Category: Toxicology
Keywords: toxic substance, online retailers, amazon.com, (PubMed Search)
Posted: 6/6/2019 by Hong Kim, MD, MPH
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Many chemicals and substances - both legal and illegal - can be purchased from an online retailer. A recent study searched Amazon.com to see if any of the "extremely hazardaous substances" identified by Environmental Protection Agency (EPA) were available for purchase.
Amazon.com was searched over 10-month period.
Result:
Bottom line:
Toxic substances are readily available from many online retailers that can potentially cause serious toxicity. Online retailers should consult with experts and governmental agencies to limit the availability of such products.
Learnoad JB et al. Prime eligible poisons: identification of extremely hazardous substances available on Amazon.com. 2019 Clin Toxicol (Phila). 2019 Apr 30:1-4. doi: 10.1080/15563650.2019.1594870. [Epub ahead of print]
Category: Toxicology
Keywords: Hypoglycemia, Drug induced (PubMed Search)
Posted: 5/16/2019 by Kathy Prybys, DO
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Drug-induced hypoglycemia is an important cause of hypoglycemia which should be considered in any patient presenting with altered mental status. In one study, drug-induced hypoglycemia represented 23% of all hospital admissions attributed to adverse drug events. Risk factors for developing hypoglycemia include older age, renal or hepatic insufficiency, concurrent use of insulin or sulfonylureas, infection, ethanol use, or severe comorbidities. The most commonly cited drugs associated with hypoglycemia include:
*In Glipizide users, there was 2-3 fold higher odds of hypoglycemia with concurrent use of sulfamethoxale-trimethoprim, fluconazole, and levofloxacin compared with patients using Cephalexin.
**Tramadol potentially induces hypoglycemia by effects on hepatic gluconeogenesis and increasing insulin release and peripheral utlizilation. Was seen in elderly at initiation of therapy within first 30 days.
BOTTOM LINE:
Take care in prescribing drugs known to increase risk of hypoglycemia in elderly patients, with comorbidities, or those already taking medications associated with hypoglycemia.
Drug induced hypoglycemia, A Systematic Review. Hassan M. et al. J Clin Endo & Metab. 94(3) March 2009. 741-45.
Hypogylcemia after antimicrobial drug prescription for older patients using sulfonylureas. Parekh TM, Raji M, et al. JAMA Intern Med. 2014. 1605-12.
Tramadol Use and the Risk of Hospitalization for Hypoglycemia in Patients with Noncancer Pain. Fournier J, Azoulay L. et al. Jama Intern Med. 2015;175(2):186-193.
Hypoglycemic effects of tramadol analgesia in hospitalized patients: a case-control study. Golightly LK. Simendinger BA. et al. J Diabetes Metab Disord. 2017;16:30.
Category: Toxicology
Keywords: guanfacine, ADHD, pediatric, toxicity (PubMed Search)
Posted: 5/3/2019 by Hong Kim, MD, MPH
(Updated: 5/29/2023)
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Guanfacine is a presynaptic alpha-2 adrenergic receptor agonist (similar to clonidine) that is FDA approved to treat ADHD in pediatric patients 6 years of age and older. A recently published study characterized the pediatric exposure to guanfacine between 2000 and 2016.
Most frequently reported clinical effect (n=10927)
Severe clinical effects (n=10927)
Duration of clinical effect
Conclusion
Category: Toxicology
Keywords: laundry pod exposure, toxicity (PubMed Search)
Posted: 4/18/2019 by Hong Kim, MD, MPH
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Single use laundry pods are readily available in many homes. Due to their bright colors, they have been mistaken for edible products (e.g. candy) by children.
A recent study reviewed 4652 laundry pod exposures from United Kingdom.
95.4% involved children aged < 5 years via oral route (89.7%).
Common symptoms in moderate/severe symptom groups, including fatality (n=127)
Conclusion
Day R, Bradberry SM, Jackson G, et al. A review of 4652 exposures to liquid laundry detergent capsules reported to the United Kigndom National Poisons Information Service 2008 - 2018. Clin Toxicol (Phila). 2019 Mar 20:1-8. doi: 10.1080/15563650.2019.1590586. [Epub ahead of print]
Category: Toxicology
Keywords: lipid emulsion therapy (PubMed Search)
Posted: 4/4/2019 by Hong Kim, MD, MPH
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Intravenous lipid emulsion (ILE) is use as a therapy of last resort in refractory cardiovascular shock from toxicity of select agents (e.g. calcium channel blockers, beta blockers and select Na-channel blocking agents). There are number of case reports/series that showed positive cardiovascular/hemodynamic response after ILE, which are prone to publication bias. Results from limited number of human trials have shown mixed results.
