Keywords: amanita, mushrooms, liver (PubMed Search)
How to recognize a truly toxic mushroom ingestion (remember one mushroom can be lethal!):
1) Onset of GI symptoms within 3 hours from time of ingestion: USUALLY NONTOXIC
- Control nausea and vomiting
- Look for toxidrome: hallucinations, muscarinic symptoms, lethargy
2) Onset of GI symptoms greater than 5 hrs is associated with more toxic mushrooms
- High degree of suspicion for a cyclopeptide mushroom (Amanita phylloides)
- Follow liver enzymes and consier referral to liver transplant center
Keywords: dialysis, lithium salicylate (PubMed Search)
Keywords: naloxone, opioids (PubMed Search)
1) No IV - Try naloxone in a nebulizer - Dose: 2-4 mg and saline in your nebulizer container.
2) When using naloxone IV, use following dose: 0.05 mg IV - you will find it reverses the respiratory depression without inducing withdrawal. Anesthesia doses naloxone in micrograms, we often overdose our patients. The effect is delayed and not as pronounced as the 0.4 mg blast that causes nausea, vomiting, diarrhea, agitation - all not desirable in the ED.
Keywords: antiepileptics, suicide, carbamezepine, felbamate, gabapentin, lamotrigine, levetiracetam, valproate, pregabalin (PubMed Search)
SUICIDE RISK WITH ANTIEPILEPTICS
Drugs in the analysis included:
Carbamazepine (Carbatrol, Equetro, Tegretol, Tegretol XR)
Valproate (Depakote, Depakote ER, Depakene, Depacon)
Interestingly, other agents including varenicline (a partial nicotinic antagonist, for smoking cessation), levetiracetam (Keppra), zolpidem (Ambien), oseltamivir (Tamiflu), isotretinoin (Accutane), and other agents have been noted to have an increased rate of bizarre and aggressive behavior.
There is actually very little data that actually supports the administration of activated charcoal (AC) to the poisoned patient. AC works by binding the toxin and preventing its absorption from the GI tract. Here are some of the practical points:
Once you have assessed your risk:benefit ratio, then administer AC. Of note, it definitely works in the right situation as noted in a landmark article that showed a decrease in mortality following poisoning by oleander - a plant that contains a digoxin like substance.(1)
1 - de Silva HA, et al. Multiple-dose activated charcoal for treatment of yellow oleander poisoning: a single-blind, randomised, placebo-controlled trial. Lancet 2003: 361(9373):1935-8.
Keywords: heparin, chondroitin, toxicity (PubMed Search)
Heparin FDA Alert
In case you had not heard, there was a major recall of Baxter's Heparin. It was responsible for dozens of deaths in the USA and an investigation was launched. It has been found that the contaminant comes from manufacturing plants in China. The most concerning part is that it looks like it was chemically synthesized sulfated chondroitin. This brings the suspicion of intentional adulteration. First lead in toys now cartilage in our heparin - what's next?
Some fascinomas of Heparin:
News link for FDA Heparin Alert:
Keywords: sumatriptan, myocardial infarction, migraine (PubMed Search)
Keywords: amiodarone, torsades, hypothyroidism, toxicity, adverse effects, medication induced (PubMed Search)
Did you know how many toxicities and adverse effects amiodarone has? Many are severe, and many VERY common.
1. CARDIAC: hypotension with rapid infusion, prolonged QT, torsades
2. NEUROLOGIC problems occur in 20-40%, including malaise, ataxia, and peripheral neuropathies
3. ENDOCRINE: hypothyroidism and hyperthyroidism
4. GI problems occur in 25%
5. OPHTHALMOLOGIC disturbances include optic neuropathy, papilledema, and photosensitivity
6. SKIN: blue grey pigmentation
7. PULMONARY: pulmonary fibrosis
Keywords: zolpidem, benzodiazepines, eszopiclone (PubMed Search)
Both dealing with the adverse effects from therapeutic administration, like when you order it on the floors or take yourself - to the overdose setting. Here is a brief list of the common sleep aids, MOA and toxicity. (Zolpidem or Ambien gets the award for most entertaining adverse effect of "Sleep Eating")
Keywords: influenza, tamiflu, oseltamivir (PubMed Search)
Here are a couple of herbals touted as aphrodesiac's and the toxcity associated with them (the price of love):
Chan Su or "Love Stone" - A chinese herbal that is suppose to be topically applied, unfortunately all of the instructions are in chinese and those who ingest it will die a digoxin-like death. It has a compound that is essentially a potent digoxin-like substance.
