‘Meow meow’: patterns of toxicity in mephedrone use
As this paper intimates, patterns of recreational drug use are changing; while the vast majority of UK drug deaths are still related to opioids (European Monitoring Centre for Drugs and Drug Addiction, 2012), ‘traditional’ club drugs such as MDMA (Ecstasy) are showing a decreasing trend in use. Indeed, in its introduction, this paper presents some interesting data suggesting MDMA use has fallen from 79.3% to 48.4% among club goers during a 10-year period (1999–2009).
Emerging evidence suggests that novel psychoactive substances (NPS) may be taking the place of older club drugs—in particular the synthetic cathiones such as mephedrone (also known as ‘meow, meow’, snow, bubbles). Paramedics are often the first-contact practitioners in calls involving recreational drug use and face increasing challenges in identifying the agents involved, relying on physical findings at scene.
This paper offers case report data relating to the clinical patterns of toxicity related to mephedrone. During a 2-year period from 1 January 2007 until 31 December 2009, retrospective analysis of a clinical toxicology database from an inner city ED was conducted for self-reported use of mephedrone. The review gathered data on age, sex, physiological signs and symptoms, as well as other co-ingested drugs; additional analysis included length of stay and complications.
There were 15 presentations relating to mephedrone use, all in 2009; 80% (n=12) were male, median age 29 years for males and 27 years for females. None of the presentations reported solely mephedrone use, with two people reporting concomitant NPS use. In terms of physiological findings Tables 1 and 2 provide quickly accessible findings, with tachycardia (40%) and agitation (53.3%) occurring with the greatest frequency.
Overall, 60% were GCS 15 on presentation; of those with a GCS ≤8 concomitant CNS depressants had been used GHB/GBL (n=3) and opioids (n=1). Most (73.3%) were discharged following a period of observation or symptom control with fluids and anti-emetics; 20% (n=3) required benzodiazepines for agitation on presentation.
This paper provides useful material for anyone interested in the management of toxicological emergencies, particularly NPS, and is written by field experts from the poisons unit at Guy's Hospital in London. As with most studies in this field, case studies are often the only way to gather data, thus small sample numbers pose a challenge. Furthermore, concomitant drug ingestion makes attribution of clinical findings to one agent difficult; this does not detract from the paper, which indicates amplification in the use of NPS and provides useful background as to the clinical findings.
Are you awake? Challenges in measuring conscious level
It has been over 40 years since Teasdale and Jennett proposed a scale for the measurement of conscious level (Teasdale and Jennett, 1974). Since then the Glasgow Coma Score (GCS) has been regularly used by paramedics in the pre-hospital environment. There remains, however, concerns regarding its between- and within-discipline reliability, with variations in interrater reliability reported and difficulty assessing patients affected by alcohol (Bazarian et al, 2003; Sperry et al, 2006).
This study, conducted at Monash University, Victoria, Australia sought to assess paramedic students' abilities to interpret the GCS of four differing conscious states. Utilising a prospective double-blinded observational study, students studying on the Bachelor of Emergency Health (Paramedic) and Bachelor of Nursing (BN) were asked to participate. From a total of n=345 eligible students, n=137 opted to participate. The participants were shown four individual DVDs between 35 and 45 seconds duration demonstrating a paramedic interviewing a simulated patient; there were 10-second breaks between individual DVDs to allow participants to score the GCS.
The simulated GCS score ranged from 7–15; data analysis revealed that GCS interpretation appeared related to the derivation from normal, with 92% correctly identifying GCS 15 (patient 4) and 86% correctly identifying GCS 14 (patient 1). However, GCS 7 (patient 3) was correctly identified by 37%, while GCS 12 (patient 2) was accurately identified by only 20% of participants. Additionally, it was noted during the analysis that the motor component appeared to be the most troublesome feature to interpret.
The paper provides details of the individual patients, and demographic details of participants in Table 1. Tables 2 and 3 provide easy to read data regarding the results. Within the discussion section the AVPU (Alert, Voice, Pain, Unconscious) and ACDU (Alert, Confused, Drowsy, Unconscious) scales and their applicability as an alternative to the GCS (Table 4) are presented; both are thought to correlate well with GCS when used by neurosurgical nurses. Furthermore, AVPU was compared to GCS in a separate study involving poisoned patients and, again, performed well.
The limitations of the study are covered and the discussion provides additional context to the study findings. The study does mention a questionnaire but it is not made explicit exactly what the purpose of this was. Aside from this, the paper raises interesting questions regarding the Glasgow Coma Score and its applicability in the pre-hospital environment.