A study reviewed fatal cases of poisoning that received ILE from the National Poison Data System to characterize the clinical response of ILE therapy.
Results
N=459 cases from 2010 to 2015.
Most common substance involved
| N (%) | Number with ROSC (%) |
Ca-channel blockers | 183 (40) | 8 (4.4) |
Beta blockers | 102 (22) | 5 (4.9) |
Bupropion* | 53 (12) | 5 (9.4) |
TCAs* | 48 (10) | 2 (4.2) |
Citalopram/escitalopram | 36 (8) | 0 |
Quetiapine | 26 (6) | 1 (3.8) |
Flecainide | 21 (5) | 5 (23.8) |
Local anesthetics – parenteral* | 8 (2) | 1 (12.5) |
*Use of ILE supported by Lipid work group
Response rate
Possible adverse reactions (n)
Conclusion
Category: Toxicology
Keywords: Scromboid, Histamine (PubMed Search)
Posted: 3/28/2019 by Kathy Prybys, DO
(Emailed: 3/29/2019)
(Updated: 3/29/2019)
Click here to contact Kathy Prybys, DO
Scromboid (histamine fish poisoning) can be easily misdiagnosed since its' clinical presentation can mimic that of allergy. Seen most frequently in the summer and occurring with Scombroideafish (tuna, mackerel, bonito, skipjack) but also with large dark meat fish (sardines and anchovies) and even more commonly with nonscromboid fish such as mahi mahi and amber jack. In warm conditions when fish is improperly refrigerated, bacterial histidine decarboxylase converts muscle histidine into histamine which quickly accumulates. Histamine is heat stable and not destroyed with cooking.
Bottom Line:
Scromboid poisoning is due to histamine ingestion and is often misdiagnosed as allergic reaction. It is preventable with proper fish storage.
Severe scombroid fish poisoning: an underrecognized dermatologic emergency. Jantschitsch C, Kinaciyan T, et al. J Am Acad Dermatol 2011; 65:246–7.
Histamine fish poisoning: a common but frequently misdiagnosed condition. Attaran RR, Probst F. Emerg Med J 2002;19:474–5.
Category: Toxicology
Keywords: kratom, adverse effects, poison center data (PubMed Search)
Posted: 3/14/2019 by Hong Kim, MD, MPH
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Kratom (Mitragyna speciosa) has been used for centuries in Southeast Asia to manage pain and opium withdrawal. It is increasingly being used in the U.S. for similar purpose. The U.S. DEA lists Kratom as a “drug of concern”.
Effects of Kratom leaves
A study reviewed National Poison Data System (2011 to 2017) to evaluate the clinical effects/outcomes of Kratom exposure.
Finding: (N=1807; single-substance: 1174; multiple-substance: 633])
Common symptoms
Disposition
Bottom line:
Sara Post, Henry A. Spiller, Thitphalak Chounthirath & Gary A. Smith (2019): Kratom exposures reported to United States poison control centers: 2011–2017, Clinical Toxicology, DOI: 10.1080/15563650.2019.1569236
Category: Toxicology
Keywords: CT, Overdose, Pills (PubMed Search)
Posted: 2/21/2019 by Kathy Prybys, DO
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The primary tenet of poisoning treatment is to separate the patient from the poison. Gastric decontamination has been the cornerstone of poisoning treatment throughout history and methods include induced emesis, nasogastric suctioning, EGD or gastrostomy retrieval, activated charcoal, and whole bowel irrigation. Current guidelines for gastic decontamination are limited to few clinical situations. The detection of residual life threatening poisons in the stomach would be of value in predicting who might benefit from gastric decontamination in overdose.
Plain radiographs have variable sensitvity in detecting radioopaque pills. Computed tomography (CT) has been successful and gained wide acceptance in the detection of drug in body packers. In a recent study, authors studied the usefulness of non-contrast abdominal computed tomography for detection of residual drugs in the stomach in patients presenting over 60 minutes from acute drug overdose:
BOTTOM LINE:
Non-contrast CT may help to predict which patients would benefit from gastric decontamination in acute life-threatening drug poisonings.
Position paper update: gastric lavage for gastrointestinal decontamination. Benson B, Hoppu K, et al. Clin Toxicol. 2013;51:140–146.
American Academy of Clinical Toxicology & European Association of Poisons Centres and Clinical Toxicologists (2005) Position Paper: Single-Dose Activated Charcoal, Clinical Toxicology, 43:2, 61-87.
