582 Correspondence

The rise in K2 use with varying clinical symptoms and the potential for ED crowding

Ivan Becerra, MD Department of Emergency Medicine Metropolitan Hospital Center, New York, NY

To the Editor,

The rise in recreational drug abuse and corresponding increases in the production of newer and more potent synthetic drugs are alarming [1]. Our institution has experienced periodic increases in emergency department (ED) visits from synthetic drug use at music festivals [2,3]. However more recently, daily visits have increased significantly due to Synthetic cannabinoid (SC) abuse. The Substance Abuse and Mental Health Services Administration reported 11 406 SC ED visits in 2010 in- creasing to 28 531 in 2012 [4]. Presenting symptoms include agitation, altered mental status, seizures, vomiting, delusions, and hallucinations. Many patients require sedation and continuous cardiac and Pulse oximetry monitoring, leading to increased length of stay in the ED and ED crowding. A study by Pines [5] recently reported that ED crowding contributed to a 5% higher chance of death, 1% longer hospital stay, and 1% higher costs per admission.

In 2012, the White House reported that the use of SC contributed to 11.3% of the illicit drug use by 12th graders [6]. Their relatively low cost and ease of availability made them increasingly popular [2]. Sold as K2, Spice or Fake weed, they compromise a variety of herbal mixtures that are intentionally adulterated with SC compounds in order to produce marijuana-like effects [7,8]. Clearly labeled as “not for human consumption” and marketed as incense, the packaging specifically indicates that they do not contain tetrahydrocannabinol (THC)-like compounds such as JWH- 018, HU-210, or CP-47.

The first severe toxic effects of SCs were reported in 2010 in Iowa when an 18 year old male committed suicide after smoking K2, leading to efforts to categorized SC as class I controlled substances in 2012 [9]. Despite these legislative efforts, the distribution of SCs is difficult to con- trol as continuous minimal alterations of the chemical structure enable them to be legally marketed as aromatic products and incense [3].

Castaneto et al [10] reported symptoms such as suicidal ideations and thought disorder that required inPatient psychiatric admission from SC use in young healthy men. Their pronounced central inhibition of ?-amino butyric acid as compared with tetrahydrocannabinol (THC) is thought to lower seizure threshold [2].

Currently, there is no specific antidote to reverse the toxic effects of SCs. The concomitant use of other substances such as phencyclidine, co- caine, and alcohol further complicates the clinical picture. These sub- stances can produce anxiety, tremors, hypertension, tachycardia, and tachydysrhythmia [11]. Chest pain is a common complaint, and a case of myocardial infarction and death has been reported [12]. Synthetic cannabinoids increase psychomotor activity and dystonia, leading to an increased risk of rhabdomyolysis and renal failure [13].

It remains vitally important for ED physicians to recognize symptoms of SC intoxication in order to prevent life-threatening events. Surveillance of SC use is of utmost public health importance in order to assess prevalence of abuse and adverse outcomes. Information about the type of SC used and the corresponding symptoms, as well as the de- mographics of SC users, may help assess risks of adverse outcomes asso- ciated with specific products and initiate community outreach and education to prevent their increased use.

Asha A. Roy, MD Department of Emergency Medicine Metropolitan Hospital Center, New York, NY

Lara DeNonno, MD, MPH Department of Emergency Medicine, Harlem Hospital Center, New York, NY

Roger Chirurgi, MD Peter McCorkell

Getaw Worku Hassen, MD, PhD? Department of Emergency Medicine NYMC, Metropolitan Hospital Center, New York, NY

?Corresponding author. NYMC, Metropolitan Hospital Center, 1901 First Avenue, New York, NY 10029. Tel.: +1 2124236464

