PIG-EMS: Synthetic Cannabinoids — A Report From the K2 Triangle

Disclaimer: The contents of this episode are from PERSONAL EXPERIENCE. K2 and synthetic cannabinoids are new enough that there’s not enough published research, and the nature of the drugs makes them extremely variable. This is current as of October 2015, and is my experience only. Got it? Good.

Imagine if you will a hospital, in the center of a triangle. At each point, you’ll find a shelter, a place for undomiciled men fallen on hard times to lay down their heads. On the surface, all is well. But a wave of darkness has overtaken each point on the triangle, separate and unique, a plague of unconsciousness and psychosis, all connected to what is supposedly the same drug.

You’ve entered… The K2 Zone.

*cue Twilight Zone music*

Synthetic Cannabinoids? That’s Basically Pot, Right?

NO. WRONG.

These drugs target the same receptors, true. But they’re very different on a molecular level. They’re designed to hit them HARD.

  • A typical joint of marijuana only hafs a few mg of THC
  • A typical joint of K2 may have gram-levels of ???
  • Formulas constantly change; no two products are exactly the same
What does it look like? How do people get it?

It’s sold over-the-counter in smoke shops, head shops, gas stations, etc. It’s packaged as potpourri, or incense. It’s all labeled “not for human consumption.” It’s cheap, it’s “legal” (dubiously; not actually legal in State of Janus), it’s readily available. It has names like K2 and Spice and AK-47.

Why K2? Why not “real pot”?
  • Experiment!
  • Cheaper ($5 for 3 “doses”)
  • Easier to find
  • “Legal” (not really, but EXTREMELY low on PD’s priority list)
  • Euphoria
  • Doesn’t show up on urine / toxicology tests
Who Uses This Crap, Anyway?
  • Students (HS especially)
  • Military (remember, drug tests)
  • Psych facility patients
  • Homeless/undomiciled people
    • Large proportion of homeless population have mental health, substance dependence problems

Janus Regional (not Janus General) happens to be in a bad neighborhood. There are 3 local shelters that generally form a triangle around the hospital. K2 has invaded each of these shelters like a disease. These guys hang out outside, they smoke up, they….

…behave very differently based on which shelter they come from.

Wait, huh?

A Passed-Out Piggy. Courtesy of hoobly.com

A Passed-Out Piggy. Courtesy of hoobly.com and Himalayan Misadventures.

Kameleon-2?

Synthetic cannabinoids are designer drugs, and they’re constantly changing to stay ahead of legislation. Different locations may sell different products. So why is each shelter different? Because the retailer(s) supplying each shelter are different.

Point A: Complete cardiovascular collapse. These patients will present with:

  • Tremors
  • Seizures
    • Benzos can cause them to CRASH REALLY HARD (resp/cardiac crash)
  • Unconsciousness OR unconsciousness with transient psychosis
    • Take NPAs like champs
  • Pupils are sluggish/unreactive, dilated or constricted
  • Tachypnea (40) OR bradypnea (4)
  • Hypoxemia (80s or less)
  • Tachycardic (~130, sinus tach) OR bradycardic (40s)
  • Initially normotensive; 10 minutes later they’re VERY hypotensive (MAP ~50)
    • Vasodilatory? Cardiogenic? Neurogenic? NO ONE KNOWS. Pressors?
    • Can require fluids > 2 L to maintain MAP 65
    • Pressors?
  • Can be extremely hypoglycemic (“LO” even in non-diabetics)
  • One particular patient with severe cardiac issues has been intubated by 2+ of our medics

Point B: Ragers against EVERYTHING — Think PCP

  • Psychosis +- violence
  • Require physical restraint (LEO! Big blue lions!)
    • Cuffs vs soft restraint
    • I always prefer one-up-one-down for arm restraint
  • Require chemical restraint (benzos safe in this population)
  • Hyperthermic (excited delirium)
  • Tachycardic / tachypneic
  • Usually don’t require fluid challenges
  • Not dissimilar to PCP presentations

Point C: Baby Bear?

  • AMS (usually not unconscious)
  • “High” / detached affect
  • Normo/hypertensive
  • May be tachycardic OR bradycardic
    • Anecdotally respond well to atropine
  • Not much supportive care required

 

Trenchside Tips-N-Tricks
  • BE CAREFUL.
    • Violence
    • Off-gassing!!! Burnt/acrid smell? Open windows, turn on vents, limit your exposure
      • N/V, H/A, dizziness, …? (Anecdotal)
      • N-95s not likely to work (gas, not particulate)
  • BIG IVs
    • Don’t wait for them to fall off the cliff!
    • Distal brachial IVs are AMAZING in this group
    • Seriously consider B/L 16ga
    • Start fluids BEFORE their BP drops
  • NPAs Are Your Friends
    • Don’t forget the lube (even if they don’t need it, you’ll feel more humane)
  • I’m not a fan of oxygen… but if they look tachy/bradypneic, give some O’s
  • Restraining them? Right arm up, Left arm down
    • Maintains brachial access (L)
    • “Junkie special” (R) – vein in the posterior forearm “in the seam” between flexor carpi ulnaris and extensor carpi ulnaris muscle
  • Be SUPER cautious with benzos in the absence of excited delirium
    • If you need benzos, be prepared to resuscitate & intubate
Sources:
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