UMEM Educational Pearls - Toxicology

Category: Toxicology

Title: Bupropion overdose in adolescents

Keywords: Bupropion, TCAs, adolescents (PubMed Search)

Posted: 12/20/2018 by Hong Kim, MD
Click here to contact Hong Kim, MD

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.

 

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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:

  • Active DT: 260 mg IV x 1 dose -> 97.2 mg PO TID x 6 doses -> 64.8 mg PO TID x 6 doses -> 32.4 mg PO TID x 6 doses
  • History of DT: 97.2 mg PO TID x 6 doses -> 64.8 mg PO TID x 6 doses -> 32.4 mg PO TID x 6 doses
  • No history of DT: 64.8 mg PO TID x 6 dose -> 32.4 mg PO TID x 6 doses.

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. 

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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

  • They asymptomatic at their initial presentation and after 6-8 hours of observation.
  • All had normal CXR

 

Admitted patients: n=150

  • 79 symptomatic patients at the time of initial evaluation with abnormal CXR.
  • 71 patients were asymptomatic but CXR showed pulmonary involvement/pneumonitis or had pulmonary symptoms prior to hospital presentation
  • 7 symptomatic patients developed pneumonia

 

This study recommended that hospitalization is required in patients…

  1. Who are symptomatic at the time of initial evaluation
  2. Who become symptomatic during the 6-8 hour observation period.

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Category: Toxicology

Title: Hyperemesis Cannabinoid Syndrome

Keywords: Hyperemesis, Cannabinoid (PubMed Search)

Posted: 10/18/2018 by Kathy Prybys, MD (Emailed: 10/19/2018) (Updated: 10/19/2018)
Click here to contact Kathy Prybys, MD

Despite the well established antiemetic properties of marijuana, Cannabinoid Hyperemesis Syndrome (CHS) is a distinct under recognized syndrome characterized by severe cyclic vomiting and refractory abdominal pain. CHS can be divided into three phases with varying time lags: pre-emetic or prodromal, hyperemetic, and recovery phase. The hyperemetic phase consists of paroxsyms of overwhelming incapacitating nausea and vomiting.The underlying mechanism of the hyperemesis in CHS is not well understood but appears to be associated with cummulative and toxic effects of Δ9-tetrahydrocannabinol (Δ9-THC) in predisposed patients.
 
Diagnostic criteria include:
  • History of regular cannabis use at least weekly for any duration of time.
  • Compulsive hot water bathing multiple times per day for symptom relief which is mediated by the TRPV capsaicin receptors.
  • Resolution of symptoms with cannabis cessation.
  • Prior nonrevealing extensive diagnostic work up.

 

CHS Treatment:

  • Definitive and most effective treatment is to stop cannabinoid use which provides complete relief within 7–10 days.
  • Temporary relief occurs with hot water bathing, Capsaicin topical cream, Haldol administration, and fluid resuscitation.

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. 

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Category: Toxicology

Title: A Bad Natural "High"

Keywords: Anticholinergic, Plant (PubMed Search)

Posted: 9/20/2018 by Kathy Prybys, MD
Click here to contact Kathy Prybys, MD

Question

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?

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Category: Toxicology

Title: Anaphylatoid reaction to IV N-acetylcysteine

Keywords: anaphylactoid reaction, IV NAC (PubMed Search)

Posted: 9/13/2018 by Hong Kim, MD (Emailed: 9/14/2018)
Click here to contact Hong Kim, MD

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

  • Cutaneous reaction (urticarial, pruritus and angioedema) occurred in 398 (75.4%)
  • Systemic reaction (respiratory symptoms or hypotension): 34 (6.4%)
  • Both reactions: 96 (18.2%)

Over 90% patients developed analphylatoid reaction within 5 hours.

Onset of reaction: 

  • 1stNAC dosing (150 mg/kg over 1 hour): 133/528
  • 2ndNAC dosing (50 mg/kg over 4 hours): 371/528
  • 3rdNAC dosing (100 mg/kg over 16 hours): 24/528

Administered medication for treatment

  • Antihistamine: 371
  • Beta-2 agonist: 15
  • Epinephrine: 10
  • Corticosteroids: 7

Patient characteristics that were associated with higher incidence of Anaphylactoid reaction includes

  • Female
  • Single acute ingestion
  • Low serum acetaminophen level.

 

Bottom line

  1. Anaphylactoid reaction to NAC is uncommon
  2. Cutaneous symptoms are most common
  3. Female, single acute ingestion and low serum acetaminophen levels are associated with incidence of anaphylactoid reaction. 

