Keywords: RCIN, renal failure (PubMed Search)
Radiocontrast Induced Nephropathy (RCIN)
Baker CS, Wragg A, Kumar S, De Palma R, Baker LR, Knight CJ.
J Am Coll Cardiol. 2003 Jun 18;41(12):2114-8.
Keywords: levofloxacin (PubMed Search)
Quinolone Induced Deliurim
Just to give you another reason NOT to give a quinolone - aside from the C. diff. This adverse effect occurs with quinolones unlike many other antibiotics. It can prolong hospital stay, cause falls and further medical work ups. Some risk factors are:
Keywords: christmas rose (PubMed Search)
A quick christmas one:
The Christmas Rose (Helleborus niger)
Actually containes cardioactive steroids - eating it will help your A fib with RVR as it will act like digoxin, as well as kill like it.
Keywords: manganese, parkinsons, tremor (PubMed Search)
Here is a table adapted from Goldfrank's Textbook of Toxicologic Emergencies 8th Edition - Drugs that May Induce Parkinsonism. MPTP is the story that everyone hears about and actually has links to Maryland. In 1976, Barry Kidston, a 23-year-old chemistry Maryland graduate student, synthesized MPPP (Meperidine or Demerol) incorrectly and injected the result. It was contaminated with MPTP, and within three days he began exhibiting symptoms of Parkinson's disease. Ooops - permanent.
Keywords: sodium azide (PubMed Search)
Toxicology Expert: Poisoning Of Harvard University Scientists "No Accident"
Keywords: partial agonist, buprenorphine (PubMed Search)
This is a semi-synthetic opiate with partial agonist activity at the mu receptor. For an example of what a partial agonist is - see attached illustration. It is used in opioid addiction but is not as regulated as methadone clinics. Take a small course and you are licensed to prescribed it. Primary caregivers are now able to administer buprenorphine to assist addicts though it is not recommended if the patient is requiring more than 40mg of methadone (rules out everyone in Baltimore).
The tablets (Suboxone) also contain naloxone to prevent intravenous injection which would induce withdrawal. Naloxone is not orally bioavailable and thus can be mixed into the pill.
Overdose is treated like any other opioid and naloxone should work.
Buprenorphine can illicit an opioid withdrawal response if the patient is currently on an opioid and then takes buprenorphine.
Suppose to be safer than methadone - no QT prolongation and less respiratory depression
Keywords: atypical antipsychotic, aripiprazole (PubMed Search)
Aripiprazole (Abilify): a new atypical antipsychotic partially agonizes D2 and serotonin receptors though its compelte mechanism is not known. Used in schizophrenia, in overdose you may see the following symptoms (from a retrospective study done over 4 years worth of calls to a PCC):
The study was with over 255 patients. Though QT prolongation is listed, it is not common with this medication.
Young MC, et al. Risk assessment of isolated aripiprazole exposures and toxicities: a retrospective study. Clin Tox 2009; 47(6): 580-3.
Valproic Acid (Depakote)
Keywords: priapism, yohimine, trazadone (PubMed Search)
Priapism - prolonged involuntary erection - is an adverse effect with some drugs. Here is a list of the more commonly reported:
Keywords: lidocaine (PubMed Search)
To feed of off Dr. Liferidge's last pearl - a few more points relevant to your Emergency Department practice:
1) Hess GP, Walson PD: Seizures secondary to oral viscous lidocaine. Ann Emerg Med 1988; 17:725-272.
2) Rothstein P, Dornbusch J, Shaywitz B: Prolonged seizures associated with the use of viscous lidocaine. J Pediatr 1982; 101:461-463.
Keywords: ciguatera toxin, marine toxin (PubMed Search)
Keywords: barbiturates, meprobamate, bromides, propofol (PubMed Search)
The followings is a list of unique clinical findings related to a certain sedative-hypnotic overdose:
1) Hypothermia:Barbiturates, bromides, ethchlorvynol (others but these more pronounced)
2) Unique odors: chloral hydrate, ethchlorvynol (which is Placidyl)
3) Bradycardia: GHB (again others but pronounced in this OD)
4) Tachydysrhythmias: chloral hydrate
5) Muscular twitching: GHB, methaqualone, etomidate
6) Discolored urine: propofol (green/pink)
Adapted from Goldfrank's Toxicologic Emergencies 8th Edition, p1102.
