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On April 2, 2015, four patients were evaluated at the University of Mississippi Medical Center (UMMC) in Jackson, Mississippi, for agitated delirium after using synthetic cannabinoids. Over the next 3 days, 24 additional persons went to UMMC with illnesses suspected to be related to synthetic cannabinoid use; one patient died. UMMC notified the Mississippi State Department of Health, which issued a statewide alert via the Health Alert Network on April 5, requesting that health care providers report suspected cases of synthetic cannabinoid intoxication to the Mississippi Poison Control Center (MPCC). A suspected case was defined as the occurrence of at least two of the following symptoms: sweating, severe agitation, or psychosis in a person with known or suspected synthetic cannabinoid use. A second statewide alert was issued on April 13, instructing all Mississippi emergency departments to submit line lists of suspected patients to MPCC each day. By April 21, 16 days after the first alert was issued, MPCC had received reports of approximately 400 cases, including eight deaths possibly linked to synthetic cannabinoid use; in contrast, during April 2012–March 2015, the median number of telephone calls to MPCC regarding synthetic cannabinoid use was one per month (range = 0–11). The Mississippi State Department of Health, with the assistance of CDC, initiated an investigation to better characterize the outbreak, identify risk factors associated with severe illness, and prevent additional illnesses and deaths.

SC use can cause severe health effects. MAB-CHMINACA was the most commonly detected SC in this outbreak. As new SCs are created, new strategies to optimize surveillance and patient care are needed to address this evolving public health threat.

The purpose of this paper is to review the most common and quickest growing classes of novel, or new, psychoactive substances. Abuse of novel psychoactive substances continues to increase, resulting in subsequent increases in hospitalizations. Furthermore, the chemical structures are ever-changing and substances are increasing in potency. Reviewing the chemistry behind these agents will facilitate a better understanding of the toxicity associated with them and allow for successful identification of and management in the critical care unit. Being familiar with the most common psychoactive substances and trends of abuse, as well as the challenges health care providers face when managing intoxication, is essential to the overall understanding and care of these critically ill patients.

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We present a case of refractory methemoglobinemia with subsequent autoimmune hemolytic anemia in a young female after two days of topical dapsone use. A 15-year-old female with no known genetic risk factors was found to have a methemoglobinemia concentration of 37.1% after presenting with cyanosis, dyspnea, tachycardia, and oxygen saturation of 88% on 15 L of oxygen via a non-rebreather mask. Despite treatment with methylene blue, her methemoglobin concentrations continued to spike, requiring additional doses of methylene blue in addition to ascorbic acid and cimetidine. After discharge on the fourth day, she presented to another hospital with similar symptoms and was again found to have methemoglobinemia before developing autoimmune hemolytic anemia. This patient had no known underlying risk factors, including a normal BMI, normal renal function, two negative glucose-6-phosphate-dehydrogenase (G6PD) deficiency tests, and surprisingly a negative Coombs test. Although rare, particularly in the setting of topical dapsone use, methemoglobinemia remains an important consideration in the differential diagnosis of cyanosis and hypoxia, with early recognition by the emergency medicine physician being imperative for good patient outcomes.

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