Salvia toxicity

Background

Salvia divinorum

• Historically used by shamans in rituals
• Active ingredient: Salvinorin A
• Kappa opioid receptor agonist and D2 agonist
• Hallucinogen
• Dissociative effects similar to ketamine
• Tea: 10 min onset, duration 30-90 min
• Smoked: 1-2 minute onset, tapers over 10-20 min and may last up to 1-2 hours
• Does not appear on typical tox screens

Clinical Features

• Uncontrollable laughter
• Intense hallucinations
• Diaphoresis
• Sensations of motion, lights, visions, overlapping realities
• Low toxicity, little hangover, low abuse potential
• Few reports of psychosis and suicide associated with use

Differential Diagnosis

Hallucinations

Serotonin-Like Agents

• Lysergic acid diethylamide (LSD)
• Psilocybin ("magic mushrooms")
• N,N-Dimethyltryptamine (DMT)
• 5-methoxy- dimethyltryptamine (5-MeO-DMT)
• 25C-NBOMe

Enactogens

• Designer amphetamines
• Bath salts
• Ecstasy (MDMA)
• Mescaline (peyote)
• Synthetic cannabinoids

Dissociative Agents

• Phencyclidine (PCP)
• Ketamine
• Dextromethorphan
• Nitrous oxide

Plant-based Hallucinogenics

• Marijuana
• Salvia
• Absinthe
• Isoxazole Mushrooms
• Hawaiian baby woodrose (Argyreia nervosa)
• Hawaiian woodrose (Merremia tuberosa)
• Morning glory (Ipomoea violacea)
• Olili- uqui (Rivea corymbosa)

Organic causes

• Delirium
• Intracranial mass to occipital or temporal lobes
• Encephalitis, limbic encephalitis, anti-NMDA receptor encephalitis
• Migraine
• Seizure
• Hypocalcemia/Hypercalcemia
• Rift valley fever
• Rabies
• Syphilis
• Vitamin B7 deficiency
• Pellagra
• Dementia
  • Parkinson's Disease

Other Toxicologic Causes

• Alcohol withdrawal
• Anticholinergic Toxicity
• Tricyclic (TCA) Toxicity
• Synthetic cannabinoids
• Inhalant abuse
• Nitrogen narcosis
• GHB withdrawal
• Hydrocarbon toxicity
• Heavy metal toxicity
• Multiple medications: montelukast, doxapram, hyoscyamine, tizanidine, peramivir, amantadine, rimantadine, bromocriptine, methylergonovine, benztropine, doxepin, voriconazole, acyclovir, valacyclovir, ganciclovir, cimetidine, penicillin G Procaine, clarithromycin, metoclopramide
• Inhalant abuse

Psychiatric Causes

• Schizophrenia, schizoaffective disorder, schizophreniform disorder
• Depression with psychotic features
• Bipolar disorder
• Charles Bonnet Syndrome (in the visually impaired)

Management

• Supportive
• Benzodiazepines as needed
• Most patients will have symptoms resolve prior to ED arrival given short duration of action

See Also

• Hallucinogens