UMEM Educational Pearls - Toxicology

Category: Toxicology

Title: Methadone-induced QT prolongation

Keywords: methadone, QT prolongation, torsade de pointes, magnesium (PubMed Search)

Posted: 1/7/2009 by Bryan Hayes, PharmD (Emailed: 1/8/2009) (Updated: 5/28/2023)
Click here to contact Bryan Hayes, PharmD

A few previous pearls have touched on identifying drugs that cause QT prolongation.  In our patient population, methadone is one of the more common causes of drug-induced prolonged QT syndrome.  Of 692 physicians surveyed (35% family practitioners, 25% internests, 22% psychiatrists, and 8% self-identified addiction specialists) only 41% were aware of methadone's QT-prolonging properties and just 24% were aware of methadone's association with torsade de pointes.


Now that you know, what do you do when a patient on methadone presents with a QTC of 580 msec and intermittent runs of vtach and torsade de pointes?


The answer is... the exact same thing you would do with any other patient who presents this way, regardless of the cause.

  • Give magnesium sulfate 2 gm IV for torsade de pointes
  • Check magnesium and potassium levels.  If low (which they often are), replete.
  • Monitor continuous EKG.

Buprenorphine, an alternative to methadone, is not associated with prolonged QT syndrome.


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Category: Toxicology

Title: Non-Cardiac Cocaine Toxicity

Keywords: Cocaine, stroke, crack lung, headache, seizures, hyperthermia, stroke (PubMed Search)

Posted: 1/1/2009 by Ellen Lemkin, MD, PharmD (Updated: 5/28/2023)
Click here to contact Ellen Lemkin, MD, PharmD

Although we tend to think of ACS with cocaine use, there are many other serious complications, including:

  • Agitation, psychosis, and anxiety
  • Hyperthermia
  • Vascular headache of withdrawal
  • Seizures
  • Hemorrhagic stroke (many of these patients have an underlying vascular abnormality)
  • Ischemic stroke
  • Acute Renal Failure
  • Crack Lung: acute pulmonary syndrome that occurs after inhaling freebase cocaine presents as fever, dyspnea, hypoxemia, diffuse alveolar infiltrates, and respiratory failure
  • Intestinal perforations

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Category: Toxicology

Title: Toxicology - Happy Holidays

Keywords: adverse drug reaction (PubMed Search)

Posted: 12/25/2008 by Fermin Barrueto, MD (Updated: 5/28/2023)
Click here to contact Fermin Barrueto, MD

Watch out for tradename and generic name's of medications.

They can get the patient and yourself into trouble:

  • coumadin: warfarin, jantoven
  • diphenhydramine: unisom, benadryl, tylenol PM

Classic example is my own case: Insert a central line in a patient - subclavian - and shortly after completion am alerted the patient's INR is 25. No adverse outcome but when I reviewed the med list, I did not see coumadin or warfarin and assumed I was in the clear. Patient was on jantoven.

Happy Holidays

Category: Toxicology

Title: Fat emulsion for treating local anesthetic toxicity

Keywords: Fat emulsion, intralipid, local anesthetic (PubMed Search)

Posted: 12/25/2008 by Ellen Lemkin, MD, PharmD (Updated: 5/28/2023)
Click here to contact Ellen Lemkin, MD, PharmD

  • Local anesthetics work through reversible binding of sodium channels
  • If inadvertantly administered intravenously or as an overdose, serious CNS and cardiac toxicities can occur, including seizures, arrhythmias, and cardiovascular collapse
  • Fat emulsion has been shown to increase the lethal dose of bupivicaine required, and also resuscitate animals that have local-anesthetic induced cardiac collapse
  • There have been successful case reports of patiets treated with fat emulsion that had cardiac arrest, seizures, and EKG changes. All patients recovered successfully with no neurologic sequale
  • Regimens used in these cases have included bolus doses between 1.2 -2 ml/kg followed by continuous infusions of 0.25 -0.5 ml/kg/min
  • Toxicity may be ameloriated by extracting lipophilic anesthetics from plasma or tissue, or by countering inhibition of myocardial fatty acid oxygenation

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Category: Toxicology

Title: LABAs

Keywords: serevent, foradil (PubMed Search)

Posted: 12/19/2008 by Fermin Barrueto, MD (Updated: 5/28/2023)
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The FDA has ruled that Long-Acting Beta Agonists (LABAs) are not worth the risk with increased hospitalization and increased mortality. Serevent has largely been replaced by Advair now. Unfortunately, for the children, it took 3 years to look at the data and finally come to this conclusion. Advair (LABA + fluticasone) has escaped the ruling with lack of evidence.

