Keywords: brodifacoum, cholecalciferol, strychnine (PubMed Search)
Rodenticides have taken many forms. The following is a list of some of the more interesting ones either due to the mechanism of toxicity or how it is lethal. All of these are also toxic to people.
1) Strychnine - Glycine Antagonist at the post-synaptic spinal cord neurons - patient or rat will have convulsion of the extremeties but will be awake, alert and in extreme pain. Essentially look like generalized seizure except awake. Treatment: Benzodiazepines, Analgesia, Supportive
2) Brodifacoum - Long Acting Coumarin - rat eats, later develops elevated INR then tries to run through thin cracks in the wall or takes a little too high of a jump, then boom - subdural or some other internal hemorrhage. In human, they can stay anticoagulated for weeks after an overdose. Treatment: Vitamin K and large padded room
3) Cholecalciferol - Vitamin D precursor - there are big blocks of this drug in the NY and other subway systems. Rat nibbles, gets hypercalcemic, then gets thirsty because of this. Rat runs out into middle of subway to drink out of puddle then - splatt - the M train to Brooklyn comes along. Treatment: IVF, Loop Diuretics, Bisphosphonates
Keywords: octreotide, sulfonylurea, hypoglycemia (PubMed Search)
Fasano CJ, O'Malley G, Dominici P, Aguilera E, Latta DR. Comparison of octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia. Ann Emerg Med. 2008 Apr;51(4):400-6. Epub 2007 Aug 30.
Keywords: tetrodotoxin, sushi (PubMed Search)
Tetrodotoxin - Sodium Channel blocker - Extremely toxic causes paresthesias, dysrhythmias and paralysis - Found in the sushi called Fugu (From the Pufferfish) - Eating the sushi is considered a delicacy and goal is to get just enough of the toxin to get perioral paresthesias after eating. - Also found in the blue-ringed octopus, angelfish and parrot fish. Enjoy your seafood and take a look at the attached pic of actual fugu.
Keywords: adverse drug reaction (PubMed Search)
Watch out for tradename and generic name's of medications.
They can get the patient and yourself into trouble:
Classic example is my own case: Insert a central line in a patient - subclavian - and shortly after completion am alerted the patient's INR is 25. No adverse outcome but when I reviewed the med list, I did not see coumadin or warfarin and assumed I was in the clear. Patient was on jantoven.
Keywords: serevent, foradil (PubMed Search)
Keywords: tryptophan (PubMed Search)
Tryptophan - a precursor to melatonin, it is often blamed for the post prandial coma that many go into after a big turkey dinner. Never mind the 5000 kcals that was consumed during the meal. The supplement really doesn't help with sleeping. Interestingly, turkey isn't even in the top 10 or 20 of foods that contain tryptophan. The top five are:
1) Game meat (Elk): 746 mg of tryptophan
2) Seaweed (Spirulina): 736 mg of tryptophan
3) Spinach: 690 mg of tryptophan
4) Egg White: 673 mg of tryptophan
5) Soy protein: 630 mg of tryptophan
Supplements of L-tryptophan have been contaminated with a compound that has been associated with eosinophilia myalgia syndrome.
Keywords: cardiotoxicity, marcaine, bupivacaine (PubMed Search)
Keywords: siadh, mdma, ecstasy (PubMed Search)
Methylenedioxymethamphetamine (MDMA) or "Ecstasy"
A designer club drug that has been classified as a "hallucinogenic" amphetamine though it does not cause visual hallucinations like are reported with LSD. It has many of the sympathomimetic effects like other amphetamines but its main mechanism of action which both causes the euphoria and toxicity is serotonin agonism. Since Anti-diuretic hormone is released by the hypothalamus under the direct regulation of serotonin, there is a transient but dangerous episode of Syndrome of Inappropriate ADH (SIADH). Combined with the club culture and fear of dehydration while taking MDMA, patients ingest MDMA concomitantly with free water through the night further exacerbating the hyponatremia. The time sequence of events for these patient is (women appear genetically predisposed to this phenomena):
Treatment: Fluid restriction - this is the one time that the 1L NS Bolus can kill a patient with cerebral edema. If you must give fluid give 3% NaCl if there is symptomatic hyponatremia. Remember the patient has dropped their sodium in about 24 hours so you can replenish in about the same time quite safely and even faster in severe cases. Treated correctly, patients improve rapidly - within 24-48 hours. Read a great case report in the reference below.
Traub SJ, Hoffman RS, Nelson LS. The "ecstasy" hangover: hyponatremia due to 3,4-methylenedioxymethamphetamine. J Urban Health. 2002 Dec;79(4):549-55.
Keywords: anticholinergic, olanzapineA (PubMed Search)
This is an atypical antipsychotic that gained popularity because it caused less sedation and fewer extrapyramidal effects. However, there are many other adverse effects that need to be emphasized. Some of these may contribute to a patient's condition in the ED:
Keywords: bisphenol A, diabetes (PubMed Search)
Bisphenol A (BPA) is found in epoxy resins that line common food and beverage materials. There has been concern that this compound, like phthalates, may be causing harm through chronic low exposure. An epidemiologic study was performed and published in JAMA that has raised this question. Amazingly, the study did find that:
Lange et al. JAMA 2008; 300(11): 1303-1310.
Keywords: lead (PubMed Search)
Clinical Manifestations in relation to lead level in children:
Keywords: melamine, infant, milk (PubMed Search)
Keywords: diphenhydramine, heroinI (PubMed Search)
Cheese Heroin: a slang term for the combination of heroin with an over-the-counter antihistamine
Keywords: latrodectus, black widow, spider (PubMed Search)
Latrodectus sp (Black Widow Spider)
Take a look at a picture of the black widow on the following attachment
Keywords: methadone, buprenorphine (PubMed Search)
Keywords: arsenic, diabetes (PubMed Search)
A recent landmark article has cited a connection between non-insulin dependent diabetes and low-level arsenic in our drinking water.
Keywords: mercury, poisoning (PubMed Search)
Keywords: Salicylate, aspirin, metabolic acidosisM (PubMed Search)
First Line Therapy: Urine Alkalinization (pH >7.5) by administrating NaHCO3
Other Indications for Hemodialysis in Salicylate Poisoned Patient:
Keywords: lactic acidosis, metformin, renal failure (PubMed Search)
Perrone et al. Occult metformin Toxicity in Three patients with profound lactic acidosis. J Emerg Med 2008, June 18.
Keywords: dapsone, methemoglobinemia, methylene blue (PubMed Search)