Are ingested lithium sulphate tablets visible on x-ray? A one-year prospective clinical survey. Höjer J, Svanhagen AC. 2012. Clinical Toxicology, 50:9, 864-865.
The usefulness of non-contrast abdominal computed tomography for detection of residual drugs in the stomach of patients with acute drug overdose, Yong Sung C, Seung-Whan C, et al. 2019. Clinical Toxicology.
Category: Toxicology
Keywords: physostigmine, anticholinergic toxicity, adverse effects (PubMed Search)
Posted: 2/14/2019 by Hong Kim, MD, MPH
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Physostigmine is a cholinergic agent that can be administered to reverse delirium associated with anticholinergic toxicity. However, it is infrequenly used since the reports of cardiac arrest in patients with TCA overdose.
A recently published study reviewed 161 articles – involving 2299 patients – to determine the adverse effects and their frequency after the administration of physostigmine.
Findings
Adverse effects were observed in 415 patients (18.1%)
Specific adverse effects
Of 394 TCA overdose, adverse effects occurred in 14 patients (3.6%)
Conclusion
Arens AM et al. Adverse effects of physostigmine. J Med Toxciol. Feb 11. doi: 10.1007/s13181-019-00697-z. [Epub ahead of print] Review.
Category: Toxicology
Keywords: Methylene Blue (PubMed Search)
Posted: 1/24/2019 by Kathy Prybys, DO
(Emailed: 1/31/2019)
(Updated: 1/31/2019)
Click here to contact Kathy Prybys, DO
Most clinicians are familiar with use of methylene blue for the treatment of methemoglobinemia, as a urinary analgesic, anti-infective, and anti-spasmodic agent, or for its use in endoscopy as a gastrointestinal dye, but this compound also has a role as a rescue antidote in life threatening poisonings causing refractory shock states and other shock states.
Bottom Line:
Methylene blue should be considered when standard treatment of distributive shock fails.
Methylene Blue for Distributive Shock: a Potential New Use of An Old Antidote. Jang DH, Nelson LS, Hoffman RS. J Med Toxicol. 2013;9(3):242-9.
Methylene blue used in treatment of refractory shock resulting from drug poisoning. Fischer J. Taori G. et al. Clin Toxicol 2014 Jan;52(1) 63-65.
Calcium channel antagonist and beta blocker overdoses: antidotes and adjunct therapies. Graudins A, Lee HM, Druda D. Br J Clin Pharmacol. 2016 Mar 81(3):453-61.
A Review of Methylene Blue Treatment for Cardiovascular Collapse. Lo A, Jean CY, et al. Journal of Emerg Med. May 2014. Vol 46 (6): 670-679.
A Systematic Analysis of methylene Blue for Drug-Induced Shock. Warrick BJ, Tataru AP, Smolinske S. Clin Toxicol 2016 Aug;54(7):547-55.
Category: Toxicology
Keywords: tramadol, seizure, risk factors (PubMed Search)
Posted: 1/24/2019 by Hong Kim, MD, MPH
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Therapeutic use or overdose of tramadol has been associated with seizure. However, it is unknown if there are any specific predisposing factor that increases a patient’s risk of seizure after tramadol use/overdose.
In a recently published study, eighty patient data with single ingestion of tramadol were reviewed.
Risk of seizure
Conclusion
In this small study, Asian patients and patients with abuse/misuse were at higher risk of developing seizure compared to patients who overdose tramadol.
Murray, BP et al. Seizures in tramadol overdoses reported in the ToxIC registry: predisposing factors and the role of naloxone. Clin Toxicol. 2018 DOI: 10.1080/15563650.2018.1547826
Category: Toxicology
Keywords: take home naloxone, opioid overdose (PubMed Search)
Posted: 1/10/2019 by Hong Kim, MD, MPH
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Take home naloxone (THN) programs have been expanded to help reduce the opioid overdose-related deaths. A study was done in Australia to characterize a cohort of heroin overdose deaths to examine if there was an opportunity for a bystander to intervene at the time of fatal overdose.
235 heroin-overdose deaths were investigated during a 2 year study period in Victoria, Australia.
Conclusion
Stam NC et al. Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia. Clin Toxicol 2018 Nov 17:1-6. doi: 10.1080/15563650.2018.1529319. [Epub ahead of print]
Category: Toxicology
Keywords: double-dose of single medication (PubMed Search)
Posted: 12/27/2018 by Hong Kim, MD, MPH
(Updated: 5/29/2023)
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Taking a double-dose of a single medication is presumed to be safe in most cases. However, there is limited data to support this assumption.