Yohimbine - herbals that contain this can cause priapism - shocker
Keywords: crotimaton, permethrin, lindane (PubMed Search)
We have seen this lovely bug infect our patients and have to instutitue therapy. But do you know what is the first line drug and which one has now become second line due to its toxicity? Here is the short list:
First Line Therapy: Permethrin (Nix) - least toxic, only causes local irritation
Second Line Therapy: Crotamiton (Eurax) - again local irritation
Third LIne Therapy: Lindane - SEIZURES if you leave it on too long or put on too much. Children were particularly susceptible and relatively contraindicated.
Keywords: hyperkalemia, medications (PubMed Search)
Keywords: bisphosphonates (PubMed Search)
With the aging population, bisphosphonate use will continue to increase. They promote bone growth by inhibiting osteoclast action and resorption of bone. Unfortunately, they have their side effects and the FDA has sent out a recent warning that affects us all:
If a patient presents with severe bone/joint pain, check the med list to see if they are on a bisphosphonate - they may not be faking the pain. This can occur days, weeks or even years after initiation of dose
Keywords: anticonvulsant, status epilepticus, keppra (PubMed Search)
Knake et al. Intravenous levetriacetam in thetreatment of benzodiazepine-refractory status epilepticus. J Neurol Neurosurg Psychiatry 2007 Sept 26; Epub
Keywords: phenytoin, anticonvulsants, loading dose (PubMed Search)
Phenytoin po Phenytoin IV Fosphenytoin
Time to therapeutic 6.4 hrs 1.7 hrs 1.3 hrs
Adverse Events 0.69/pt 1.86/pt 1.87/pt
Also to take into account is that the adverse events with IV phenytoin include soft-tissue necrosis if there is extravasation of infusion. The cardiotoxicity seen with phenytoin and fosphenytoin is largely due to the propylene glycol diluent and thus not seen with oral loading or even in oral overdosing.
You decide, at least you have the data to properly evaluate the risk:benefit ratio.
Keywords: NSAID, ketorolac, gastritis, renal failure (PubMed Search)
Ketorolac: an NSAID that gained popularity since it is not an opioid, has excellent anti-inflammatory/analgesic effects and is given IM or IV. Also has been used in renal colic secondary to smooth muscle relaxation (Prostaglandin mediated) in the ureters. You should know:
Corelli et al. Renal Insufficiency and ketorolac. Ann Pharmacother. 1993; 27(9): 1055-7
Keywords: thyroid, hypothyroid, hyperthyroid (PubMed Search)
Lithium: Hypothyroidism (5-15% of pts) and goiter (37% of pts), mechanism unclear
Amiodarone (37% Iodine by weight): Hyper or Hypothroidism
Beta-Blockers: by blocking peripheral conversion of T4 to T3 cause hypothyroidism
Corticosteroid: same as beta-blockers but can also cause transient thyrotoxicosis (Jod-Basedow effect)
Iodine, Iodinated contrast, radiactive iodine all can cause hypothyroidism but iodinated contrast material can actually induce thyrotoxicosis and thyroid storm from unknown mechanism.
Keywords: ondansetron,metoclopramide (PubMed Search)
Everything you need to know about anti-emetics, mechanism of action, potency and toxicity:
1) 5-HT3 Blockers - Ondansetron, Granistron
- The most potent anti-emetic, only toxicity is really cost
2) Dopamine Blockers - Metoclopramide
- Can titrate to high doses, causes dystonia, akathisia and mild QT prolongation
3) Anticholinergic - Promethazine, meclizine, diphenhydramine
- Cannot titrate, most sedating, urinary retention in elderly, mild QT prolongation
Keywords: radiocontrast, nephropathy, renal failure (PubMed Search)