Category: Toxicology
Keywords: thrombocytopenia, sulfa, bactrim (PubMed Search)
Posted: 6/28/2012 by Fermin Barrueto
(Updated: 12/12/2024)
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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
Methyldopa, procainamide
Rifampin, trimethoprim-sulfamethoxazole, vancomycin
Category: Toxicology
Keywords: transplant, cyclosporine, tacrolimus (PubMed Search)
Posted: 6/21/2012 by Fermin Barrueto
(Updated: 12/12/2024)
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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
Category: Toxicology
Keywords: azithromycin, cardiovascular, death (PubMed Search)
Posted: 6/12/2012 by Bryan Hayes, PharmD
(Updated: 6/15/2012)
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Ray WA, Murray KT, Hall K, et al. Azithromycin and the Risk of Cardiac Death. N Engl J Med 2012;366:1881-90.
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Category: Toxicology
Keywords: Warfarin,vitamin K,coagulation,INR,supratherapeutic (PubMed Search)
Posted: 6/7/2012 by Ellen Lemkin, MD, PharmD
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It may not be necessary to give oral vitamin K to patients that are not bleeding that have INRs between 4.5 and 10.
Patients who were supratherapeutic on warfarin were randomized to vitamin K 1.25 mg (n=355) versus placebo (n=369).
In the 90 days after enrollment, 15.8% of patients allocated to vitamin K and 16.3% allocated to placebo had a bleeding event. Major bleeding events occurred in 9 patients in the vitamin K group and 4 in the placebo.
Thromboembolic events occurred in 1.1% of patients in the vitamin K group, compared to 0.8% of patients in the placebo group. An equal number of patients died in each group (n=7).
Crowther MA, Ageno W, Garcia D, et. al. Oral Vitamin K Versus Placebo to Correct Excessive Anticoagulation in Patients Receiving Warfarin. Ann Intern Med 2009, 150:293-300.
Category: Toxicology
Keywords: Nitrous Oxide (PubMed Search)
Posted: 5/24/2012 by Fermin Barrueto
(Updated: 12/12/2024)
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Nitrous Oxide(N2O) is a common gas utilized to assist with procedural sedation especially in the pediatric population and dental offices. It has a long track history of safety but also has been abused.
N2O is 35x more solube in blood than N2. This means any air-filled space can have pressure increase thus complications like pneumothorax, TM rupture and bowel distention can occur.
When abused chronically can cause bone marrow suppression, B12 deficiency and resulting in polyneruopathy.
On the street, "whip its" are N2O from whipped cream containers. Balloons filled with N2O are inhaled which combine nitrous oxide and hypoxia effects.
Category: Toxicology
Keywords: vitamins (PubMed Search)
Posted: 5/17/2012 by Fermin Barrueto
(Updated: 12/12/2024)
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More and more people are going to holistic medicine and "naturopaths". These have been an interesting source of toxicology case reports due to therapeutic misadventures. Vitamins have been an ever increasing adjunct to these health philosophies. The following are the vitamins and their related toxicity in overdose:
Vitamin A: Pseudotumor cerebri, increase ICH, hair thinning, hepatotoxicity
Vitamin D: Hypercalcemia
Vitamin E: can antagonize vitamin K particularly in vitamin K deficient people, could result in coagulopathy
Vitamin K: problem if supplement contains this and patient on coumadin, ask patient
Vitamin C: Association with increased kidney stones though controversial
Category: Toxicology
Keywords: lactate, lactic acid, ethylene glycol (PubMed Search)
Posted: 5/9/2012 by Bryan Hayes, PharmD
(Updated: 6/15/2012)
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Ethylene glycol can result in elevated lactate concentrations secondary to hypotension and organ failure in severely poisoned patients. However, lactate production by these mechanisms tends to result in serum concentrations less than 5 mmol/L.
Unfortunately, higher lactate levels don't necessarily rule out ethylene glycol. The glycolate metabolite causes a false-positive lactate elevation when measured by some analyzers, particularly with whole blood arterial blood gas analyzers. Specific models implicated include: ABL 625, Radiometer ABL 700, Beckman LX 20, Chiron 865, Bayer (formerly Chiron) 860, Rapidlab (Bayer) 865, Integra and to a lesser extent, Hitachi 911 analyzers, but not the Vitros 950 or Vitros 250.
