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Yet there had seemed no chance of that being the case midway through the contest at a packed Principality Stadium. When Duhan van der Merwe scorched over for his second try three minutes after the break, it put Scotland up. It looked as though we were heading for one of the most one-sided affairs in the years of matches between the two countries. Wales were inaccurate in just about everything they did, with the lineout particularly dysfunctional as they went awry five times on their own throw. The contrast between the two sides in terms of speed of ball was also painfully stark. That contributed to them resorting to putting boot to ball time and again. Now a kicking strategy is fine if you win the aerial battle or the territorial contest. Wales did neither and compounded things by giving away penalties for going offside from kicks. But you just never know what lies around the corner in this fixture and what followed was to prove the ultimate illustration of that. They kept the ball in hand and found the tempo that had been so absent in the first half, while capitalising on the numerical advantage presented by yellow cards to George Turner and Sione Tuipulotu. On top of that, the lineout went from being a disaster to an area of real strength, producing maul drive tries for flankers James Botham and Alex Mann, as sub hooker Elliot Dee hit his targets. Bit by bit, the gap closed, with Man of the Match Aaron Wainwright stepping inside to the line following a tap-and-go from Dee on the hour mark. No 8 Wainwright was galloping around the field like a man possessed, wing Dyer was running this way and that, causing all kinds of havoc, while Tomos Williams and Ioan Lloyd were providing a creative spark as replacement half-backs. Then when debutant Mann broke away from a fast moving lineout drive to score 11 minutes from time, Wales really were in dreamland. The leap in the air from the celebrating Nick Tompkins summed up the feeling in the ground, with Ioan Lloyd landing the conversion from wide out to cut the gap to just a point and turn up the volume still further. Could they really turn around a deficit to complete the comeback of all comebacks? For Wales, there was the consolation of two losing bonus points, but more important is what they will have taken out of the second half both individually and collectively. Dee, Tomos Williams and Lloyd have all staked major claims to start against England at Twickenham next Saturday, while fellow subs Mann and Keiron Assiratti have also pushed themselves right into the frame. With George North and Will Rowlands potentially back available to provide further options, it will be an intriguing selection. What Wales have also hit upon out of adversity is an enterprising, high-pace style that suits this group of players. Where there had seemed no hope whatsoever after 43 minutes, there is now some hope and reason to look ahead to the rest of the Six Nations with a degree of positivity, rather than positively dreading it. It was probably one of the worst performances, 40 minutes of rugby, in my whole career as a coach. It was terrible. We were shocking. We were so slow, our discipline was poor. There was nothing flashy about what was said, it was go out there and play some rugby. If Wales had lost by 40 or 50 points, there could have been a lot of boys in the international abyss for a few years, but many of them redeemed themselves in the second half. For the price of a cup of coffee a month you can help us create an independent, not-for-profit, national news service for the people of Wales, by the people of Wales. The penalty try that never was, was never a penalty try. A penalty try is awarded if the offence prevented a try or prevented one being scored in a better position. But, a try was scored and no-one could honestly say that, but for the offence, we would have scored in a better position. And, despite everything, Scotland did actually fully deserve their win. All information provided to Nation. Cymru will be handled sensitively and within the boundaries of the Data Protection Act Skip to content. No-one, but no-one could have imagined what was about to happen next. Former England captain Martin Johnson perhaps summed it up best. Share this: Facebook Twitter Email. Support our Nation today For the price of a cup of coffee a month you can help us create an independent, not-for-profit, national news service for the people of Wales, by the people of Wales. Notify of. Oldest Newest Most Voted. Inline Feedbacks. Steve George. You are going to send email to. Move Comment.

