Keywords: strychnine, seizure, tetanus (PubMed Search)
Strychnine poisoning is still occasionally found in rat poisons and in adulterated street drugs and herbal products. The typical symptoms are involuntary, generalized muscular contractions resulting in neck, back, and limb pain. The contractions are easily triggered by trivial stimuli (such as turning on a light) and each episode usually lasts for 30 seconds to 2 minutes, for 12 to 24 hours. Classic signs include opisthotonus, facial trismus, and risus sardonicus.
Differential diagnosis includes:
Chan Y. Chapter 112. Strychnine. In: Chan Y, ed. Goldfrank's Toxicologic Emergencies. 9th ed. New York: McGraw-Hill; 2011. http://www.accesspharmacy.com/content.aspx?aID=6528306. Accessed May 7, 2013.
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Keywords: Kings College, apap, acetaminophen (PubMed Search)
If you are working in a community hospital and have an acetaminophen overdose, one of the criteria to transfer the patient to a tertiary care center is presence of the King's College Criteria.
The below is taken from mdcalc.com - http://www.mdcalc.com/kings-college-criteria-for-acetaminophen-toxicity/
Each one is assigned points and can be prognostic for severe toxicity and need for transplant. The lactate and phosphorus are new ones and have modified the criteria. Phosphorus is utilized to create glycogen. If the liver is injured and trying to heal, your phosphorus will be low (good). If the liver is injured and unable to repair itself the phosphorus will be high (bad). This single test has an excellent prognostic ability.
|Lactate > 3.5 mg/dL (0.39 mmol/L) 4 hrs after early fluid resuscitation?|
|pH < 7.30 or lactate > 3 mg/dL (0.33 mmol/L) after full fluid resuscitation at 12 hours|
|INR > 6.5 (PTT > 100s)|
|Creatinine > 3.4 mg/dL (300 µmol/L)|
|Grade 3 or 4 Hepatic Encephalopathy?|
|Phosphorus > 3.75 mg/dL (1.2 mmol/L) at 48 hours|
Keywords: Ricin (PubMed Search)
With recent events, a few notes about ricin seems appropriate:
CDC website: http://www.bt.cdc.gov/agent/ricin/
Keywords: dexmedetomidine, cocaine (PubMed Search)
Cocaine toxicity is characterized by the sympathomimetic toxidrome: tachycardia, hypertension, hyperpyrexia, diaphoresis as well as sodium channel blocking effects that can cause local anesthesia topically, QRS widening and even seizure.
Usual treatment for a cocaine toxic patient is benzodiazepines and cooling. Be wary of end organ damage, trauma and seizures.
There was a recent study that looked at dexmedetomidine to treat the sympathomimetic effects. Placebo-controlled trial used cocaine-addicted volunteer and applied intranasal cocaine. Measuring skin sympathetic nerve activity and skin vascular resistance, this study, unfortunately, showed as the dose increased MAP did not fall further and increased paradoxically in 4 of 12 subjects.
This highlights the incredible physiologic mechanism of catecholamine release from the CNS with cocaine. This mechanism overlaps some with the centrally acting alpha agonist - dexmedetomidine and was shown in the study by Kontak et al.
Kontak AC, Victor RG, Vongpatanasin W.
Hypertension. 2013 Feb;61(2):388-94
Keywords: gastric lavage, GI decontamination (PubMed Search)
In 2013, the American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists published a second update to their position statement on gastric lavage for GI decontamination (original 1997, 1st update 2004).
Bottom line: Gastric lavage generally causes more harm than good. It should not be thought of as a viable GI decontamination method.
Bonus: Dr. Leon Gussow (@poisonreview) reviews the position paper on his blog, The Poison Review, here: http://www.thepoisonreview.com/2013/02/23/gastric-lavage-fuggedaboutit/
Benson BE, et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol 2013 Feb 18. [Epub ahead of print]
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Keywords: carbon monoxide, rhabdomyolysis, hydroxycobalamin (PubMed Search)
A foley is inserted in a fire victim patient. Urine return is in picture. Describe the reason for this colored urine.
Special Thanks to Dr. Doug Sward for the urine picture
Rhabdomyolysis causes a tea colored urine and can be seen in carbon monoxide poisoning. This picture is NOT from rhabdomyolysis.
In some fires, especially if there was a lactate > 10mmol/L, patients may also suffer from inhaled cyanide poisoning. Adminstration of the cyanide antidote, hydroxycobalamin, will cause an artificial drop in your pulse ox during administration due to the color of the infused liquid. It will, as the picture is showing, also change the color of the urine.
Keywords: opioid, withdrawal, seizure (PubMed Search)
Typical opioid withdrawal include clinical symtpoms of piloerection, nausea, vomiting and diarrhea. If you were to see seizure, another etiology other than opioid withdrawal should be investigated.
Except in the case of neonates borne to women who have been taking opioids chronically such as a methodone patient. Once the child is born, symptoms of withdrawal may take days to weeks to materialize though seizures typically occur <10 days. The child is at increased risk of SIDS as well.