Keywords: isoniazid, sulfonylureas, tetramine, bupropion (PubMed Search)
A patient presents to the University of MD ED in generalized convulsive status epilepticus. Continuous seizure activity that is not stopped by any dose of benzodiazepine [This is actually a very rare entity]. What is your next move?
- Check your basics: Fingerstick blood glucose (hypoglycemics can cause SE)
- Phenytoin is not going to work fast enough, the clock is ticking and the patient's brain cannot handle continuous status epilepticus, after 45-60min permanent neurologic sequelae or death will occur. If the cause is toxin induced, it just won't work.
- In an area where HIV is endemic, you have to consider Isoniazid - an antituberculous drug - and administer antidotal therapy: empiric dosing of vitamin B6 (pyridoxine) 5g IV. It is the only thing that will work.
- From the ED perspective, you will also be using a barbituate though there is evidence to support the use of propofol (after intubation for both). This will hopefully stop the seizure
- General anesthesia is the last chance if all else fails.
Prasad A, Worrall BB, Bertram EH, Bleck TP.
Epilepsia. 2001 Mar;42(3):380-6.
Keywords: lithium, heparin (PubMed Search)
You have a patient that is on lithium and a serum concentration is checked: 4.3 mmol/l
Therapeutic range is between 0.5 and 1.5 mmol/l
The patient shows no symptoms - is that possible? what do you do?
Answer: highly unlikely that the patient would asymptomatic, at least nystagmus would be present. Remember the symptoms are cerebellar in nature. What may have happened is the blood was drawn in an inappropriate tube. There are green "Lithium Heparinized" tubes in our Emergency Department. They are typically used for cardiac enzymes. This has been a well reported source of error (1)
Falsely elevated lithium levels in plasma samples obtained in lithium containing tubes. Lee DC, Klachko MN. J Toxicol Clin Toxicol. 1996;34(4):467-9.
Lee DC, Klachko MN.
J Toxicol Clin Toxicol. 1996;34(4):467-9.
Keywords: ondansetron, antiemetics (PubMed Search)
Keywords: colchicine, gout (PubMed Search)
Colchicine is a drug used for the treatment of acute gout attacks. It inhibits microtubule formation vital for cellular mitosis. It is also a drug with a narrow therapeutic index and lethal toxicity:
- Colchicine can be lethal at 0.5 mg/kg or even lower. Though this would be about 50 tablets and seems alot, remember it is prescribed 2 tablets initially then every hour until diarrhea presents (i.e. preliminary toxicity)
- Toxicity presents in 3 stages:
- No antidote, supportive care only available.
- Presentation is similiar to that of a radiation exposure
Keywords: serotonin (PubMed Search)
Serotonin is a neurotransmitter that has central and peripheral effects. It regulates the secretion of ADH from the hypothalamus and also controls the chemoreceptive trigger zone (CTZ) which induces emesis. Here are a list of medications categorized by the way they affect serotonin. Remember, any combination of these agonists could precipitate serotonin syndrome:
Enhance 5-HT synthesis: L-tryptophan
Direct HT agonists: Ergots, metoclopramide, sumatriptan, buspirone
Increase 5-HT release: amphetamines, cocaine, dextromethorphan, MDMA, L-dopa
Inhibit 5-HT breakdown: MAOIs, Linezolid
Inhibit 5-HT re-uptake: SSRIs (paxil), amphetamines, carbamazapine, tramadol, TCAs, citalopram, trazodone, lamotrigine, meperidine
Keywords: acetone, cyanide, odor (PubMed Search)
Goldfrank's sniffing bar: no this is not a pub where toxicologist's hang out but rather a bar that assists with teaching the recognition of odors related to toxicology. Certain drugs and compounds have a distinct aroma.
The following is a list odors, see if you can name a medication or compound that has that odor - scroll down further to see the corresponding answers (if you really got all 5 email me and convince me):
1) Bitter Almond
2) Rotten Eggs
5) Sweet, Fruity (acetone)
1) Cyanide; 2) N-acetylcysteine or Hydrogen Sulfide; 3) Methylsalicylate (like bengay); 4) Arsenic, organophosphate insecticides; 5) Chloroform, chloral hydrate
Keywords: ondansetron, albuterol (PubMed Search)
Keywords: rocuronium, succinylcholine (PubMed Search)
Rocuronium is fast becoming the agent of choice for RSI in the Emergency Department. Here is a head to head comparison of the two drugs to understand why:
Severe Brady rare
Other Adverse Effect
No fasciculations, No ICP effect, No Rhabdo
Fasciculations, increase ICP, rhabdo, movement of displaced Fxs