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When children and adolescents present to the emergency department with agitation or mental status changes, intoxication from synthetic drug use should be in the differential diagnosis. Identifying the responsible compound s may be difficult, so asking the patient broad questions and utilizing appropriate diagnostic studies, when indicated, will aid in making the diagnosis and help identify more-serious complications. This issue discusses the challenges presented by the changing chemical formulations of synthetic cannabinoids, cathinones, and phenethylamines; outlines common presentations of intoxication from these substances; and summarizes best practices for evaluating and managing patients who present with intoxication after consumption of these synthetic drugs of abuse. A year-old girl presents to your ED at 3 am. She is brought in by her mother, who woke up and found the girl staggering around their living room. On examination, she is mildly tachycardic; injected conjunctiva and diaphoresis are noted. The girl laughs intermittently and inappropriately during your encounter. Upon further discussion, she admits smoking marijuana that was purchased on the Internet by an older sibling. Several hours later, her mentation improves, but she now reports 6 out of 10 chest pain. Is any management beyond supportive care indicated for this patient? A year-old boy presents to the ED via EMS after his friends called for help while at an electronic dance music festival. On examination, the boy is agitated, and he admits drinking several alcoholic beverages but denies any co-ingestions. What other ingestions may have occurred? How can you anticipate such exposures? Synthetic cannabinoids, cathinones, and phenethylamines have gained popularity due to a public perception that they were relatively safe to consume and that they were legal. In , a temporary ban was placed by the United States Drug Enforcement Administration on some synthetic cannabinoids, and in , federal legislation was passed that covered all synthetic cannabimimetic agents. Other nations have also worked to close legal loopholes and target synthetic cannabinoids. One study from New Zealand demonstrated that legislation that reduced the availability of synthetic cannabinoids was correlated with a decrease in psychiatric ED visits associated with synthetic cannabinoid use. Moreover, synthetic cannabinoids continue to be available for sale online and in many stores. Many emergency clinicians remain unfamiliar with terminology regarding synthetic drugs. Additionally, clinicians appeared less likely to ask about synthetic drug use compared to conventional drug use. Most commonly, these patients will present with agitation or with changes in mental status; however, maintaining a high index of suspicion for complaints of chest or abdominal pain is necessary to detect some of the more serious sequelae. In recent years, synthetic drugs have made their mark in the United States. While ascertaining the true prevalence of these synthetic drugs has been challenging because of underreporting, experts believe that their use has been on the rise. This issue of Pediatric Emergency Medicine Practice will guide emergency clinicians through the diagnosis, management, and disposition of children who present with synthetic drug intoxication. A literature search was performed in PubMed using the search terms synthetic cannabinoids and pediatric , synthetic cannabinoids and emergency medicine , s ynthetic cathinone and pediatrics , synthetic cathinone and emergency medicine , phenethylamines and pediatrics , and phenethylamines and emergency medicine. A search of the Library of Congress found 2 relevant reports. Background information on this topic was obtained from PubMed using the general search terms synthetic cannabinoids , synthetic cathinones , bath salts , phenethylamine intoxication , and MDMA intoxication. The vast majority of publications were case reports, case series, or review articles. Higher-grade evidence was sparse for several possible reasons. The most significant reason is that designing randomized controlled trials of a toxic exposure would be clearly unethical. Diagnosis of synthetic cannabinoid and synthetic stimulant intoxication, in particular, is often presumed based on history only, as definitive laboratory testing is difficult to obtain and cost-prohibitive for many EDs. Moreover, many synthetic cannabinoids have a variety of active agents, complicating analysis of the clinical effects of a single substance. Finally, presentation of a patient with an acute intoxication to the ED is often due to polysubstance use. This creates a confounding effect, for which establishing an appropriate control is difficult. As technology is developed to better assess synthetic compound use, this may change. However, significant ethical considerations and confounding variables from polysubstance ingestion are still likely to limit quality evidence on this subject. She was a bit anxious, but looked fine. It was a hot day, and I wanted to keep her hydrated, so I told her to drink plenty of water and sent her home. While this patient may appear to be doing well, MDMA is known to increase antidiuretic hormone release and can lead to hyponatremia. Multiple reports have found significant morbidity and mortality secondary to cerebral edema in patients who consumed MDMA, and this is thought to be secondary to low serum sodium levels. A basic metabolic panel should be ordered for any patient suspected of presenting with acute MDMA intoxication. Having the patient drink fluids containing electrolytes or administering a normal saline bolus would be more appropriate courses of management and can help prevent worsening electrolyte disturbances. This pitfall highlights 2 points. First, it is effectively impossible for patients to accurately know how much MDMA or other substance, for that matter they are ingesting when they take ecstasy. Second, cases of delayed psychosis secondary to MDMA use have been reported. Children are adventurous explorers when they become mobile, and continuously place items in their mouths. Synthetic drugs are often packaged in shiny, colorful packaging, and may be especially enticing to young children. Oral ingestion of K2 by a month-old child has been documented, 30 and such cases are likely to recur. Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report. To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted. My Content Log In. Below is a free preview. Log in or subscribe for full access. Free Sample. Table of Contents. About This Issue. Content you might be interested in. Already purchased this course? More information. Money-back Guarantee. Plus receive updates on EB Medicine every month. Get My Sample Please provide a valid email address. Call Us Email Us ebm ebmedicine. Connect With Us. Accredited By. Our Partners. All rights reserved.

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