Category: Toxicology

Title: Naloxone for non-opioid overdoses?

Keywords: naloxone, clonidine, valproic acid, captopril (PubMed Search)

Posted: 12/1/2008 by Bryan Hayes, PharmD (Emailed: 12/11/2008) (Updated: 5/28/2023)
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A search of the toxicology literature will reveal that naloxone has been tried in many different overdose situations.  It is thought that the endogenous opioid system mediates several physiologic and pharmacologic pathways.

  • Captopril – naloxone reverses hypotension (Ann Emerg Med 1991;20(10):1125-7)
    • Evidence: One case report.
  • Valproic Acid  naloxone reverses CNS depression possibly through GABA attenuation
    • Evidence: Two case reports demonstrated effectiveness in patients with minimally elevated VPA levels.  Other reports showed no effect in patients with much higher concentrations.
  • Clonidine – naloxone reverses coma, bradycardia, and hypotension
    • Evidence: Several case reports suggest positive response while others demonstrate no benefit.  Anecdotal experience estimates a response in about 50% of cases.

Bottom line: In none of these instances was improvement as dramatic or consistent as in the reversal of the toxic effects of an opioid.  Naloxone can certainly be tried in non-opioid overdoses but should not be considered a first-line antidote.  The most benefit appears to be with clonidine.

Category: Toxicology

Title: Carbon Monoxide (CO) Poisoning

Keywords: carbon monoxide, CO, hyperbarics, HBO (PubMed Search)

Posted: 12/4/2008 by Ellen Lemkin, MD, PharmD (Updated: 5/28/2023)
Click here to contact Ellen Lemkin, MD, PharmD

CO is formed from the incomplete combustion of carbon materials, eg. fires, stoves, portable heaters CO reversibly binds hemoglobin, producing carboxyhemoglobin (HbCO). This causes oxygen to bind more tightly to hemoglobin, releasing less in the tissues. Because of this, it affects the organs with the highest oxygen requirements most profoundly (eg. brain and heart).

Symptoms are mainly neurological and cardiovascular, but may include a wide variety of non-specific symptoms. The initial symptoms of CO poisoning may include headache and flu-like illness progressing to confusion, agitation, lethargy, seizures and coma.

Place patients on 100% oxygen to decrease the half-life of HbCO. Though controversial, HBO therapy is thought to decrease the incidence of neurologic sequelae. HBO therapy should be considered for patients with a HbCO level above 20%, severely symptomatic patients with lower levels, and pregnant patients. Remember that pulse oximetry will not be accurate.

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Category: Toxicology

Title: Thanksgiving Toxicology

Keywords: tryptophan (PubMed Search)

Posted: 11/28/2008 by Fermin Barrueto, MD (Updated: 5/28/2023)
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Tryptophan - a precursor to melatonin, it is often blamed for the post prandial coma that many go into after a big turkey dinner. Never mind the 5000 kcals that was consumed during the meal. The supplement really doesn't help with sleeping. Interestingly, turkey isn't even in the top 10 or 20 of foods that contain tryptophan. The top five are:

1) Game meat (Elk): 746 mg of tryptophan

2) Seaweed (Spirulina): 736 mg of tryptophan

3) Spinach: 690 mg of tryptophan

4) Egg White: 673 mg of tryptophan

5) Soy protein: 630 mg of tryptophan

Supplements of L-tryptophan have been contaminated with a compound that has been associated with eosinophilia myalgia syndrome.


Category: Toxicology

Title: Bupivacaine

Keywords: cardiotoxicity, marcaine, bupivacaine (PubMed Search)

Posted: 11/20/2008 by Fermin Barrueto, MD (Updated: 5/28/2023)
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Local Anesthetic - Bupivacaine (Marcaine) - Sodium channel blocker with duration of action 2-4 hrs (w/epi 3-7 hrs) - Toxic dose is > 2.5 mg/kg or > 175 mg total dose (Infiltrating into SQ) - Bupivacaine 0.25% = 2.5 mg/mL - Inadvertent intravenous injection can result in toxicity - Lethally cardiotoxic with widened QRS, V-tach and neurotoxic with inebriation and seizures - Anesthesia literature reports successful use of Intralipid as an antidote

Category: Toxicology

Title: Opioid Allergies and Cross-reactivity

Keywords: opioid, opiate, allergy, hypersensitivity (PubMed Search)

Posted: 11/5/2008 by Bryan Hayes, PharmD (Emailed: 11/13/2008) (Updated: 5/28/2023)
Click here to contact Bryan Hayes, PharmD

How many times have you had a patient with an allergy to codeine described as stomach upset?  Or how about a rash with morphine (probably secondary to histamine release)?  True anaphylactic reactions to opioids are very rare (< 1%).  But what happens when you have a patient with a true allergy, but still need to give an opioid?  No problem, you just need to choose one that is structurally different.

  • Group 1 (aka opiates) - Naturally occurring agents derived from the opium plant
    • Morphine, codeine, thebaine
  • Group 2 - Semi-synthetics
    • Hydrocodone, oxycodone, hydromorphone, oxymorphone, buprenorphine (heroin is also in this group)
  • Group 3 - Synthetics
    • Fentanyl (alfentanil, sufentanil, etc.), methadone, tramadol, propoxyphene, meperidine

All of the group 1 and 2 agents are structurally very similar to each other and should not be given if a true allergy exists to any other natural or semi-synthetic derivative.  Group 3 agents have structures different enough that they can be given to a patient intolerant to the natural or semi-synthetics without fear of cross reactivity.  They are also very different from others in this same group.

The bottom line is that most of our patients don’t have true opioid allergies.  Just as an example, you will many times see a patient listed as having a percocet or morphine allergy and yet they tolerate hydromorphone without a problem. Go figure…

Category: Toxicology

Title: Salvia Divinorum

Keywords: Drugs of abuse, salvia, sage (PubMed Search)

Posted: 11/6/2008 by Ellen Lemkin, MD, PharmD (Emailed: 11/7/2008) (Updated: 5/28/2023)
Click here to contact Ellen Lemkin, MD, PharmD

This is a psychoactive herb which can induce strong dissociative effects by stimulation of the kappa receptor. It has become increasingly well known and available in modern culture, and popularized by YouTube Salvia (also known as Sage, Diviner's Sage, Magic Mint, or Sally D) is usually smoked, but can be chewed or ingested.

The high it produces is very intense, but lasts only approximately 10 minutes. Currently many states have enacted legislation against it, including Fla, IL, KA, MI, MO, ND, OK and VA, but it is available over the internet.


The following video demonstrates clinical effects of drug.
Although it is amusing, this is not meant to condone use.

(if you can not view the embeded video here is the link)

Category: Toxicology

Title: MDMA and SIADH

Keywords: siadh, mdma, ecstasy (PubMed Search)

Posted: 10/30/2008 by Fermin Barrueto, MD (Updated: 5/28/2023)
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Methylenedioxymethamphetamine (MDMA) or "Ecstasy"

A designer club drug that has been classified as a "hallucinogenic" amphetamine though it does not cause visual hallucinations like are reported with LSD. It has many of the sympathomimetic effects like other amphetamines but its main mechanism of action which both causes the euphoria and toxicity is serotonin agonism. Since Anti-diuretic hormone is released by the hypothalamus under the direct regulation of serotonin, there is a transient but dangerous episode of Syndrome of Inappropriate ADH (SIADH). Combined with the club culture and fear of dehydration while taking MDMA, patients ingest MDMA concomitantly with free water through the night further exacerbating the hyponatremia. The time sequence of events for these patient is (women appear genetically predisposed to this phenomena):

  • Friday Night: Ingestion of MDMA (even one pill is enough) +/- free water
  • Saturday Morning: headache, nausea, vomiting
  • Saturday Afternoon: (Realizes its not a hangover) patient becomes confused progressing to unresponsive and eventually seizures
  • Saturday Evening: Presents to ED with seizures

Treatment: Fluid restriction - this is the one time that the 1L NS Bolus can kill a patient with cerebral edema. If you must give fluid give 3% NaCl if there is symptomatic hyponatremia. Remember the patient has dropped their sodium in about 24 hours so you can replenish in about the same time quite safely and even faster in severe cases. Treated correctly, patients improve rapidly - within 24-48 hours. Read a great case report in the reference below.

