://www.medscape.com/viewarticle/751981?src=mp&spon=45


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## dahus7712 (Nov 14, 2011)

*K12 treatment*

Went on a k12'casethis weekend as a student. Pt was a 16 yo female, c/o vomit, vomit, vomit. Pt was responsive to verbal. We basically put her on O's, 18 g, tried 0.4 of narcan to rule out...didn't work, then 4mg of zofran. Didn't help..vomit, vomit, vomit....bad stuff


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## systemet (Nov 14, 2011)

dahus7712 said:


> Went on a k12'casethis weekend as a student. Pt was a 16 yo female, c/o vomit, vomit, vomit. Pt was responsive to verbal. We basically put her on O's, 18 g, tried 0.4 of narcan to rule out...didn't work, then 4mg of zofran. Didn't help..vomit, vomit, vomit....bad stuff



Just a thought:

* Does a lack of response to 0.4 mg of narcan really constitute a rule out?  Aren't there plenty of synthetics out there, including methadone and darvon, that might not show any increased respiratory drive / alertness with this dose?

It's probably clear from previous posts that I fall into the anti-narcan group, especially if there's any question about mixed overdose, and it's likely that airway management is in the near future.  

But if I did choose to give narcan, because I believed that an isolated overdose was present and that I could avoid intubating someone, I'd start with 0.4 mg, quite slowly, but I'd be ready to give more if it wasn't working.  I wouldn't take a lack of response to a single 0.4mg dose as some sort of evidence that the patient's altered LOC is not due to opiates.


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## RocketMedic (Nov 15, 2011)

We had a soldier die from bath-salt related aspiration (bath salts + lots of alcohol). We're also noticing some longer-term psychological affects in the psych ward that a lot of the providers up there are curious about.


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## HC30 (Sep 16, 2015)

Trevor said:


> Bath Salts are very similar to other stimulants, and patient's symptoms are close as well. You can expect tachycardia, tachypnea, anxiety and or paranoia/combativeness, hyperthermia/profuse diaphoresis, and generally a hypermetabolic state. I would be VERY hesitant to administer ANY cardiac drugs to these patients. The goal of treatment should be, like stated above, managing symptoms. Treatment should be at decreasing the hypermetabolic state (with valium/Ativan {if you have an IV}, or versed {if you dont have an IV}. That, coupled with IV fluid, should help with the tachycardia. If your patient is extemely hyperthermic, then cooling him down, would be beneficial as well.
> 
> As far as the Narcan?!?!?!?! Why do we give Narcan???? Not for any type of overdose, but for only OPIATE overdoses... And not just Opiate Overdoses, but Opiate Overdoses with respiratory depression... So I wouldnt give Narcan either.




Trevor pretty much nailed this, though I wanted to add some clarification.

Bath salts and K12 do act very much like stimulants and 'primarily target' the CNS and to a great degree the autonomic nervous system; which regulates involuntary bodily functions ---- e.g.. cardiovascular, respiratory and endocrine systems. Hence, the cluster of symptoms encountered in patients taking these drugs, present as a 'hyper-metabolic' and 'overly vigilant' ( the paranoia and combativeness) state! All these symptoms, the HBP, hyperthermia, diaphoresis, tachycardia, tachypnea, vomiting and probably pupillary effects, are indicators of a CNS / autonomic nervous system that is in overdrive and resulting in multiple, systemic effects!

Getting back to xrsm002's original question. If I may, Wanting to give a patient under the influence of bath salts or K12 cardiac meds to lower BP and slow the heart rate (likely due to adrenaline overload, from the autonomic effects of the causative drugs) is akin to attacking an enemy on it's flank and piecemeal, in a sense; when a full on frontal assault is called for!

As these drugs are primarily acting on the CNS, you want to attempt to calm the CNS and any number of anxiolytic, sedative type medications will help in doing so. Hey, if the patient is on telemetry and you're in direct contact with the ER physician and he or she thinks the anxiolytic's and other, already mentioned, supportive measures are not doing enough, they may well order cardiac meds to be administered if they feel it necessary.

Peace.


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## RedAirplane (Sep 16, 2015)

Out of curiosity, do they actually have any use in a bathtub?


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## Flying (Sep 16, 2015)

RedAirplane said:


> Out of curiosity, do they actually have any use in a bathtub?


Nope. Name came about b/c the drug comes in a coarse crystalline form and superficially resembles other substances.


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## TXmed (Sep 18, 2015)

From my experience if they mix either k12 or bath salts with either alcohol or weed they can deteriorate quick for no apparent reason and come out of it just as fast. Definitely wierd. Just pay attention to the respiratory drive like all ODs and safety ofcourse


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## NTXFF (Sep 27, 2015)

Best case scenario had a woman who thought she was a dog walking around on all 4's.  A little versed, 12 lead, 02, and supportive care did her good.  I've also had a 17 year old that did k2 was unresponsive and presented as stroke.  RSI, 12 lead, two IV's, and rapid transport.  Ended up having a massive stroke from the K2 and had to take a fixed wing back home since he was only visiting....


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## bizzy522 (Oct 13, 2015)

Support ABCs.. soft restraints and versed as needed.


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## PMWQs (Oct 16, 2015)

DT4EMS said:


> We were having a real problem with it here in Missouri. Both K2 (never heard of K12) and K-3 when they made K-2 illegal. Then the bath salts hit. Now they are all illegal and it has slowed a little.
> 
> I had one guy in 5 point restraints that had snorted the bath salts 4 days prior. He was still tripping.
> 
> ...



Just curious, what did you do for the 50 year old?


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