A retrospective study of the California Poison Control System was performed to assess adverse effects of taking double dose of a single medication. During a 10-year period, 876 cases of double-dose ingestion of single medication were identified.
Adverse effects were rare (12 cases). However, medication classes that were involved in severe adverse effects included:
Conclusion:
Correia MS et al. A 10-year review of single medication double-dose ingestions in the nation's largest poison control system. Clin Toxicol 2018 Nov 28:1-5. doi: 10.1080/15563650.2018.1493205. [Epub ahead of print]
Category: Toxicology
Keywords: Bupropion, TCAs, adolescents (PubMed Search)
Posted: 12/20/2018 by Hong Kim, MD, MPH
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Selective serotonin reuptake inhibitors are the most common anti-depressant used today. However, the use bupropion in adolescents is increasing due the belief that it has fewer side effects than TCAs.
Using the National Poison Data System (2013 – 2016), the adverse effects of bupropion were compared to TCA in adolescents (13 – 19 years old) with a history of overdose (self harm).
Common clinical effects were:
TCA: n=1496; Bupropion: n=2257
Clinical effects | TCAs | Bupropion |
Tachycardia | 59.9% | 70.7% |
Drowsiness/lethargy | 51.5% | 18.1% |
Conduction disturbance | 22.2% | 15.6% |
Agitation | 19.1% | 16.4% |
Hallucination/delusions | 4.2% | 23.9% |
Seizure | 3.9% | 30.7% |
Vomiting | 2.7% | 20.0% |
Tremor | 3.7% | 18.1% |
Hypotension | 2.7% | 8.0% |
Death | 0.3% | 0.3% |
Conclusion:
Bupropion overdose results in significant adverse effects in overdose; however, death is relatively rare.
Sheridan DC et al. Suicidal bupropion ingestions in adolescents: increased morbidity compared to other antidepressants. Clin Toxicol. 2018;56:360-364.
Category: Toxicology
Keywords: alcohol withdrawal syndrome, phenobarbital (PubMed Search)
Posted: 11/29/2018 by Hong Kim, MD, MPH
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Alcohol withdrawal syndrome is frequently treated with benzodiazepines following CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol scale). There are other medications that are used as either second line or as adjunctive agents along with benzodiazepines. A retrospective study compared the clinical outcomes between phenobarbital vs. benzodiazepines-based CIWA-Ar protocol to treat AWS.
The primary was ICU length of stay (LOS); secondary outcome were hospital LOS, intubation, and use of adjunctive pharmacotherapy.
Study sample: 60 received phenobarbital and 60 received lorazepam per CIWA-Ar.
Phenobarbital protocol:
Results
| Phenobarbital | CIWA-Ar |
ICU LOS | 2.4 days | 4.4 days |
Hospital LOS | 4.3 days | 6.9 days |
Intubation | 1 (2%) | 14 (23%) |
Adjunctive agent use | 4 (7%) | 17 (27%) |
Conclusion
Phenobarbital therapy appears to be a promising alternative therapy for AWS. However, additional studies are needed prior to adapting phenobarbital as first line agent for AWS management.
Tidwell WP et al. Treatment of alcohol withdrawal syndrome: phenobarbital vs. CIWA-Ar protocol. Am J Crit Care. 2018 Nov;27(6):454-460. PMID: 30385536.
Category: Toxicology
Keywords: hydrocarbon ingestion, pediatric poisoning (PubMed Search)
Posted: 11/9/2018 by Hong Kim, MD, MPH
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The management of pediatric hydrocarbon ingestion has not changed significantly over the past several decades. One of the earlier study that helped established the management approach is by Anas N et al. published in JAMA, 1981.
It was a retrospective study of 950 children who ingested household hydrocarbon containing products.
Discharged patients: n=800
Admitted patients: n=150
This study recommended that hospitalization is required in patients…
Anas N. et al. Criteria for hospitalizing children who have ingeted products containing hydrocarbons. JAMA 1981;246:840-843
Category: Toxicology
Keywords: Hyperemesis, Cannabinoid (PubMed Search)
Posted: 10/18/2018 by Kathy Prybys, DO
(Emailed: 10/19/2018)
(Updated: 10/19/2018)
Click here to contact Kathy Prybys, DO
CHS Treatment:
Bottom line: Patient education should be provided on the paradoxical and recurrent nature of the symptoms of CHS to discourage relapse of use often stemming from false preception of beneficial effects of cannabis on nausea.
