Category: Toxicology
Keywords: Alcohol (PubMed Search)
Posted: 6/16/2009 by Rob Rogers, MD
(Updated: 5/31/2023)
Click here to contact Rob Rogers, MD
The Alcoholic Patient in the ED
Well, we have all been there....EMS rolls in with "another drunk guy" found down in the street. The nurses tell you, "he is here all the time...he is just drunk." You should be scared any time you hear this phrase uttered. Always be a little nervous about this group of patients and you won't fall victim to many of the pitfalls that some of us have experienced.
Pearls and Pitfalls in Caring for the Intoxicated Patient in the ED:
Category: Toxicology
Keywords: vitamin K, phytonadione, warfarin, INR (PubMed Search)
Posted: 6/9/2009 by Bryan Hayes, PharmD
(Emailed: 6/11/2009)
(Updated: 6/11/2009)
Click here to contact Bryan Hayes, PharmD
Patients who present to the ED with an elevated INR due to vitamin K antagonists many times do not need to be reversed. Simply holding a dose is all that is usually necessary for patients with an INR < 9. Fortunately, guidelines published in CHEST are available to help guide management.
Reference:
Ansell, J, Hirsh, J, Hylek, E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; (6 Suppl):160s.
Ansell, J, Hirsh, J, Hylek, E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; (6 Suppl):160s.
Category: Toxicology
Keywords: Oseltamivir,tamiflu,h1n1,influenza (PubMed Search)
Posted: 6/4/2009 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
Oseltamivir (Tamiflu)
For complete indications and dosing: www.cdc.gov/h1n1flu/recommendations.htm
www.cdc.gov/h1n1flu/recommendations.htm
www.cdc.gov/flu/professionals/antivirals/side-effects.htm
Category: Toxicology
Keywords: benzodiazepine, oxazepam, toxicology, urine, blood (PubMed Search)
Posted: 5/14/2009 by Bryan Hayes, PharmD
(Updated: 5/31/2023)
Click here to contact Bryan Hayes, PharmD
Your patient presents unresponsive with an empty bottle of alprazolam (Xanax). You order a urine and blood toxicology screen. The blood comes back negative for benzodiazepines but the urine test is positive. How do you interpret this result?
Category: Toxicology
Keywords: ethanol,fomepizole,toxic alcohols,ethylene glycol,methanol (PubMed Search)
Posted: 5/7/2009 by Ellen Lemkin, MD, PharmD
(Updated: 5/31/2023)
Click here to contact Ellen Lemkin, MD, PharmD
Category: Toxicology
Keywords: ondansetron, antiemetics (PubMed Search)
Posted: 4/23/2009 by Fermin Barrueto, MD
(Updated: 5/31/2023)
Click here to contact Fermin Barrueto, MD
Category: Toxicology
Keywords: colchicine, gout (PubMed Search)
Posted: 4/16/2009 by Fermin Barrueto, MD
(Updated: 5/31/2023)
Click here to contact Fermin Barrueto, MD
Colchicine is a drug used for the treatment of acute gout attacks. It inhibits microtubule formation vital for cellular mitosis. It is also a drug with a narrow therapeutic index and lethal toxicity:
- Colchicine can be lethal at 0.5 mg/kg or even lower. Though this would be about 50 tablets and seems alot, remember it is prescribed 2 tablets initially then every hour until diarrhea presents (i.e. preliminary toxicity)
- Toxicity presents in 3 stages:
- No antidote, supportive care only available.
- Presentation is similiar to that of a radiation exposure
Category: Toxicology
Keywords: glargine, insulin, lantus (PubMed Search)
Posted: 4/9/2009 by Bryan Hayes, PharmD
(Updated: 5/31/2023)
Click here to contact Bryan Hayes, PharmD
Overdoses of insulin glargine (Lantus) are rarely reported in the literature. In fact, there are only 6 case reports. We recently had a patient in our ED who was hypoglycemic from insulin glargine. The hypoglycemic episode was quite prolonged (> 24 hours) in the ED before being the patient was transferred to the MICU. Here are a few points to remember:
Category: Toxicology
Keywords: overdose, precription drugs, pediatric, substance abuse (PubMed Search)
Posted: 4/1/2009 by Dan Lemkin, MD, MS
(Emailed: 4/2/2009)
(Updated: 5/24/2009)
Click here to contact Dan Lemkin, MD, MS
Classical illicit recreational drugs like cocaine, ecstacy, and marajuana are sometimes difficult for teens to acquire. As a result, many are turning to their parents medicine cabinets as a source for recreational drugs.
[From the website drugabuse.gov] In 2008, 15.4 percent of 12th-graders reported using a prescription drug nonmedically within the past year. This category includes:
When adolescent patient presents to the ED, consider the possibility of a poly-pharmacy overdose. Always query parents about the presence of OTC and Rx medications in their home, and what is within reach of their kids.
While sedatives and analgesics are concerning, be alert for overdoses of more mundane medications like beta blockers and calcium-channel blockers which often pose a much more lethal threat. Consider overdose in adolescent patients with:
Monitoring the Future Study: Trends in Prevalence of Various Drugs for 8th-Graders, 10th-Graders, and 12th-Graders
2005-2008 (in percent)*
8th-Graders | 10th-Graders | 12th-Graders | ||||||||||
2005 | 2006 | 2007 | 2008 | 2005 | 2006 | 2007 | 2008 | 2005 | 2006 | 2007 | 2008 | |
Any Illicit Drug Use | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Lifetime | 21.4 | 20.9 | [19.0] | 19.6 | 38.2 | 36.1 | 35.6 | 34.1 | 50.4 | 48.2 | 46.8 | 47.4 |
Full chart available by clicking link in references.
Category: Toxicology
Keywords: serotonin (PubMed Search)
Posted: 3/26/2009 by Fermin Barrueto, MD
(Updated: 5/31/2023)
Click here to contact Fermin Barrueto, MD
Serotonin is a neurotransmitter that has central and peripheral effects. It regulates the secretion of ADH from the hypothalamus and also controls the chemoreceptive trigger zone (CTZ) which induces emesis. Here are a list of medications categorized by the way they affect serotonin. Remember, any combination of these agonists could precipitate serotonin syndrome:
Enhance 5-HT synthesis: L-tryptophan
Direct HT agonists: Ergots, metoclopramide, sumatriptan, buspirone
Increase 5-HT release: amphetamines, cocaine, dextromethorphan, MDMA, L-dopa
Inhibit 5-HT breakdown: MAOIs, Linezolid
Inhibit 5-HT re-uptake: SSRIs (paxil), amphetamines, carbamazapine, tramadol, TCAs, citalopram, trazodone, lamotrigine, meperidine
Category: Toxicology
Keywords: acetone, cyanide, odor (PubMed Search)
Posted: 3/19/2009 by Fermin Barrueto, MD
(Updated: 5/31/2023)
Click here to contact Fermin Barrueto, MD
Goldfrank's sniffing bar: no this is not a pub where toxicologist's hang out but rather a bar that assists with teaching the recognition of odors related to toxicology. Certain drugs and compounds have a distinct aroma.
The following is a list odors, see if you can name a medication or compound that has that odor - scroll down further to see the corresponding answers (if you really got all 5 email me and convince me):
1) Bitter Almond
2) Rotten Eggs
3) Wintergreen
4) Garlic
5) Sweet, Fruity (acetone)
Answers:
1) Cyanide; 2) N-acetylcysteine or Hydrogen Sulfide; 3) Methylsalicylate (like bengay); 4) Arsenic, organophosphate insecticides; 5) Chloroform, chloral hydrate
Category: Toxicology
Keywords: metoclopramide, black box warning, tardive dyskinesia (PubMed Search)
Posted: 3/12/2009 by Bryan Hayes, PharmD
(Updated: 5/31/2023)
Click here to contact Bryan Hayes, PharmD
Add metoclopramide (Reglan) to the laundry list of medications with black box warnings from the FDA. Why was a black box warning added?