The degree of lactate elevation directly correlates with the concentration of glycolate present, and the artifact probably results from the lack of specificity of the lactate oxidase enzyme used in these machines.
Woo MY, et al. Artifactual elevation of lactate in ethylene glycol poisoning. J Emerg Med. 2003;25:289-93.
Fijen J, et al. False hyperlactatemia in ethylene glycol poisoning. Intensive Care Med. 2006;32:626-7.
Brindley PG, et al. Falsely elevated point-of-care lactate measurement after ingestion of ethylene glycol. CMAJ. 2007;176:1097-9.
Manini AF, et al. Relationship between serum glycolate and falsely elevated lactate in severe ethylene glycol poisoning. J Anal Toxicol. 2009;33:227-9.
Morgan TJ, et al. Artifactual elevation of measured plasma L-lactate concentration in the presence of glycolate. Crit Care Med. 1999;27:2177-9.
Porter WH, et al. Interference by glycolic acid in the Beckman Synchron method for lactate: a useful clue for unsuspected ethylene glycol intoxication. Clin Chem. 2000;46:874-5.
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Category: Toxicology
Keywords: sedation, dexmedetomidine (PubMed Search)
Posted: 4/26/2012 by Fermin Barrueto
(Updated: 12/12/2024)
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Dexmedetomidine is an alpha2-agonist that has a similiar mechanism of action to clonidine. Short half-life and no respiratory depression make it possibly more effective than propofol in procedural sedation. Cost/Availability are the biggest barriers. Transient bradycardia is also possible but the actual incidence of clinically significant bradycardia is not yet elucidated.
I am still awaiting the first emergency department study looking at dexmedetomidine for procedural sedation.
A recent article actually brought up the possibility of utilizing it intranasally which could have some tantalizing pediatric applications.
Yuen VM, Irwin MG, Hui TW, Yuen MK, Lee LH.
Anesth Analg. 2007 Aug;105(2):374-80.
Category: Toxicology
Keywords: Opioid, breastfeeding, breast milk, newborn, infant (PubMed Search)
Posted: 4/5/2012 by Bryan Hayes, PharmD
(Updated: 4/12/2012)
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Over the last few decades, the rate of breastfeeding has increased steadily in the developed countries of the world. During this time, opioid use in the general population has steadily increased as well. Despite this, clinicians remain unclear whether opioid use is safe during breastfeeding.
Hendrickson RG, McKeown NJ. Is maternal opiod use hazardous to breast-fed infants? Clin Toxicol. 2012;59(1):1-14.
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Category: Toxicology
Keywords: protamine, enoxaparin, Xa (PubMed Search)
Posted: 4/5/2012 by Ellen Lemkin, MD, PharmD
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Protamine for enoxaparin overdose
Category: Toxicology
Keywords: epinephrine, carbon monoxide, smoke inhalation (PubMed Search)
Posted: 3/29/2012 by Fermin Barrueto
(Updated: 12/12/2024)
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Animal studies can pave the way for new clinical treatment modalities. In the setting of lung injury due to smoke inhalation, one of the problems (if you can get the ET tube in) are the elevated ventilatory pressures due to the massive edema. In this sheep model of smoke inhalation, nebulized epinephrine improved ventilatory pressures, PaO2/FiO2 ratio and pulmonary shunting.
We may have these sheep to thank for this new treatment.
Lange M, Hamahata A, Traber DL, Cox RA, Kulp GA, Nakano Y, Traber LD, Herndon DN, Enkhbaatar P.
Crit Care Med. 2011 Apr;39(4):718-24.
Category: Toxicology
Keywords: ticagrelor, brillinta, xarelto, pradaxa (PubMed Search)
Posted: 3/15/2012 by Fermin Barrueto
(Updated: 12/12/2024)
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Coumadin Wannabe's - have indication non-valvular atrial fibrillation
1) Dabigatran (Pradaxa)
2) Rivaroxaban (Xarelto)
Clopidogrel Wannabe's - both are antiplatelets
1) Ticagrelor (Brilinta)
2) Prasugrel (Effient)
If you were looking for the first case reports of lethal hemorrhage due to pradaxa that could not be reversed - look no further. One patient fall from standing dies from ICH and another death in a spine trauma patient on pradaxa. I am waiting for the first epidural hematoma due to pradaxa, xarelto, etc in ED. Watch out! :
1: Garber ST, Sivakumar W, Schmidt RH. Neurosurgical complications of direct thrombin inhibitors-catastrophic hemorrhage after mild traumatic brain injury in a patient receiving dabigatran. J Neurosurg. 2012 Mar 6. 2: Truumees E, Gaudu T, Dieterichs C, Geck M, Stokes J. Epidural Hematoma & Intra-operative Hemorrhage in a Spine Trauma Patient on Pradaxa® [Dabigatran]. Spine (Phila Pa 1976). 2012 Feb 16.
Category: Toxicology
Keywords: crotalinae, snake, pressure immobilization, envenomation (PubMed Search)
Posted: 3/4/2012 by Bryan Hayes, PharmD
(Updated: 3/8/2012)
Click here to contact Bryan Hayes, PharmD
Pressure immobilization involves wrapping the entire extremity with a bandage and then immobilizing the extremity with a splint. It is a technique routinely employed in the pre-hospital management of neurotoxic snakes in Australia.
A position statement was recently published by several international toxicology societies regarding the utility of pressure immobilization after North American Crotalinae snake envenomation (e.g., Copperheads, Timber rattlesnakes, Cottonmouths).
"Available evidence fails to establish the efficacy of pressure immobilization in humans, but indicates the possibility of serious adverse events arising from its use. The use of pressure immobilization for the pre-hospital treatment of North American Crotalinae envenomation is NOT recommended."
Pressure immobilization after North American Crotalinae snake envenomation. Clin Toxicol;2011;49(10):881-2.
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Category: Toxicology
Keywords: Octreotide, sulfonylurea, glucose, insulin (PubMed Search)
Posted: 3/1/2012 by Ellen Lemkin, MD, PharmD
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Dougherty PP, Klein-Schwartz W. J. Med Toxicol 2010;6:199-206.
Category: Toxicology
Keywords: midazolam, lorazepam (PubMed Search)
Posted: 2/23/2012 by Fermin Barrueto
(Updated: 12/12/2024)
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You have seen the study comparing diazepam to lorazepam IV for the cessation of seizures. Lorazepam one that one. Now, for prehospital status epilepticus midazolam IM went head to head with IV lorazepam to see which would stop seizure more quickly.
This study was more about the practicality of starting an IV than it was of the pharmacokinetics or onset of action of a particular benzodiazepine. It was a large enough study to warrant publication in New Engl J Med last month and is worth noting.
Subjects whose seizures ceased before ED arrival (median):
Time to active treatment: 1.2 min IM Midazolam group; 4.8 min IV Lorazepam group
Median times active treatment to cessation of SZ: 3.3 min IM Midazolam and 1.6 min IV Lorazepam
Safety was equal in both groups. This study validates EMS initiating therapy with IM midazolam for the cessation of seizures while intravenous access is being attempted.
Intramuscular versus intravenous therapy for prehospital status epilepticus.
Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, Barsan W; NETT Investigators.
N Engl J Med. 2012 Feb 16;366(7):591-600.
Category: Toxicology
Keywords: DRESS, anticonvulsant, eosinophilia, phenytoin, carbamazepine (PubMed Search)
Posted: 2/7/2012 by Bryan Hayes, PharmD
(Updated: 2/19/2012)
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Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome, previously named “anticonvulsant hypersensitivity syndrome,” is a severe adverse drug reaction which occurs in approximately 1 of every 1,000–10,000 uses of anticonvulsants.
Characterized by triad of fever, rash, and internal organ involvement.
Usually involves aromatic anticonvulsants such as phenytoin, carbamazepine, phenobarbital, primidone, lamotrigine, and possibly oxcarbazepine.
DRESS occurs most frequently within the first 2 months of therapy and is not related to dose or serum concentration.
Treatment includes prompt discontinuation of the offending agent. Patients should be admitted to the hospital and receive methylprednisolone 0.5–1 mg/kg/d divided in four doses. Other promising therapies include use of IVIG.
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Category: Toxicology
Keywords: paralytic, hyperkalemia, succinylcholine (PubMed Search)
Posted: 1/26/2012 by Fermin Barrueto
(Updated: 12/12/2024)
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As we go through the problems of national drug shortages it is important to remember the old drugs but to also remember why they became old and seldom used drugs. Prime example is many hospitals are beginning to develop shortages of rocuronium - the nondepolarizing paralytic that has a fast onset. This shortage has caused many to switch back to succinylcholine. The following case report should serve as reminder of how succinylcholine - due to its depolarizing nature and fasciculations - can cause a transient but significant hyperkalemia.