Cannabinoid hyperemesis: a case series of 98 patients. Simonetto DA, Oxentenko AS, et al,Mayo Clin Proc. 2012;87(2):114–9
Cannabinoid hyperemesis syndrome: potential mechanisms for the benfit of capsaicin and hot water hydrotherapy in treatment. Richards JR, Lapoint JM, et al. Clin Tox(phila) 2018 Jan :56(1): 15-24.
Cannabinoid Hyperemesis Syndrome: Public Health Implications and Novel Model Treatment Guidelines. West J Emerg Med. 2018 Mar:19(2):380-386.
Category: Toxicology
Keywords: Anticholinergic, Plant (PubMed Search)
Posted: 9/20/2018 by Kathy Prybys, DO
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A 19 year old male presents confused and very agitated complaining of seeing things and stomach pain. His friends report he ingested a naturally occurring plant to get high a few hours ago but is having a "bad trip". His physical exam :
Temp 100.3, HR 120, RR 14, BP 130/88. Pulse Ox 98%.
Skin: Dry, hot , flushed
HEENT: Marked mydriasis 6mm
Lungs: Clear
Heart: Tachycardic
Abdomen: Distended tender suprapubic with absent bowel sounds,
Neuro: Extremely agitated pacing, no muscular rigidity.
What has he ingested and what is the treatment?
Datura stramonium, aka: Jimson Weed, flowers in the summer with white to violet trumpet petals, green irregular toothed leaves, and a green thorny round walnut sized seed pod (aka: thorn apple) the base of the stem. In the fall, the seed pods turn brown and split open to reveal chambers that are packed with dozens of small black seeds containing the anticholinergic tropane alkaloids, atropine, hyoscyamine, and scopolamine.
All parts of the plant are toxic and it has long been used in traditional medicine. Toxicity consists of anticholinergic toxidrome: Delirium and agitation, visual hallucinations, dry flushed skin, hyperthermia, mydriaisis, tachycardia, absent bowel sounds, urinary retention, remembered by the pneumonic "Red as a beet, hot as a hare, dry as a bone, blind as a bat, mad as a hatter, the bowel and bladder lose their tone, and the heart runs alone" . Toxicity is usually 12 hours but can be quite prolonged.
Treatment consists of :
-Gastric decontamination with activated charcoal and whole bowel irrigation for seed ingestion (seeds get caught up in gastric folds prolonging toxicity)
-IV Physostigmine, a reversible short acting acetylcholinesterase inhibitor increases acetylcholine at the synaptic clef, crosses the blood brain barrier, and is antidotal. Physostigmine has been demonstrated to be more effective and without significant complications when compared with benzodiazepines for the diagnosis and treatment of anticholinergic agitation and delirium. Usual dose is 0.5-2 mg with repeat dosages as needed.
Category: Toxicology
Keywords: anaphylactoid reaction, IV NAC (PubMed Search)
Posted: 9/13/2018 by Hong Kim, MD, MPH
(Emailed: 9/14/2018)
Click here to contact Hong Kim, MD, MPH
Analphylatoid reaction is caused by non-IgE mediated histamine released. Intravenous N-acetylcysteine (NAC) infusion is well known to cause analphylatoid reaction. However, it’s incidence is unknown.
Recently, a large retrospective study of all patients who received 21-hour IV NAC in 34 Canadian hospitals (1980 to 2005) was performed.
Anaphylactoid reaction was documented in 528 (8.2%) of 6455 treatment courses
Over 90% patients developed analphylatoid reaction within 5 hours.
Onset of reaction:
Administered medication for treatment
Patient characteristics that were associated with higher incidence of Anaphylactoid reaction includes
Bottom line
Yarema M et al. Anaphylactoid reactions to intravenous N-acetylcysteine during treatment for acetaminophen poisoning. J Med Toxicol 2018: Jun;14(2):120-127. doi: 10.1007/s13181-018-0653-9. Epub 2018 Feb 8.
Category: Toxicology
Keywords: Weakness (PubMed Search)
Posted: 8/2/2018 by Kathy Prybys, DO
(Emailed: 8/31/2018)
(Updated: 8/31/2018)
Click here to contact Kathy Prybys, DO
A 68 year old male presents to the ED complaining of weakness to his legs. He states today his yard chores took him over 2 hours to complete instead of the usual 15-20 minutes due need to take frequent breaks for rest due to leg pain. He denied any chest pain or shortness of breath. Past medical history included hypercholesteremia, HTN, and CAD. He is taking aspirin and recently started on rosuvastatin.
His physical exam was unremarkable.
Results showed normal EKG and CBC. Bun was 70, Creatinine was 3.4, and CPK of 1025.
This patient has statin induced rhabdomyolysis and acute renal failure.
Take Home Points: