Keywords: naloxone, intranasal (PubMed Search)
Keywords: Diabetes; incretin; dipeptidyl peptidase; dpp (PubMed Search)
NEW TREATMENT in diabetes
It was discovered that glucose given ORALLY caused more insulin release than glucose administered INTRAVENOUSLY. This led to the discovery of the incretin hormones, which are secreted by the gut (INtestinal SECRETion of INsulin), GIP and GLP-1.
The incretin-based therapies increase levels of GLP-1, either by providing an incretin mimetic (exenatide and liraglutide), or by inhibiting their breakdown by DPP-4 (sitagliptin, saxagliptin, vilagliptin)
Their administration results in:
STAY TUNED FOR DOSING AND ADVERSE EVENTS!
Barnett AH. New Treatment in type 2 Diabetes: A Focus on the Incretin-Based Therapies. Clinical Endocrinology Sep 2008;70(3):343-53.
Keywords: hydroxocobalamin, cyanokit (PubMed Search)
The newest antidote for cyanide poisoning, hydroxocobalamin, has several advantages over the older Cyanide Antidote Kit (amyl nitrite, sodium nitrite, sodium thiosulfate). Hydroxocobalamin works rapidly, does not induce methemoglobinemia, and does not cause vasodilation/hypotension.
Uhl W, Nolting A, Golor G, Rost KL, Kovar A. Safety of hydroxocobalamin in healthy volunteers in a randomized, placebo-controlled study. Clin Toxicol 2006;44:S17-S28.
Keywords: sodium azide (PubMed Search)
Toxicology Expert: Poisoning Of Harvard University Scientists "No Accident"
Keywords: Relenza, zanamivir, influenza, H1N1 (PubMed Search)
Zanamivir (Relenza) is another neuraminidase inhibitor effective against influenza strains A and B. We are currently reserving its use for patients with H1N1 that may develop resistance to oseltamivir (Tamiflu) since it has been effective in these situations with past influenza strains.
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: haloperidol, cocaine, amphetamine, sympathomimetic (PubMed Search)
A 34 y/o m presents to the ED agitated and combative with the following vitals signs: T 104.6, P 136, BP 198/124. His urine toxicology screen is positive for amphetamines.
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.
Keywords: hand sanitizer, ethanol, alcohol (PubMed Search)
Most hand sanitizers contain ethanol, while some contain isopropyl alcohol. The concentration of alcohol in these products varies from 45% to 95%, with the most commonly used products containing 62%. How much would a 15 kg child have to ingest to obtain a blood alcohol concentration of 100 mg/dL (or 0.1%)?
Assuming a volume of distribution of 0.6 L/kg and 100% bioavailability, only 15-20 mL is required to produce this toxic level. That is equivalent to 3-4 teaspoons or approximately 8-10 “squirts” of hand sanitizer!
Keywords: Iron; Poisoning; Deferoxamine (PubMed Search)
|Checking TIBC to determine if treatment is necessary||Checking iron levels...If peak is > 500 mcg/dl, or the patient shows signs of systemic toxicity, treat with deferoxamine|
|Deferoxamine challenge... no longer recommended!||Using WBI for ingestion of 20 mg/kg iron, if visible iron pills on x-ray, or symptoms of mild toxicity (for treatment of severe toxicity see above)|
|Platform shoes||Strappy sandals|
WBI: whole bowel irrigation
Reminder from Poisondex:
OVERDOSE: SEVERE: Stupor, shock, acidosis, GI bleed, coagulopathy, hepatotoxicity, and coma. MILD/MODERATE: Nausea, vomiting, diarrhea, lethargy, leukocytosis, and hyperglycemia. Clinical phases: (1) 0-2 hours: Nausea, vomiting, diarrhea, and abdominal pain. Lethargy, shock, GI bleeding, and acidosis if severe; (2) Apparent recovery; (3) 2-12 hours: Acidosis, hypotension; (4) 2-4 days: Hepatotoxicity; (5) days-weeks: GI strictures.
Balmadrid C, Bono M. Recognizing and Managing Iron Toxicity. Emergency Medicine May 2009;14-21.
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: treprostinil, epoprostenol, pulmonary hypertension (PubMed Search)
One of the treatment options for NYHA class III and IV pulmonary hypertension is prostanoids. All of the prostanoid formulations have the limitations of a short half-life and a heterogeneous response to therapy. Because the drugs need to be given by continuous infusion, patients may present to the ED due to pump failure. Sudden cardiopulmonary collapse can occur with infusion interruption. Here are some important points to remember regarding kinetics:
Keywords: Menthol, camphor, vicks, seizure (PubMed Search)
Vicks VapoRub Toxicity
With the removal of OTC product indications for children under the age of 2 for cough and colds, more parents are turning to other agents such as Vicks VapoRub for the relief of cough and cold symptoms. Unfortunately these agents are also associated with toxicities and the potential exists for an increased number of poisonings. The primary components of these agents are:
Menthol is used to relieve symptoms of chest congestion. There is NO data to support efficacy, and paradoxically, studies have indicated increased airflow resistance with application. There is a case report of an 18 month old who developed respiratory distress after application. Symptoms associated with overdose, or inappropriate route (mucosal, oral) are:
Camphor in products with higher concentrations such as Campho-phenique can cause additional toxicity with effects:
Treatment for both is supportive.
"Vicks VapoRub Safety in Children" Pharmacists Letter: Detail Document 250306, March 2009
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: lidocaine, nebulized (PubMed Search)
One of the options in our armamentarium prior to inserting an NG tube or performing a non-emergent nasotracheal intubation is nebulized lidocaine. However, the total dose is always a concern with this anesthetic agent before we have to worry about toxicity such as lightheadedness, tremors, hallucinations, seizures, and cardiac arrest. Here are some points to remember:
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.