Keywords: antidote, pregnancy, ethanol, amyl nitrate, methylene blue, penicillamine, lorazepam, diazepam (PubMed Search)
Most antidotes have not been adequately studied in pregancy and hold a Pregnancy Risk Category 'C' by the FDA. However, there are a few antidotes that hold a category 'D' or 'X' rating (contraindicated).
In most cases, the benefits of short-term use probably outweigh the risk, especially when accounting for the health and prognosis of the mother.
Lexi-Comp Online, Lexi-Drugs Online, Hudson, Ohio: Lexi-Comp, Inc.; February 14, 2013.
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Keywords: anabolic, bodybuilding, weightlifting, beta agonist, myocardial infarction (PubMed Search)
Keywords: atorvastatin, acetylcysteine (PubMed Search)
There have been many attempts to reduce the incidence of contrast-induced nephropathy. Mechanism usually centers around antioxidant properties or free radical scavengers that prevent the acute kidney injury that may result after intravenous contrast. IV Fluid hydration, sodium bicarbonate and acetycysteine have been studied with only some evidence. There is also some controversial data that is beginning to surface regarding the use of atorvastatin with a recent article in Circulation 2012 that showed high dose atorvastatin (80mg) 24 hrs prior to angiography prevented contrast-induced acute kidney injury in patients with mild to medium risk. Link to article has been provided:
Keywords: cyclophosphamide (PubMed Search)
Cyclophosphamide-induced hemorrhagic cystitis is a well known to oncologists. This unique complication of this chemotherapeutic drug has a defined mechanism and could be seen in your Emergency Department.
- Hemorrhagic cystitis occurs in 46% of patients that receive cyclophosphamide
- Can occur even months after administration
- 5% can actually die from the hemorrhage
- Treatment: Bladder irrigation, hydration, supportive. Oral adminsitration of MESNA (2mercaptoethan sulfonate) and bladder irrigation with prostaglandins and even methylene blue have been attempted.
Keywords: Ssri, Hyponatremia (PubMed Search)
SSRIs and SNRIs like venlafaxine and sertraline are well known to cause hyponatremia. Usually considered safe, this adverse drug event can lead to weakness, confusion, seizure and even cerebral edema. Elderly are more susceptible to this adverse effect.
ADH is regulated by serotonin and thus the mechanism for the Hyponatremia is SIADH.
Tolvaptan, a vasopressin receptor antagonist, has been a new treatment that has been used anecdotally in Europe. Waiting for the first US case report.
Keywords: tapentadol, methadone, false positive, urine toxicology (PubMed Search)
Several medications can produce a false-positive result for methadone on the urine drug screen: diphenhydramine, doxylamine, clomipramine, chlorpromazine, quetiapine, thioridazine, and verapamil.
Add a new one to the list. Tapentadol, a relatively new opioid analgesic similar to tramadol, can also produce a false-positive result for methadone on certain immunoassays.
A separate study concluded that tapentadol does not affect the amphetamine screen.
Brahm NC, Yeager LL, Fox MD, et al. Commonly prescribed medications and potential false-positive urine drug screens. Am J Health Syst Pharm 2010;67(16):1344-50. [PMID 20689123]
Collins AA, Merritt AP, Bourland JA. Cross-reactivity of tapentadol specimens with DRI methadone enzyme immunoassay. J Anal Toxicol 2012;36(8):582-7. [PMID 22879537]
Tang S, Mullins ME, Braun BM, et al. Can tapentadol cause a false-positive urine drug screen for amphetamine? Clin Toxicol 2012;50(10):1174-5. [PMID 23088194]
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Keywords: creatine, supplement, weight lifting (PubMed Search)
Adverse effects: weight gain, edema, GI cramping, fatigue and diarrhea
Dandoy C, Gereige RS. Performance-Enhancing Drugs. Pediatrics in Review June 2012;33(6):265-72.
Keywords: ketamine, pain (PubMed Search)
Despite a paucity of data, pain management clinics are administering topical gel mixtures that have included ketamine, tricyclics, calcium channel blockers and baclofen. Internet blogs have already identified this gel mixture as a way to "get high". This is one of those google searches you have to do on your own.
1: Lynch ME, Clark AJ, Sawynok J, Sullivan MJ. Topical 2% amitriptyline and 1% ketamine in neuropathic pain syndromes: a randomized, double-blind, placebo-controlled trial. Anesthesiology. 2005 Jul;103(1):140-6. 2: Lynch ME, Clark AJ, Sawynok J. A pilot study examining topical amitriptyline, ketamine, and a combination of both in the treatment of neuropathic pain. Clin J Pain. 2003 Sep-Oct;19(5):323-8. 3: Uzaraga I, Gerbis B, Holwerda E, Gillis D, Wai E. Topical amitriptyline, ketamine, and lidocaine in neuropathic pain caused by radiation skin reaction: a pilot study. Support Care Cancer. 2012 Jul;20(7):1515-24.