Category: Toxicology
Keywords: Clevidipine, calcium channel antagonist, calcium channel blocker, antihypertensive (PubMed Search)
Posted: 3/5/2009 by Ellen Lemkin, MD, PharmD
(Updated: 5/31/2023)
Click here to contact Ellen Lemkin, MD, PharmD
Clevidipine
1. Anon. The Medical Letter. Sept 22 2008;50(1295)73-4.
Category: Toxicology
Keywords: ondansetron, albuterol (PubMed Search)
Posted: 2/26/2009 by Fermin Barrueto, MD
(Updated: 5/31/2023)
Click here to contact Fermin Barrueto, MD
Category: Toxicology
Keywords: rocuronium, succinylcholine (PubMed Search)
Posted: 2/19/2009 by Fermin Barrueto, MD
(Updated: 5/31/2023)
Click here to contact Fermin Barrueto, MD
Rocuronium is fast becoming the agent of choice for RSI in the Emergency Department. Here is a head to head comparison of the two drugs to understand why:
Rocuronium | Succinycholine | |
Dose | 1-1.2mg/kg | 1mg/kg |
Onset | 1-1.5min | 1min |
Duration | 7-12min | 30-40min |
Histamine Release | No | Minimal Yes |
CVS Effect | Tachycardia rare | Severe Brady rare |
Other Adverse Effect | No fasciculations, No ICP effect, No Rhabdo | Fasciculations, increase ICP, rhabdo, movement of displaced Fxs |
Category: Toxicology
Keywords: phentolamine, tyramine, pheochromocytoma (PubMed Search)
Posted: 2/12/2009 by Bryan Hayes, PharmD
(Updated: 5/31/2023)
Click here to contact Bryan Hayes, PharmD
You have a 44 y/o female patient with an arterial line monitoring her blood pressure which is reading 302/156 mm Hg. Her heart rate is 140 bpm. Her history reveals she is taking a monoamine oxidase inhibitor (MAOI) and has inadvertantly ingested tyramine at her friend's cheese/wine party. What do you do?
Category: Toxicology
Keywords: Clopidogrel, DVT, thrombosis, stents (PubMed Search)
Posted: 2/5/2009 by Ellen Lemkin, MD, PharmD
(Updated: 5/31/2023)
Click here to contact Ellen Lemkin, MD, PharmD
Category: Toxicology
Keywords: brodifacoum, cholecalciferol, strychnine (PubMed Search)
Posted: 1/29/2009 by Fermin Barrueto, MD
(Updated: 5/31/2023)
Click here to contact Fermin Barrueto, MD
Rodenticides have taken many forms. The following is a list of some of the more interesting ones either due to the mechanism of toxicity or how it is lethal. All of these are also toxic to people.
1) Strychnine - Glycine Antagonist at the post-synaptic spinal cord neurons - patient or rat will have convulsion of the extremeties but will be awake, alert and in extreme pain. Essentially look like generalized seizure except awake. Treatment: Benzodiazepines, Analgesia, Supportive
2) Brodifacoum - Long Acting Coumarin - rat eats, later develops elevated INR then tries to run through thin cracks in the wall or takes a little too high of a jump, then boom - subdural or some other internal hemorrhage. In human, they can stay anticoagulated for weeks after an overdose. Treatment: Vitamin K and large padded room
3) Cholecalciferol - Vitamin D precursor - there are big blocks of this drug in the NY and other subway systems. Rat nibbles, gets hypercalcemic, then gets thirsty because of this. Rat runs out into middle of subway to drink out of puddle then - splatt - the M train to Brooklyn comes along. Treatment: IVF, Loop Diuretics, Bisphosphonates
Category: Toxicology
Keywords: octreotide, sulfonylurea, hypoglycemia (PubMed Search)
Posted: 1/22/2009 by Fermin Barrueto, MD
(Updated: 5/31/2023)
Click here to contact Fermin Barrueto, MD
Octreotide
Fasano CJ, O'Malley G, Dominici P, Aguilera E, Latta DR. Comparison of octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia. Ann Emerg Med. 2008 Apr;51(4):400-6. Epub 2007 Aug 30.
Category: Toxicology
Keywords: tetrodotoxin, sushi (PubMed Search)
Posted: 1/15/2009 by Fermin Barrueto, MD
(Updated: 5/31/2023)
Click here to contact Fermin Barrueto, MD
Tetrodotoxin - Sodium Channel blocker - Extremely toxic causes paresthesias, dysrhythmias and paralysis - Found in the sushi called Fugu (From the Pufferfish) - Eating the sushi is considered a delicacy and goal is to get just enough of the toxin to get perioral paresthesias after eating. - Also found in the blue-ringed octopus, angelfish and parrot fish. Enjoy your seafood and take a look at the attached pic of actual fugu.