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Category: Toxicology

Title: Muscle weakness

Keywords: Weakness (PubMed Search)

Posted: 8/2/2018 by Kathy Prybys, MD (Emailed: 8/31/2018) (Updated: 8/31/2018)
Click here to contact Kathy Prybys, MD

Question

 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:

  • Rhabdomyolysis is characterized by muscle necrosis which causes the release of myoglobin into the bloodstream.
  • Clinical manifestations can range from asymptomatic elevation of CPK to life-threatening cases with extremely high CPK levels, electrolyte imbalance, and acute renal failure.
  • Classic triad is: muscle aches and pains, weakness, and tea-colored urine.
  • Numerous recreational drugs, pharmaceuticals, and toxins can alter myocyte function. Ethanol, statins, and cocaine in particular have high risk to cause rhabdomyolysis.
  • 50% of cases of statin-induced-rhabdomyolysis were due to drug interactions.

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Various intial doses of naloxone (0.4 to 2 mg) are administered to reverse the signs and symptoms of opioid toxicity. However, there is limited data regarding the duration of action of naloxone is correlated to the administered dose.

A recently published retrospective study investigated whether initial naloxone doses (IV), low-dose (0.4 mg) vs. high-dose (1-2 mg), lead to different time to recurrence of opioid toxicity.

 

Study sample: 274 patient screened but 84 patients were included.

  1. Low-dose naloxone (0.4 mg IV): 42
    • Mean age: 50
    • History of opiod/heroin use: 33 (78.6%)
    • Positive opioid/opiate on drug screening: 27 (64%)
    • Median time to repeat naloxone dose: 72 min (IQR: 46 - 139)
    • 12 patients (29%) required continuous naloxone infusion

 

  1. High-dose naloxone (1 - 2 mg IV): 42
  • Mean age: 48
  • History of opiod/heron use: 32 (76.2%)
  • Positive opioid/opiate on drug screening: 26 (62%)
  • Median time to repeat naloxone dose: 77 min (IQR: 44 - 126)
  • 17 patients (41%) required continuous naloxone infusion

Higher rate of adverse effects (withdrawal symptoms - vomiting, agitation, tachycardia, etc.) were observed in high-dose group (41% vs. 31%) but this was not statistically signficant. 

Conclusion:

  1. High-dose naloxone (1 - 2 mg) does not result in longer duration of reversal of opioid toxicity.
  2. Duration of opioid toxicity reversal by naloxone administration were similar to previously reported duration of action of naloxone (30 to 90 min).
  3. Note: there are several lmitations to the study study including retrospective design - documentation issues, small sample size, patient selection - patients were included if positive response to naloxone was observed, unknown opioid exposure, variable dosing in high-dose group (1 to 2 mg vs. 0.4 mg) and naloxone was given via IV only.   

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Category: Toxicology

Title: Can transaminase and CK ratio help differentiate rhabdomyolysis vs. delayed acetaminophen overdose?

Keywords: transaminitis, delayed acetaminophen toxicity, rhabdomyolysis (PubMed Search)

Posted: 7/26/2018 by Hong Kim, MD (Updated: 7/22/2024)
Click here to contact Hong Kim, MD

Elevated transaminases are found in both rhabdomyolysis and delayed acetaminophen (APAP) toxicity. Establishing the cause of elevated transaminase can be difficult when there is unclear history of acetaminophen ingestion.

A retrospective study of patients with delayed acetaminophen toxicity or rhabdomyolysis from 2006 to 2011 was recently published.

The authors compared AST/ALT, CK/AST and CK/ALT ratio of 

  • 160 in the rhabdomyolysis group
  • 68 in the acetaminophen overdose (all)
  • 29 in the delayed acetaminophen overdose group

Results

AST/ALT ratio

  • Rhabdomyolysis group: 1.66
  • APAP overdose (all): 1.38
  • Delayed APAP overdose: 1.3

CK/AST ratio

  • Rhabdomyolysis group: 21.3
  • APAP overdose (all): 5.49
  • Delayed APAP overdose: 3.8

CK/ALT ratio

  • Rhabdomyolysis group: 37.1
  • APAP overdose (all): 5.77
  • Delayed APAP overdose: 5.03

Conclusion

  • Significantly higher ratio of AST/ALT, CK/AST and CK/ALT were found in rhabdomyolysis patients than delayed APAP overdose patients.
  • These finding are based on small study population and need further validation/research before clinical application.


