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
Keywords: methadone (PubMed Search)
Many who work in urban EDs and have a patient population that has a high rate of methadone use have probably wondered - why don't I see many STEMIs in the ED?
One study has actually attempted to answer the question - is methadone cardioprotective? Comparing 98 decedents with known long-term methadone exposure and compared autopsy coronary artery findings to match controls without, there was significant decrease in incidence of severe CAD:
5/98 Methadone Patients post-mortem had severe CAD vs 16/97 match controls
Better than a baby ASA, who knew?
[I thank Dr. Hoffman for citing this article to me]
Keywords: charcoal, prehospital, EMS, gastrointestinal decontamination (PubMed Search)
Activated charcoal is most effective if given within 1 hour of overdose.
Prehospital administration of charcoal can be challenging, but may save significant time compared to waiting until arrival to the ED. The patient has to be transported by EMS, registered, seen by a provider, order for charocal placed...
Two studies evaluated the time difference between prehospital and hospital administration of GI decontamination.
Bottom line: Don't underestimate the amount of time that goes by before you evaluate non-crashing patients upon arrival to the ED. If the story supports an overdose and the patient doesn't have contraindications for receiving charcoal, recommend it be given in the prehospital setting for greatest potential benefit.
Wax PM, Cobaugh DJ. Prehospital gastrointestinal deconatmination of toxic ingestions: a missed opportunity. Am J Emerg Med 1998;16:114-6.
Crockett R, et al. Prehospital use of activated charcoal: a pilot study. J Emerg Med 1996;14(3):335-8.
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Keywords: propylene glycol, lorazepam, phenytoin (PubMed Search)
Ever have that alcholic who requires lorazapam doses that start to approach 10mg? 20mg? or even higher. The next step is usually a lorazepam infusion and then send them to the ICU. In the ICU, the patient develops an unexplained anion gap lactic acidosis.
Check a Lactate - lorazepam has 80% propylene glycol (PG). PG is metabolized to lactate which can accumulate when a lorazepam infusion at an elevated dose is running constantly. Hypotension, bradycardia and even other EKG changes have been reported. Simply discontinue the infusion and assess your acid-base status.
Other IV meds that contain PG:
lorazepam - 80% PG
Phenytoin - 40% PG
Phenobarbital - 67.8%
Diazepam - 40% PG
Keywords: Cannabinoid,hyperemesis, marijauna (PubMed Search)
Michael Hiotis PharmD, CSPI. ToxTidbits. Maryland Poison Center Sep 2012
Keywords: arsenic, rice (PubMed Search)
Just when you think buying organic protects you from chemicals and pesticide, along comes the studies detecting arsenic in rice products and specficially in organic foods with brown rice organic sweetener. An organic toddler milk formula reportedly had 6x EPA standards for safe drinking water limit.
The more toxic arsenic is the inorganic arsenic which can cause neuropathy but after chronic exposure can cause a classic arsenic keratosis - see attached pic. The inorganic is seen commonly in seafood and is more easily excreted by the body. Unfortunately, in the study referenced here, inorganic As was the predominant type.
Keywords: cyanide, smoke inhalation, enclosed-space fire, carbon monoxide (PubMed Search)
Carbon monoxide (CO) and hydrogen cyanide (HCN) are two of the main gases causing injury and death from smoke inhalation in fire victims. During the first phase of a fire, and prior to depletion of oxygen reserves and subsequent production of CO, formation of HCN from the thermal breakdown of nitrogen-containing materials may be the primary cause of lethal poisoning in an enclosed-space fire.
A recent, retrospective, observational study from Poland assessed the prevalence of toxic HCN exposure in victims of enclosed-space fires.
Conclusion: The high prevalence of coincident HCN concentrations and COHb levels in victims of enclosed-space fires emphasises the need to suspect HCN as a co-toxin in all persons rescued from fire who show signs and symptoms of respiratory distress.
Grabowska T, et al. Prevalence of hydrogen cyanide and carboxyhaemoglobin in victims of smoke inhalation during enclosed-space fires: a combined toxicological risk. Clin Toxicol 2012;50:759-63.
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Keywords: organophosphates, intermediate syndrome (PubMed Search)
Keywords: LSD, hashish, marijuana, jobs (PubMed Search)
I was reading the biography of Steve Jobs looking for incredible insights into leadership and innovation. I have realized that you basically have to be a genuis and it doesn't matter what you do. His favorite drug was LSD which he believed was necessary to improve creativity and innovation. His description of the hallucinations confirm that he was taking this drug.
We describe LSD hallucinations as a crossing of the senses or "synesthesias" - you hear the color blue, you see the smell of roses.
Steve Jobs describes a moment in a wheat field while on LSD and (paraphrasing from the biography) ..." the wheat was playing Bach beautifully"
If you have a patient describing this type of hallucination you can almost be guaranteed that they have taken LSD or some other tryptamine.
Keywords: valproic acid, carnitine (PubMed Search)
Patients that experience altered mental status (specifically lethargy) and are on valproic acid - check a serum ammonia level regardless if it is an overdose or just therapeutically on VPA.
If the ammonia is elevated in combination with the mental status change consider administration of L-carnitine either po or IV. It will lower the ammonia and improve the mental status within hours.
High risk patients for hyperammonia who therapeutically take VPA are certain pediatric patients that experience malnutrition, have seizure disorder and are on multiple seizure medications.
Keywords: acetaminophen, Rumack-Matthew nomogram, diphenhydramine, opioid (PubMed Search)
There is a growing recognition of patients who have a subtoxic acetaminophen level at the 4-hour mark, but then still go on to have a toxic level later.
This is concerning in that we usually can exclude the chance for toxicity if the 4-hour, post-ingestion level is < 150 mcg/mL following an acute ingestion (plotted on Rumack-Matthew nomogram).
It still is not clear exactly what subset of patients need to have a second level drawn, but a recurring theme seems to be ingestion of acetaminophen in combination with agents that slow GI motility, such as diphenhydramine or opioids. It may be worth ordering a second APAP level (possibly at 8 hours) in patients ingesting these prodcuts.
Dougherty PP, Klein-Schwartz W. Unexpected late rise in plasma acetaminophen concentrations with change in risk stratification in acute acetaminophen overdoses. J Emerg Med 2012;43:58-63.
Keywords: CIWA, alcohol, withdrawal (PubMed Search)
CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised)
The use of a scoring system for the disposition of an ethanol withdrawal patient can be helpful. The CIWA-Ar Score can guide both treatment in the ED as well as admission versus discharge. Most studies have verified that a score of <8 can be treated outpatient; 8-15 requires treatment and >15 wil require admission/IV benzodiazepines.
N/V: 0-7 (None to Constant N/V)
Tremor: 0-7 (None to Severe even with arms not extended)
Sweats: 0-7 (None to Drenching Sweats)
Anxiety: 0-7 (None to panic attack/delirium)
Agitation: 0-7 (None to pacing/thrashing during interview)
Tactile Disturbance: 0-7 (Mild itching to Continuous Hallucinations)
Auditory Disturbances: 0-7 (None to Continuous Hallucinations)
Visual Disturbances: 0-7 (None to Continuous Hallucinations)
Headache: 1-7 (Miild to Extremely Severe)
Go to this website to see the actual tool and how it should be administered:
Keywords: cocaine, levamisole, leukoencephalopathy (PubMed Search)
Levamisole is a pharmaceutical with anthelminthic and immunomodulatory properties that was previously used in both animals and humans to treat inflammatory conditions and cancer.
It has been identified as a cocaine adulterant in the U.S. since 2003, with the DEA estimating that by 2009 up to 70% of cocaine seized contained levamisole.
Leukopenia, agranulocytosis, and vasculitis are well known complications of levamisole use.
One important complication to keep in mind is the possibility of multifocal inflammatory leukoencephalopathy (MIL). Although no formal case of leukoencephalopathy in the setting of cocaine use has yet been reported, various neurological side effects were described with levamisole therapy, the most concerning complication being MIL.
Larocque A, Hoffman RS. Levamisole in cocaine: Unexpected news from an old acquaintance. Clin Toxicol. 2012;50:231-41.
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Keywords: envenomation,stings,jellyfish (PubMed Search)
No one treatment has demonstrated consistency of pain relief from jellyfish stings over all species; conversely, a treatment for one species may worsen an envenomation from another.
Deionized water, seawater, meat tenderizer, and urea treatment do not appear to produce any improvement in pain sensation.
Ammonia, acetic acid, and ethanol may cause an increased stinging sensation, and in most species vinegar may cause nematocyst discharge.
Application of topical lidocaine reduced the local sensation of pain (10% and 15% produced immediate pain relief), and hot water results in pain relief in the majority of patients tested.
Ward NT, Darracq MA, Tomasewski C, Clark RF. Evidence-Based Treatment of Jellyﬁsh Stings in North America and Hawaii. Article published online, Annals of Emergency Medicine June 8, 2012.
Keywords: thrombocytopenia, sulfa, bactrim (PubMed Search)
Though an uncommon event, Drug-Induced Autoimmune thrombocytopenia occurs in a variety of drugs. Having recently diagnosed a patient that was receiving the "double-dose" bactrim for an MRSA abscess, it is worth mentioning the other drugs that have been reported to do it. Platelet count can go down to lethal levels and result in death due to the coagulopathy. Treatment is effective with platelets and no contraindication like in TTP.
Drugs that have been reported to do it:
abciximab, acetaminophen, amiodarone, amphotericin B
Carbamazepine, danazol, diclofenac, digoxin
Rifampin, trimethoprim-sulfamethoxazole, vancomycin
Keywords: transplant, cyclosporine, tacrolimus (PubMed Search)
Transplant patients are the norm now in the ED. Their drug lists are immense and are usually on some form of immunosuppression to prevent rejection of the transplanted organ. Two common medications are cyclosporine and tacrolimus. They share many adverse effects like hepatotoxicity, nephrotoxicity and hypertension. Here is the mechanism of action and some unique adverse effects to these powerful immunosuppressants (there are many more so be wary):
1) Cyclosporine - suppresses T-cell activation and growth. Unique toxicity - painful neuropathy of the fingertips and toes, cortical blindness
2) Tacrolimus - simiar to cyclosporine but actually hampers T-cell communication/signal transduction. Unique toxicity - can also cause cortical blindness but is also known to cause diabetes/hyperglycemiad