Keywords: poinsettia (PubMed Search)
Myth: The ornamental red plant - poinsettia - gained a reputation as a poisonous plant from a case report. In 1919, a 2-year-old child reportedly died from an ingestion and later an 8-month-old developed mucosal burns. These anectdotal case reports perpetuated the myth that poinsettia plants are poisonous. In the modern literature there is one single case of anaphylaxis(1) due to poinsettia ingestion/exposure, an allergic dermatitis(2) and one case of dermatitis(4).
Krenzelok et al.(3) showed there were 22,793 cases of poinsettia exposure and there were no fatalities reported to poison centers. 96.1% were kept at home without sequelae.
1: Kimata H. Anaphylaxis by poinsettia in infants with atopic eczema. Allergy. 2007 Jan;62(1):91-2. 2: Bala TM, Panda M. No poinsettia this Christmas. South Med J. 2006 Jul;99(7):772-3. 3: Krenzelok EP, Jacobsen TD, Aronis JM. Poinsettia exposures have good outcomes...just as we thought. Am J Emerg Med. 1996 Nov;14(7):671-4. 4: Edwards N. Local toxicity from a poinsettia plant: a case report. J Pediatr.1983 Mar;102(3):404-5.
Keywords: aspirin, salicylate, thyroid, levothyroxine, hyperthermia, isoniazid, theophylline (PubMed Search)
The more well known causes of toxin-induced hyperthermia include sympathomimetics and anticholinergics. In addition, neuroleptic malignant syndrome, serotonin syndrome, and malignant hyperthermia are high on the differential.
Several other xenobiotics can cause hyperthermia in overdose as well:
In general, benzodiazepines should be considered first-line therapy, followed by barbiturates, propofol, or other sedative hypnotics. Phenytoin rarely has a role in the management of toxin-induced seizures. Extrenal cooling measures are also warranted. Specifically for isoniazid, pyridoxine should be administered immediately with a benzodiazepine.
Levy RP, Gilger WG. Acute thyroid poisoning. N Engl J Med. 1957;256:459-460.
Boyd RE, Brennan PT, Deng JF, Rochester DF, Spyker DA. Strychnine poisoning. Recovery from profound lactic acidosis, hyperthermia, and rhabdomyolysis. Am J Med. 1983;74:507-12.
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Keywords: CT, carbon monoxide, cyanide (PubMed Search)
It is not often that a CT will be able to give you a hint to a toxicologic diagnosis. The following are CT findings that are either suggestive and even sometimes almost diagnostic for a given to toxin:
1) Intraparenchymal or Subarachnoid Hemorrhage: sympathomimetics or mycotic anuerysm rupture secondary to IV drug abuse
2) Basal Ganglia bilateral focal necrosis: characteristic of carbon monoxide, cyanide, hydrogen sulfide and even methanol
3) Severe advanced atrophy out of proportion for age: alcoholism, toluene
Adapted from Goldfranks Textbook of Toxicologic Emergencies 8th edition, p.82 Table 6-5.
Keywords: PCP, phencyclidine, haloperidol (PubMed Search)
Patients who are intoxicated with, or emerging from, phencyclidine (PCP) highs present with acute agitation that can be challenging to treat
Risks of physical restraints for combative patients include injury, hyperthermia, rhabdomyolysis, and increased agitation or excited delirium
Haloperidol is an option for chemical restraint that is typically safe and rapid acting
Some concerns related to haloperidol use in PCP-intoxicated patients include worsened PCP-induced hyperthermia, dystonic or anticholinergic reactions, lower seizure threshold, and hypotension
A recent retrospective case series assessed the frequency of adverse effects from the combination of PCP and haloperidol
Of 59 cases, only two patients experienced an adverse reaction, and neither could be conclusively linked to haloperidol administration
This analysis had several major limitations including retrospective design for identifying adverse reactions, potential for false positive PCP screens, and possible haloperidol administration more than 24 hours after PCP intoxication
While haloperidol may be safe for agitated PCP-intoxicated patients, this paper adds nothing to refute or support its use. Benzodiazepines and calm environment are still first-line therapy.
It should be noted that no data exist showing poor outcomes in PCP-intoxicated patients administered haloperidol, which begs the question "Is there even an issue?" Dr. Leon Gussow, author of The Poison Review, provides a nice answer and summary of the article here.
MacNeal JJ, et al. Use of haloperidol in PCP-intoxicated individuals. Clin Toxicol 2012;50:851-3.
Gussow L. The Poison Review. http://www.thepoisonreview.com/2012/11/07/is-haloperidol-dangerous-in-pcp-associated-agitation-a-non-answer-to-a-non-problem/ Accessed Nov 8, 2012.
Keywords: voriconazole (PubMed Search)
As everyone knows by now the New England Compounding Company has been implicated in contaminated steroid vials that were used for epidural injections. Patients that have pleocytosis on CSF after lumber puncture will be admitted and started on liposomal amphotericin B and IV voriconozaole.
IV Voriconazole Adverse Effects:
Vivid visual hallucinations
Visual Disturbances - 30 min after administration: Blurry, photosensitivity
Photoxicity - associated with increased risk of squamous cell CA of the skin