Category: Toxicology

Title: Octreotide use for Sulfonylurea Poisoning

Keywords: Sulfonylureas, Octreotide (PubMed Search)

Posted: 7/19/2018 by Kathy Prybys, MD
Click here to contact Kathy Prybys, MD

Sulfonylureas are commonly used oral hypoglycemic agents for type II diabetes. Agents on the market include glipizide (Glucotrol), glyburide (Micronase, Glynase, Dibeta) and glymepiride (Amaryl). These agents exert their effect by stimulation of insulin release from the pancreatic beta islet cells. Following overdose, hypoglycemia is usually seen within a few hours of ingestion and can be prolonged and profound. First line treatment for rapid correction of severe hypoglycemia is administration of an intravenous bolus of concentrated dextrose. However, use of dextrose infusion in attempt to maintain euglycemia is problematic as it can cause further release of insulin and rebound hypoglycemia. Octreotide ia a long acting synthetic somatostain analogue, blocks insulin secretion and has been shown to prevent recurrence of hypogylcemia better than placebo.

Bottom Line:

  • Octreotide is the antidote of choice for sulfonylurea poisoning. Its use greatly simplifies management by avoiding the need for a central line, prolonged ICU admit, and frequent monitoring.
  • Bolus 50 μg IV followed by an infusion of 25–50μg/h or give100 mcg subcutaneously with additional doses at 6-12 hour intervals for recurrent hypoglycemia. Octreotide has similar bioavailability by SC and IV route. It's duration of action can extend from 6 to 12 hours with SC use.
  • After stopping Octreotide monitor for 12-24 hours for rebound hypoglycemia.

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Category: Toxicology

Title: Utility of physostigmine in antimuscarinic delirium

Keywords: antimuscarinic/anticholinergic toxicity, reversal of delirium (PubMed Search)

Posted: 7/12/2018 by Hong Kim, MD
Click here to contact Hong Kim, MD

From 1960s to 1970s, physostigmine was routinely administered as part of the "coma cocktail." Since the publication of two cases by Pentel (1980) that resulted in asystole after administration of physostigmine in TCA poisoned patient, its use has declined significantly.

However, physostigmine still possess limited but clinically useful role in the management of patients with antimuscarinic/anticholinergic induced delirium.

Recently, a prospective observational study was performed in the use of physostigmine when recommended by a regional poison center.

In 1 year study period, physostigmine was recommended by a regional poison center in 125 of 154 patients with suspected antimuscarinic/anticholinergic toxicity. 

common exposures were

  1. antihistamines (68%)
  2. analgesics (19%)
  3. antipsychotics (19%)

57 of 125 patients received physostigmine per treating team.

  • median dose of physostigmine administered: 2 mg

Of the remaining patients,

  • 35 patients did not receive any sedative agents
  • 55 received benzodiazepines (56%)
  • others received propofol (n=10), haloperidol (n=8), olanzapine (n=4), dexmedetomidine (n=3), etc.

Delirium control

  • Physostigmine group 79% (45 of 57)
  • No-physostigmine group: 36% (35 of 97)

Adverse events (physostigmine group vs. non-physo group) - no statistically significant difference.

  • Intubation (n=7): 2 (3.5%) vs. 5 (5.2%)
  • physical restraints (n=10): 3 (5.3%) vs. 7 (7.2%)
  • vomiting (n=4): 3 (5.3%) vs. 1 (1.0%)

Conclusion:

Physostigmine can safely control antimuscarinic/anticholinergic-induced delirium.

 

 

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Category: Toxicology

Title: Midazolam for agitated patients

Keywords: acute agitation, midazolam, antipsychotics, (PubMed Search)

Posted: 6/14/2018 by Hong Kim, MD (Updated: 7/22/2024)
Click here to contact Hong Kim, MD

Acutely agitated patients in the emegency room receive single or combination of benzodiazepine (lorazepam vs. midazolam) and antipsychotic (e.g. haloperidol) agents. Recently, use of ketamine has also been advocated to sedate agitated patients.

 

A recently published article compared IM administration several medications to treat acutely agitated patients in the ED. According to established protocol, each medication was administered in predetermined 3 week blocks:

  1. Haloperidol (5 mg)
  2. Ziprasidone (20 mg)
  3. Olanzapine (10 mg)
  4. Midazolam (5 mg)
  5. Haloperidol (10 mg)

Results

N=737 with median age of 40 years, 72% men.

Midazolam resulted in greater proportion of patients with "adequate" sedation (altered mentatl status scale <1) compared to antipsychotics at 15 min post administration. Among antipsychotics, olanzapine resulted in greater proportion of patient with sedation. 

  • Midazolam (71%)
  • Haloperidol - 5 mg (40%)
  • Haloperidol - 10 mg (42%)
  • Olanzapine (61%)
  • ziprasidone (52%)

Adverse effect were limited

  • extrapyramidal AE: 0.3%
  • hypotension 0.5%
  • hypoxemia 1%
  • intubation 0.5%

Conclusion:

Midazolam 5 mg IM achieve more effective sedation at 15 min in agitated ED patients than antipsychotics.

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Category: Toxicology

Title: Methylene Blue for Poisoning

Keywords: Methylene Blue (PubMed Search)

Posted: 5/17/2018 by Kathy Prybys, MD (Emailed: 5/18/2018) (Updated: 5/18/2018)
Click here to contact Kathy Prybys, MD

Methylene Blue is a dye that was synthesized in the late 1800s as an antimalarial drug. After the emergence of chloroquine its use loss favor partly due to unpopular side effects of temporarily turning the urine, other body fluids, and the sclera blue. Methylene blue is primarily known as a highly effective fast acting antidote for methemboglobinemia. Over the past few years, it has become an important therapeutic modality with expanding uses in cardiac surgery and critical care.  As a potent inhibitor of nitric oxide mediated guanylate cyclase induced endothelium vascular smooth muscle relaxation, it has been shown to be effective in increasing arterial blood pressure and cardiac function in several clinical states, such as septic shock and calcium channel blocker poisoning.

 

BOTTOM LINE:

  • Methylene blue should be considered for treatment of refractory shock from calcium channel and beta blocker poisoning.

  • Clinical improvement in refractory hypotension and reduction of vasopressor dose has been described in several poisoning cases. 

  • Recommended dose is 1–2 mg/kg injection with effects seen within 1 hour.

 

 

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Category: Toxicology

Title: Here comes the adexanet alfa!

Keywords: Factor Xa inhibitor, reversal agent, adexanet alfa, andexxa (PubMed Search)

Posted: 5/4/2018 by Hong Kim, MD (Emailed: 5/11/2018) (Updated: 5/11/2018)
Click here to contact Hong Kim, MD

On May 3, the FDA approved adexanet alfa, the reversal agent for factor Xa inhibitors - apixaban and rivaroxaban. It received both U.S. Orphan Drug and FDA Breakthrough Therapy designations. 

Unlike indarucizumab (a monoclonal antibody fragment) to reverse dabigatran (direct thrombin inhibitor) associated bleeding, adexanet alfa is a recombinant modified human factor Xa decoy protein. 

A phase 3 study showed that adexanet alfa decreased the anti-factor Xa activity of rivaroxaban by 92% from baseline and by 94% in apixaban treated participants.

ANNEXA-4 study involving participants with acute major bleeding (GI and intracranial) showed a significant decrease in the anti-factor Xa activity after the bolus dose of adexanet alfa and "effective" hemostasis was noted in 79% of the participants at 12 hours post infusion.

Andexanet alfa is expected to become available in June 2018.

 



Despite initial excitement for the use of intravenous lipid emulsion (ILE) therapy as an antidote for serious poisonings due to lipohphilic drugs there remains an absence of evidence combined with an incomplete understanding of its efficacy, mechanisms of action, safety, and analytical interferences to recommend its use except in a few clinical scenarios.

The lipid emulsion workgroup performed a comprehensive analysis of four systematic reviews and based recommendations from consensus of expert panelists from the American Academy of Clinical Toxicology, the European Association of Poison Centres and Clinical Toxicologists, the American College of Medical Toxicology, the Asia Pacific Association of Medical Toxicology, the American Association of Poison Control Centers, and the Canadian Association of Poison Control Centers. Toxins evaluated had to have a minimum of three human cases reported in the literature.They concluded that ILE could be indicated for the following clinical situations:

  •  In Bupivacaine poisoning resulting in cardiac arrest or life threatening toxicity (dysrhythmias, VTach  with compromised organ perfusion, VFib, status epilepticus, and/or hypotension with organ compromise defined as  increased lactate concentration, acute kidney injury, increased troponin, altered mental status, or decreased capillary refill) ILE is recommended after standard ACLS is started  and if other therapies fail or as last resort.
  • In life-threatening toxicity due to other local anesthetics,  ILE recommended if other therapies fail/in last resort
  • In cardiac arrest due to toxicity from Amitriptyline (or other tricyclic antidepressants), lipid soluble and non-lipid soluble Beta-receptor antagonists,  Bupropion, Calcium channel blockers (diltiazem, verapamil and dfihydropyridines), Cocaine, Diphenhydramine, Lamotrigine,  Baclofen, Ivermectin and other Insecticides, Malathion and other Pesticides, Olanzapine and other Antipsychotics, and SSRIs.
  • Most common regimen of ILE was a bolus of 1.5 mL/kg of ILE 20% followed by infusion of 0.25 mL/kg/min
  • The use of ILE with extracorpeal membrane oxygenation may cause fat deposition in the circuit and increase blood clot formation causing malfunction and limitation of use of this potentially life saving modality. This should be considered if VA-ECMO is a treatment option.

 

The Bottom Line:

The use of Intravenous Lipid Emulsion in severe poisoning is recommended only for a few poisoning scenarios and was based on very low quality of evidence, and consideration of risks and benefits, adverse effects, laboratory interferences as well as related costs and resources.

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Category: Toxicology

Title: When can we discharge a suspected fentanyl overdose ED patient?

Keywords: fentanyl overdose, observation period (PubMed Search)

Posted: 4/26/2018 by Hong Kim, MD
Click here to contact Hong Kim, MD

Non-pharmaceutical fentanyl (NPF) is a major contributor to opioid overdoses and overdose fatality. In certain urban areas such as Vancouver, over 80% of heroin samples contain NPF.  For isolated heroin overdose ED patients, they can be safely discharged after brief observation period (~2 hours). However,  “safe” observation time for fentanyl is unknown.

Recently, a retrospective study evaluating the safe observation period in 1009 suspected (uncomplicated) fentanyl overdose ED visits (827 unique patients).

Results:

 In the field:

  • 476 (47.1%) received bystander naloxone
    • 422 (44.1%) had field GCS of 15
    • 547 (57.2%) had pulse oximetry of >= 95%.
  •  EMS administered naloxone to 546 (57.1%) patients (mean dose 0.4 mg IV)

In the ED:

  • 16 patients received additional naloxone in the ED
  • Mean length of stay: 173 minutes (IQR: 101 to 267 minutes)
  • 90% of the patients were discharged within 380 minute.
  • One patient was admitted and one patient died after discharge within 24 hours.

Conclusion:

  • Majority of the patients were safely discharged after 3 - 4 hours after receiving naloxone and if able to maintain GCS 15 with oxygen level 95% while able to ambulate normally.
  • However, some patient may require up to 6 hours of observation.  

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Category: Toxicology

Title: Toxic Bradycardias

Posted: 4/19/2018 by Kathy Prybys, MD (Emailed: 4/20/2018) (Updated: 4/20/2018)
Click here to contact Kathy Prybys, MD

Bradycardias caused by poisoning are due to the toxin's effects on cardiovascular receptors and cellular channels and transport mechanisms and are often refractory to standard ACLS drugs. The most common drug classes responsible for bradycardias are calcium channel and beta blockers and digoxin (cardiac glycosides). Sodium channel blockers, clonidine, and opiates also can cause bradycardias. Antidotes are as follows:

  • Glucagon 5-10mg IV bolus followed by 1-5 mg/hr (Always pretreat with antiemetic) - Beta Blockers
  • Calcium infusion 1-3 grams IV Bolus - Calcium Channel Blockers
  • High Dose Insulin Euglycemic therapy of reg insulin 0.5-2 unit/kg Bolus (ie. 100 Units) with D50 IV bolus followed by reg insulin 0.5-1 units/kg/hr and dextrose 0.5 grams/kg/hr - Calcium channel and Beta Blockers
  • **Intravenous Lipid Emulsion therapy bolus 1.5 mL/kg of ILE 20% followed by an infusion of 0.25 mL/kg/min-  Very small subset of toxins. See below.
  • Atropine 2mg IV - Acetylcholinestrase inhibitors (Organophosphates)
  • Sodium Bicarbonate 1-3 amps IV - Sodium Channel Blockers
  • Digibind  for acute toxicity10 vials IV (20 Vials in cardiac arrest) and for chronic toxicity 2 vials and repeat as needed - Cardiac gylcosides
  • Narcan 2 mg IV repeat boluses up to 10 mg- Opiates and Clonidine

** ILE is recommended only in life threatening poisonings where other accepted therapies have been use first or in cardiac arrest clinical scenarios. 