E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2014.12.028

References

1. Su HK, Baraff BM, Designer LJ. Drug 25B-NBOMe use likely to land overdose cases in your emergency department. ACEP Now The Official Voice of Emergency Medicine; 2014.
2. Balbuena Cabre A, D. N., Kalantari H, Hassen GW. Drugs of abuse on the rise. , 1OA: Emergency Medicine; 2013.
3. Hassen GW, Ghobadi F, Kalantari H. Synthetic drugs: a new trend and the hidden danger. Am J Emerg Med 2013;31:1413-5. http://dx.doi.org/10.1016/j.ajem.2013. 05.047.
4. Administration T.S.A. a, M.H.S. Emergency department visits linked to “synthetic marijuana” products rising; 2014.
5. Pines JM. Emergency department crowding in California: a silent killer? Ann Emerg Med 2013;61:7.
6. Office of National Drug Control Policy Synthetic drugs (a.k.a K2, Spice, Bath Salts etc.). http://www.whitehouse.gov/ondcp/ondcp-fact-sheets/synthetic-drugs-k2-spice- bath-salts; 2009.
7. Rosenbaum CD, Carreiro SP, Babu KM. Here today, gone tomorrow…and back again? A review of herbal marijuana alternatives (K2, Spice), synthetic cathinones (bath salts), kratom, Salvia divinorum, methoxetamine, and piperazines. J Med Toxicol 2012;8:15-32. http://dx.doi.org/10.1007/s13181-011-0202-2.
8. European Monitoring Center for Drugs and Drug Addiction. Synthetic cannabinoids and “spice”; 2011-2012.
9. Hoecker CC. Designer drugs of abuse; 2014.
10. Castaneto MS, Gorelick DA, Desrosiers NA, Hartman RL, Pirard S, Huestis MA. Syn- thetic cannabinoids: epidemiology, pharmacodynamics, and clinical implications. Drug Alcohol Depend 2014 Nov 1;144:12-41.
11. Wells DL, Ott CA. The “new” marijuana. Ann Pharmacother 2011;45:414-7. http:// dx.doi.org/10.1345/aph.1P580.
12. Mir A, Obafemi A, Young A, Kane C. Myocardial infarction associated with use of the synthetic cannabinoid K2. Pediatrics 2011;128:e1622-7. http://dx.doi.org/10.1542/ peds.2010-3823.
13. Harris CR, Brown A. Synthetic cannabinoid intoxication: a case series and review. J Emerg Med 2013;44:360-6. http://dx.doi.org/10.1016/j.jemermed.2012.07.061.

    Anterior chamber depth measurement using ultrasound to assess elevated Intraocular pressure

    

    To the Editor,

    We read the Letter to the editor with interest, and we thank the author(s) for the information on the different causes of anterior chamber diameter (ACD) size variations and different causes of increased Intraocular pressure . We agree that increased IOP results from several causes including trauma and traumatic or sponta- neous hemorrhage within the anterior chamber and glaucoma. As it was stated in the letter, IOP can be elevated without change in the ACD. In cases of trauma to the eye, where it is not possible to measure the IOP, ultrasound can be used for detection of retinal detachment, globe rupture (IOP measurement contraindicated in this case), lens dislocation, hyphema, and optic nerve sheath diameter (ONSD) to indirectly assess the intracranial pressure . While looking for all these pathologies, the ACD can also be assessed using ultrasound, and

    Correspondence 583

    a difference in size may suggest abnormality in that eye, especially if the abnormality appears in the affected eye. This may help prioritize man- agement decisions. It is true that the anterior chamber is a dome- shaped structure and that measurement can vary depending on where the probe is sitting, but scanning the anterior chamber in 2 planes (sagittal and transverse) helps identify the point of maximum depth. The same difficulty is present when assessing the ONSD. The Optic nerve is not always a round structure, and there will be variations de- pending on at what plane (transverse vs. sagittal) the measurements are taken [1-4].Performing bedside ultrasound including ocular ultra- sound is a core measure in the curriculum of the American College of Emergency Physicians guidelines [5] (supplement). Ultrasound use in the emergency department is an integral part of emergency medicine residency training, and there is a designated fellowship. We have used bedside ultrasound in assessing ONSD and had applied that knowledge to a patient with benign Intracranial hypertension for decision making [6,7]. It is important for emergency physicians to perform ocular ultra- sound frequently and improve their experience and Comfort level with its use. It was also stated in the letter that it is difficult to differentiate structures of the anterior chamber with bedside ultrasound. As depicted in one of the figures in our case report, the relevant structures in the an- terior chamber such as the iris, the cornea, and the anterior edge of the lens were visible. It is true that, for detailed identification of structures such as in lens operations, high-resolution imaging modalities may be necessary but not in the acute phase/emergency situations to make management decisions. In addition, our article is not recommending the use of ultrasound to measure ACD to replace tonometer. We just re- ported our observations and suggested that maybe there is a potential for using ultrasound in estimating IOP in cases where direct tonometric measurement is not feasible because of trauma. To determine a definite correlation between ACD and IOP, an observational prospective study is needed.

    Getaw Worku Hassen, MD? Hossein Kalantari, MD, MPH

    New York Medical College, Metropolitan Hospital Center Department of Emergency Medicine, New York, NY

    ?Corresponding author. New York Medical College, Metropolitan Hospital Center, 1901 First Avenue, New York, NY 10029

    Tel.: +1 2124236464

    E-mail address: [email protected]

    http://dx.doi.org/10.1016/j.ajem.2014.12.047

    References

    Blaivas M. Bedside emergency department ultrasonography in the evaluation of ocular pathology. Acad Emerg Med 2000;7(8):947-50.

14. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside Ocular ultrasonography in the emergency department. Acad Emerg Med 2002;9(8):791-9.
15. Chiao L, Sharipov S, Sargsyan AE, Melton S, Hamilton DR, McFarlin K, et al. Ocular ex- amination for trauma; clinical ultrasound aboard the International Space Station. J Trauma 2005;58(5):885-9.
16. Tayal VS, Neulander M, Norton HJ, Foster T, Saunders T, Blaivas M. Emergency depart- ment sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients. Ann Emerg Med 2007; 49(4):508-14.
17. Akhtar S, Theodoro D, Gaspari R, Tayal V, Sierzenski P, Lamantia J, et al. Resident train- ing in emergency ultrasound: consensus recommendations from the 2008 Council of Emergency Medicine Residency Directors Conference. Acad Emerg Med 2009; 16(Suppl. 2):S32-6.
18. Hassen GW, Bruck I, Donahue J, Mason B, Sweeney B, Saab W, et al. Accuracy of Optic Nerve Sheath Diameter Measurement by Emergency Physicians Using Bedside Ultra- sound. J Emerg Med 2014 [in press].
19. Hassen GW, Nazeer O, Manizate F, Patel N, Kalantari H. The role of bedside ul- trasound in pretherapeutic and posttherapeutic lumbar puncture in patient with idiopathic intracranial hypertension. Am J Emerg Med 2014;32(10): 1298.e3-4.

    Anterior chamber depth measurement using ultrasound to assess elevated intraocular pressure?^,??

    To the Editor,

    

    We have read the article entitled “Anterior chamber depth measure- ment using ultrasound to assess elevated intraocular pressure” with great interest [1]. The authors reported 2 cases with glaucoma and a case of trauma. They measured the anterior chamber depth (ACD) of pa- tients and compared the results with the intraocular pressure (IOP) measurements using a tonometer.

    The authors reported that there is a correlation between ACD and IOP in 2 cases. There are various etiologies responsible for acute IOP increases. Increased IOP may be associated with normal, increased, or decreased ACD. For instance, pupillary block glaucoma results in in- creased ACD. On the other hand, uveitic and neovascular glaucomas usually do not affect ACD. Angle-closure glaucoma causes decreased ACD. Anterior chamber depth changes may also be a sign of distinct clin- ical entities such as keratoconus or nanophthalmos. Therefore, ACD may not be a certain determinant or consequence of IOP increases. For this reason, ACD increase cannot always be attributed to IOP increase. It also cannot be used as a marker of IOP increase. Anterior chamber depth measurement can sometimes predict IOP increase in primary angle-closure glaucoma cases.

    Ultrasonography in the emergency department is becoming popular in recent years. However, most of them are not specialized for ocular purposes, particularly for ACD measurement. Anterior chamber is not a uniform space. Anterior chamber depth is commonly about 3 mm at the center and changes depending on the sector that it is measured. Fur- thermore, it is difficult to differentiate the anterior chamber structures without a high-resolution device. Therefore, assessment of acute IOP increases by measuring ACD with bedside ultrasonography cannot be efficient and reliable.

    Umit Yolcu, MD

    Department of Ophthalmology, Sarikamis Military

    Hospital, Sarikamis/Kars /Turkey Corresponding author. Sarikamis Asker Hastanesi, Goz Hastaliklari Servisi, Sarikamis/Kars, 36500, Turkey

    Tel.:+90 506 711 98 42

    E-mail address: [email protected]

    Abdullah Ilhan, MD

    Department of Ophthalmology, Erzurum Military

    Hospital, Erzurum/Turkey

    Fatih C. Gundogan, MD

    Department of Ophthalmology, Gulhane Military

    Medical Academy, Ankara/Turkey

    http://dx.doi.org/10.1016/j.ajem.2014.12.046

    Reference

    Hassen GW, Sweeney B, Portillo T, Ali D, Nazeer O, Habal R, et al. Anterior chamber depth measurement using ultrasound to assess elevated intraocular pressure. Am J Emerg Med 2014. http://dx.doi.org/10.1016/j.ajem.2014.11.042.

    ? None of the authors has any conflict of interest with the submission.

    ?? The authors of this study did not receive any financial support for this submission.