Keywords: levofloxacin (PubMed Search)
Quinolone Induced Deliurim
Just to give you another reason NOT to give a quinolone - aside from the C. diff. This adverse effect occurs with quinolones unlike many other antibiotics. It can prolong hospital stay, cause falls and further medical work ups. Some risk factors are:
Keywords: anion gap, metabolic acidosis (PubMed Search)
As we are now into the winter months, exposures to ethylene glycol (antifreeze) and methanol (windshield washer fluid) increase. Here is a good mnemonic for sorting through an anion gap metabolic acidosis:
C – cyanide, carbon monoxide
A – alcoholic ketoacidosis, acetaminophen (massive OD)
T – toluene (chronic from glue sniffing)
M – methanol, metformin
U – uremia
D – diabetic ketoacidosis
P – propofol infusion syndrome, propylene glycol, paraldehyde
I – iron, isoniazid, ibuprofen (massive OD)
L – lactic acidosis
E – ethylene glycol
S – salicylates, starvation ketoacidosis
Keywords: DMSA, succimer, lead, arsenic, mercury (PubMed Search)
Keywords: christmas rose (PubMed Search)
A quick christmas one:
The Christmas Rose (Helleborus niger)
Actually containes cardioactive steroids - eating it will help your A fib with RVR as it will act like digoxin, as well as kill like it.
Keywords: manganese, parkinsons, tremor (PubMed Search)
Here is a table adapted from Goldfrank's Textbook of Toxicologic Emergencies 8th Edition - Drugs that May Induce Parkinsonism. MPTP is the story that everyone hears about and actually has links to Maryland. In 1976, Barry Kidston, a 23-year-old chemistry Maryland graduate student, synthesized MPPP (Meperidine or Demerol) incorrectly and injected the result. It was contaminated with MPTP, and within three days he began exhibiting symptoms of Parkinson's disease. Ooops - permanent.
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.