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Category: Toxicology

Title: Sometimes more is better: naloxone and clonidine toxicity.

Keywords: clonidine toxicity, high-dose naloxone (PubMed Search)

Posted: 3/18/2018 by Hong Kim, MD (Emailed: 4/12/2018) (Updated: 7/22/2024)
Click here to contact Hong Kim, MD

Clonidine, (central alpha-2 receptor agonist) can produce opioid-like toxidrome in addition to its cardiac effects (bradycardia and hypotension). Previous studies have shown that naloxone has variable (~40%) success in reversing CNS/respiratory depression and cardiac effect.

A recent retrospective study (n=51) of pediatric poisoning showed that administration of 5 to 10 mg had improved reversal of clonidine toxicity.

Total of 51 somnolent patients: 5- 10 mg of naloxone reversed 40 patients

  • 22 patients awoke with 6 mg or less
  • Bradycardia reversed in 17 of 44 patients
  • Hypotension reversed in 7 of 11 patients

There was no adverse effect from naloxone administration.

Repeat administration of naloxone was required in some patients.

Bottom line

  • For pediatric clonidine toxicity, consider initial naloxone dose of 5 mg IV. 

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Category: Toxicology

Title: Why is the synthetic cannabinoid use making my patient bleed? - submitted by James Leonard

Keywords: adulterated synthetic cannabinoid, elevated INR, brodifacoum (PubMed Search)

Posted: 4/4/2018 by Hong Kim, MD
Click here to contact Hong Kim, MD

Question

In the past couple of weeks, there have been reports from Illinois about patients using adulterated synthetic cannabinoids, resulting in elevated INR and bleeding. To date, there are approximately 70 cases including 3 fatalities. Brodifacoum, a long-acting vitamin K mediated anticoagulant (similar to warfarin) has been identified in 10 cases. Brodifacoum is frequently used as rodenticide.

This week, Maryland Poison Center received our first notification of a patient with bleeding and elevated INR due to suspected adulterated synthetic cannabinoid use.

When evaluating our patient population:

  • Ask about synthetic cannabinoid use in patients with unexplained bleeding and elevated INR
  • Carefully examine patients with synthetic cannabinoid intoxication for any signs of bleeding, bruising or petechiae.  
     

Patient management of suspected cases:

  • ACTIVELY bleeding:
    • Fresh frozen plasma
    • Activated prothrombin complex concentrate (KCentra®) in life threatening bleeding.
    • Vitamin K 10 mg IV
    • *** Start oral vitamin K at 50 mg TID and titrate to goal INR < 2 ***
  • NOT bleeding and INR < 10: vitamin K 50 mg PO BID with titration if needed.
  • NOT bleeding and INR > 10: vitamin K 50 mg PO TID with titration if needed.

Patient can be discharged when INR < 2 is achieved with oral vitamine K regimen only (without recent FFP infusion).

Review of published cases highlights that most patients are started on a median doses of 100 mg/day (range: 15 - 600 mg) and stabilize on a PO regimen of 50-100 mg/day. Prolonged PO vitamin K course of 2 – 3 months or longer should be anticipated.

Pease call the Maryland Poison Center at 1-800-222-1222 as we are working with the Maryland Department of Health and CDC to track these cases. 

 

 

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Category: Toxicology

Title: The Russian connection 2.0 -- Sergei Skripal

Keywords: nerve agents, organophosphate compounds (PubMed Search)

Posted: 3/18/2018 by Hong Kim, MD (Emailed: 3/21/2018) (Updated: 3/21/2018)
Click here to contact Hong Kim, MD

Recently, an ex-Russian spy and his daughter were poisoned in Salisbury, England using a Soviet nerve agent called Novichok. He joins a list of defectors and ex-spies who's poisoning have been connected to Russia.

Nerve agents are organophosphate compounds, similar to the commercially available pesticides, but significantly more potent. Nerve agents such as VX take seconds to minutes to irreversibly inhibit acetylcholinesterase by “aging” and result in clinical toxicity. 

Signs and symptoms

  • Muscarinic: DUMBELS or SLUDGE and Killer B's
  • Nicotinic: muscle weakness & paralysis

Treatment

  • Decontamination
  • Atropine – 2 mg IV and double the dose every 3 – 5 minutes until clearing of bronchorrhea, bronchospasm and bradycardia
  • Pralidoxime – reverses inhibition of acetylcholinesterases that are not aged