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Category: Toxicology

Title: Olanzapine - Know the Adverse Effects

Keywords: anticholinergic, olanzapineA (PubMed Search)

Posted: 10/24/2008 by Fermin Barrueto, MD (Updated: 5/28/2023)
Click here to contact Fermin Barrueto, MD

 Olanzapine (Zyprexa)

This is an atypical antipsychotic that gained popularity because it caused less sedation and fewer extrapyramidal effects. However, there are many other adverse effects that need to be emphasized. Some of these may contribute to a patient's condition in the ED:

  • Hyperglycemia: has been reported to even cause hyperglycemic hyperosmolar nonketotic coma as well as DKA in patients that were not diabetic prior to initiation of olanzapine.
  • Anticholinergic: one of the most anticholinergic antipsychotics, watch for polypharmacy. Perhaps the patients urinary retention and mild confusion is due to the many anticholinergic medications the patient is taking.
  • Serotonin Syndrome: again a problem with polypharmacy and in overdose.

Category: Toxicology

Title: Bisphenol-A: A national concern

Keywords: bisphenol A, diabetes (PubMed Search)

Posted: 10/16/2008 by Fermin Barrueto, MD (Updated: 5/28/2023)
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Bisphenol A (BPA) is found in epoxy resins that line common food and beverage materials. There has been concern that this compound, like phthalates, may be causing harm through chronic low exposure. An epidemiologic study was performed and published in JAMA that has raised this question. Amazingly, the study did find that:

  • Higher urinary BPA levels correlated with an increase incidence of: NIDDM, CAD and elevated liver enzymes
  • Mechanism may be an estrogen effect, disruption of Beta-islet cell function and even obesity promoting effects
  • Study was strictly epidemiologic but raises a serious public health concern that you will see in the news more

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Category: Toxicology

Title: Lead in Children - Presentation

Keywords: lead (PubMed Search)

Posted: 10/10/2008 by Fermin Barrueto, MD (Updated: 5/28/2023)
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Clinical Manifestations in relation to lead level in children:

  • > 70 - 100 mcg/dL: Encephalopathy, increased ICP, anemia, vomiting
  • 50 - 70 mcg/dL: Irritable, difficult child, abdominal pain, anorexia
  • >10 mcg/dL: often asymptomatic, may develop impaired cognition, behavior, impaired fine-motor coordination, hearing and growth

Category: Toxicology


Keywords: ICP, intracranial pressure, antihypertensive, nitroprusside, nitroglycerin, hydralazine (PubMed Search)

Posted: 10/2/2008 by Ellen Lemkin, MD, PharmD (Updated: 5/28/2023)
Click here to contact Ellen Lemkin, MD, PharmD

Several antihypertensive agents raise intracranial pressure. Normal cerebral blood flow (CBF) is constant within normal cerebral perfusion pressure (CPP) ranges, recalling that CPP=MAP-ICP.

If CPP is outside the range in which autoregulation occurs, e.g. due to a structural lesion, ischemic stroke, or head trauma, CBF decreases and can adversely affect the patient.

  • Nitroprusside
    • Vasodilates both cerebral arteries and veins, increasing ICP
    • Inhibits the normal vasoconstrictive response to hypocapnia
  • Nitroglycerin
    • Causes cerebral venodilation, increasing ICP
    • Impairs vasodilatory response to hypercapnia
  • Hydralazine (varying effects)
    • Vasodilates cerebral arteries > cerebral veins
    • Impairs cerebral autoregulation
  • Nicardipine
    • Other calcium channel blockers increase ICP by vasodilating arteries
    • Has been used to treat vasospasm in SAH
    • Increases cerebral blood flow in patients with SAH and acute stroke

In patients with ischemic stroke or intracerebral pathology, labetalol or esmolol may be used to lower blood pressure without raising ICP. Nicardipine is recommended for use in patients with ischemic stroke or SAH but not in patients with brain injury

If the patient has NO structural abnormalities, but has hypertensive encephalopathy, nitroglycerin, nitroprusside, labetalol, esmolol, or nicardipine may be used.