Levine M et al. – This case report describes a 38–year–old woman with multiple sclerosis who developed life–threatening hyperkalemia after the administration of succinylcholine during rapid sequence intubation. This case highlights the potential for iatrogenic hyperkalemia after succinylcholine in patients with neurologic diseases, including multiple sclerosis.
Category: Toxicology
Keywords: pradaxa, myocardial infarction (PubMed Search)
Posted: 1/19/2012 by Fermin Barrueto
(Updated: 12/12/2024)
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Never be the first or last person to use a drug
Vioxx was once touted to be the drug that would be the new standard for anti-inflammatories until it was found to increase your chance of MI by 33% and cause hypertension.
Dabigatran was recently pulled from Japan markets and now is dealing with an impressive meta-analysis by Uchino et al. It showed that dabigatran was significantly associated with higher risk of MI or ACS than other agents.
Control arms (included warfarin, enoxaparin or placebo): MI rate 83 per 10,514
Dabigatran arms: MI rate 237 per 20,000
OR 1.33; 95% CI, 1.03-1.71; p=0.03
The rush for what is perceived as a panaceae for all that is wrong with coumadin could actually cause an MI while it tries to prevent a stroke in nonvalvular a-fib.
Look at the study and decide for yourself and remember Vioxx:
http://archinte.ama-assn.org/cgi/content/full/archinternmed.2011.1666v1
Category: Toxicology
Keywords: buprenorphine, Suboxone, overdose, children (PubMed Search)
Posted: 1/10/2012 by Bryan Hayes, PharmD
(Updated: 1/12/2012)
Click here to contact Bryan Hayes, PharmD
Suboxone = buprenorphine and naloxone in a 4:1 ratio, respectively. Formulated in 2 mg or 8mg tablets and film.
Buprenorphine acts as a partial agonist on the mu receptor and an antagonist at the kappa receptor.
If > 2 mg are ingested or age < 2 years old, these patients should be evaluated in an ED as ALL children with > 4 mg ingestion had symptoms.
There is a ceiling effect with respiratory depression however no ceiling with analgesia. This gives buprenorphine a better safety profile compared to methadone.
Onset of symptoms is about an hour and onset of respiratory depression is about 2-3 hours.
Increased doses of naloxone starting at 0.1 mg/kg may be needed to overcome high receptor affinity of buprenorphine. Remember, most children are opioid-naive and will not experience withdrawal symptoms. Repeat doses of naloxone and even infusions may be needed.
In the ED, a minimum of 6 hours observation is necessary. If no clinical effects are noted at 6 hours the patient can safely be discharged, although one small case series recommended 24 hours observation.
Unintentional overdose is common in toddlers, so advise family to keep prescriptions including family pet prescriptions locked (buprenorphine in the IV form is used for veterinary pain control).
Hayes BD, Klein-Schwartz W, Doyon S. Toxicity of buprenorphine overdoses in children. Pediatrics 2008;121(4):e782-6.
Geib AJ, Babu K, Ewald MB, et al. Adverse effects in children after unintentional buprenorphine exposure. Pediatrics 2006;118(4):1746-51.
Category: Toxicology
Keywords: pradaxa, xarelto (PubMed Search)
Posted: 12/29/2011 by Fermin Barrueto
(Updated: 12/12/2024)
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Another great example of the generic drug name being so difficult to pronounce you have no choice but to say - Xarelto. The drug touts ease of use and no need for hematologic monitoring like Pradaxa. This drug has the same indication for stroke prevention in nonvalvular atrial fibrillation. It also is being used in DVT prophylaxis in hip and knee surgeries.
Differences:
- Selective Factor Xa inhibitor unlike Pradaxa which is a competetive direct thrombin inhibitor
- Once a day dosing instead of twice a day for Pradaxa
Same concerns:
- No real reversal but can use FFP in a pinch
- Recommend waiting 24 hrs DC med to perform surgical procedure - this includes LP. I am personally waiting for the first case report of LP performed in ED on a patient taking either Xarelto or Pradaxa with subsequent epidural hematoma. Someone is bound to miss this on the med list. Be careful.
Even if your hospital has not added it to its formulary, you will see patients on this drug in the ED.