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Category: Toxicology

Title: China does it to their own children

Keywords: melamine, infant, milk (PubMed Search)

Posted: 9/25/2008 by Fermin Barrueto, MD (Updated: 5/28/2023)
Click here to contact Fermin Barrueto, MD


  • In case you thought the chinese only sent their toxin filled products to the USA, a massive scandal has been occurring with their milk.
  • Adding melamine to their milk, companies were able to get falsely elevated readings of protein which is measured by the government to make sure the milk was not watered down.
  • 53,000 illnesses, over 12,000 hospitilizations and at least 4 infant deaths have been attributed to their milk supply - 20% of China's milk supply is thought to be contaminated
  • Melamine or melamine resin is used to make plastics and involved in other polymeric reactions.
  • Toxicity involves the creation of kidney stones - imagine the pain in these poor children
  • These children died from renal failure from multiple kidney stones.
  • Check the link below to the news article

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Category: Toxicology

Title: Cheese Heroin

Keywords: diphenhydramine, heroinI (PubMed Search)

Posted: 9/18/2008 by Fermin Barrueto, MD (Updated: 5/28/2023)
Click here to contact Fermin Barrueto, MD

 Cheese Heroin: a slang term for the combination of heroin with an over-the-counter antihistamine

  • The two are combined and forms a cheesy like powder that is different from pure heroin
  • A string of deaths were reported between 2005-2007 in Texas, many adolscents
  • This concoction is more often insufflated than smoked or injected
  • Combines opioid effect with the anticholinergic confusion and hallucinations
  • Scorpion was a heroin that was combined with scopolamine that had similiar effect


  • Find the anticholinergic toxidrome, place the foley and supportive care are mainstays
  • Consider administration of physostigmine 1mg IV slowly over 2-5 minutes (call toxicologist)
  • The anticholinergic effects will linger much longer than the heroin effects ( <1hr)



Category: Toxicology

Title: Black Widow Spider

Keywords: latrodectus, black widow, spider (PubMed Search)

Posted: 9/11/2008 by Fermin Barrueto, MD (Updated: 5/28/2023)
Click here to contact Fermin Barrueto, MD

 Latrodectus sp (Black Widow Spider)

  • The only indigenous neurotoxic insect  in the state of Maryland and found through many states in the US
  • The "bite" often not visible and does not cause a necrotic lesion like the brown recluse
  • Causes Acetycholine release from post-synaptic motor and sensory nerves
  • This leads to intense muscle contraction and pain. There have been reports of a black widow spider on the leg and the patient undergoes ex lap surgery for suspected acute abdomen only to find out the abdominal muscles were fasciculating due to envenomation
  • Treat with aggresive analgesia and benzodiazepines.
  • Not often lethal with approximately 60-70 deaths in the US over 30 years

Take a look at a picture of the black widow on the following attachment


black-widow-spider-1.jpg (14 Kb)

Category: Toxicology

Title: Topical Lidocaine for Local Anesthesia

Keywords: Lidocaine, pediatrics, anesthesia (PubMed Search)

Posted: 9/4/2008 by Ellen Lemkin, MD, PharmD (Updated: 5/28/2023)
Click here to contact Ellen Lemkin, MD, PharmD

Topical Lidocaine for local anesthesia

  • Zingo® (lidocaine 0.5 mg powder) is a new product designed to reduce pain with IV access
  • Onset of action 1-3 minutes (compared with 30 minutes with lidocaine/prilocaine creams (EMLA®), liposomal lidocaine 4% (LMX®), or lidocaine/tetracaine patches (Synera®)
  • Duration of action is only 10 minutes (procedure must be done in 10 minutes)
  • Uses helium to forcefully deliver drug into the skin
  • Looks like a marker that you press down and you hear a loud pop
  • Cost $20 per dose
  • Approved for children 3-18 years of age


Disclosure: I have no financial or invested interest in the product or the company.

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