Keywords: salicylate poisoning, endotracheal intubation, hemodialysis (PubMed Search)
Patients with severe salicylate poisoning may require endotracheal intubation due to fatigue from hyperventilation or mental status change.
A previously published study (Stolbach et al. 2008) showed that mechanical ventilation increases the risk of acidemia and clinical deterioration.
A small retrospective study investigated the impact of hemodialysis (HD) in intubated patients with salicylate poisoning.
53 cases with overall survival rate of 73.2%
In patients with salicylate level > 50 mg/dL
If salicylate level > 80 mg/dL
There is moratality benefit of HD in intubated salicylate-poisoned patient.
McCabe DJ, Lu JJ. The association of hemodialysis and survival in intuated salicylate-poisoned patients. Amer J Emerg Med 2017;35:899-903.
Stolbach QI, Hoffman RS, Nelson LS. Mechanical ventilation was associated with acidemia in a case series of salicylate-poisoned patients. Acad Emerge Med 2008;15;866-869.
Keywords: Vaginal pearls, intravaginal foreign bodies (PubMed Search)
Vaginal douching is a common and potentially dangerous practice. Women engage in this practice predominately for personal hygiene reasons but also with the false belief it will prevent or treat infections and for contraception. Numerous public health agencies and medical societies discourage douching as it has been associated with many adverse outcomes including pelvic inflammatory disease, bacterial vaginosis, cervical cancer, low birth weight, preterm birth, human immunodeficiency virus transmission, sexually transmitted diseases, ectopic pregnancy, recurrent vulvovaginal candidiasis, and infertility.
An increasing fad is the use of intravaginal detox products. Claiming to enhance female health by removing toxins, these mesh cloth-covered balls containing herbs such as mothersworth, osthol, angelica, borneol, and rhizoma, not FDA-approved, are inserted into the vagina for 3 days. Clinical experience demonstrates these products decompose into numerous pieces which become scattered retained intravaginal foreign bodies, cause mucosal irritation, and thereotically could serve as a nidus for serious infections.
Keywords: hydrogen peroxide (PubMed Search)
Hydrogen peroxide (H2O2) is a common household liquid that is used for wound irrigation/antiseptic and cosmetic purposes. The concentration of household product is 3% to 5% and is considered to be relatively safe except in large volume ingestion.
High-concentration H2O2 (>10%) is commercially available as “food grade” (35%) that is diluted for household use or for alternative medicine therapy (i.e. hyperoxygenation).
Ingestion of high-concentration of H2O2 can result in caustic injury as well as ischemic injury from gas embolism.
Ingestion of 1 mL of 3% H2O2 produces 10 mL of O2 gas while 1 mL of 35% H2O2 produces 115 mL of O2 gas.
Common symptoms/findings of H2O2 ingestions includes:
A retrospective review of >10% H2O2 ingestion from National Poison Data System showed:
Hatten BW et al. Outcomes after high-concentration peroxide ingestions. Ann Emerg Med. 2017;69:726-736.
Keywords: Antidepressants (PubMed Search)
Keywords: Lactrodectus (PubMed Search)
Black widow spiders belong to the genus Latro dectus which include 31 species of widow spiders found throughout world. Approximately 1500-2500 black widow bites are reported to American poison control centers annually. A black widow can be identified by their hourglass pattern (red or orange) on the ventral aspect of their shiny globular abdomen. Fortunately, envenomation is rare but when it does occur it causes severe pain, muscle cramping, abdominal (may mimic acute abdomen) often refractory to traditional analgesics and antivenom (Antivenin Latrodectus mactans) is available and effective . Alpha-latrotoxin is the potent toxin causing presynaptic cation channels to open (calcium) and release of neurotransmitters such acetycholine. The neurological signs and symptoms caused by predominantly autonomic and include tachycardia and hypertension. The antivenom is equine based and infused over 20-30 minutes with pain relief in 20 minutes.
Neurotoxic manifestations of black widow spider envenomation in pediatric patients. Sotelo-Cruz N, Gómez-Rivera N. Neurologia. 2016 May;31(4):215-22.
The Black Widow spider bite: differential, clinical manifestations, and treatment options. Shackleford R, Veillon D, Maxwell N, LaChance L, Jusino T, Cotelingam J, Carrington P. J La State Med Soc. 2015 Mar-Apr;167(2):74-8.
Keywords: drugs of abuse, street name (PubMed Search)
Street names for illicit substance are diverse and unique. Knowing what your patient used prior to ED presentation can help with the management of their intoxication.
DEA recently released 7 page list of common street names for drugs of abuse.
But keep in mind that what our patients purchase and use may not actually contain the drug that they intended to purchase (e.g. fentanyl being sold as heroin).
Keywords: foodborne botulism (PubMed Search)
Botulism is a rare neurologic condition characterized by GI symptoms that progressed to cranial nerve dysfunction and symmetric descending paralysis. Foodborne botulism is due to ingestion of botulinum toxin that is produced by clostridium botulinum, an ubiquitous bacterium in our environment.
Maryland Department of Health and Mental Hygiene
CDC Emergency Operations Center: 770-488-7100
Foodborne botulism is characterized by
Keywords: Dextromethorphan, Robotripping (PubMed Search)
Dextromethorphan Abuse in Adolescence. Bryner JK, Wang K, et al. Archives of Pediatrics & Adolescent Medicine. 2006;160(12):1217-1222. doi:10.1001/archpedi.160.12.1217.
Dextromethorphan abuse. Antoniou T, Juurlink DN. CMAJ?: Canadian Medical Association Journal. 2014;186(16):E631. doi:10.1503/cmaj.131676.
Keywords: lactic acidosis (PubMed Search)
Lactic acids are often elevated in critical care patients (e.g. septic shock). It can be also elevated in setting of drug overdose or less frequently in therapeutic use due to interference of oxidative phosphorylation. Some of the agents include:
Kraut JA, Madias NE. Lactic acidosis, N Engl J Med 2014;371:2309-19.
Keywords: sodium bicarbonate, sodium acetate (PubMed Search)
FDA announced a shortage of sodium bicarbonate on 3/01/17. Sodium bicarbonate is frequently used in acid-base disorder as well as in poisoning (cardiac toxicity from Na-channel blockade, e.g. TCA & bupropion, and salicylate poisoning).
Acetate is a conjugate base of acetic acid where acetate anion forms acetyl CoA and enters Kreb cycle after IV administration. Final metabolic products of acetate are CO2 and H2O, which are in equilibrium with bicarbonate via carbonic anhydrase activity.
Administration of sodium acetate increases the strong ion difference by net increase in cations, as acetate is metabolize, and leads to alkalemia.
Adverse events from sodium acetate infusion have been associated with its use as dialysate buffer: myocardial depression, hypotension, hypopnea leading to hypoxemia and hyperpyrexia. However, such adverse events have not been reported in toxicologic application.
Sodium acetate can be administered safely in place of sodium bicarbonate if sodium bicarbonate is not available due to shortage.
Sodium acetate dose:
Neavyn MJ, Boyer EW, Bird SB, et al. Sodium acetate as a replacement for sodium bicarbonate in medical toxicology: a review. J Med Toxicol 2013;9:250-254.
Keywords: Pediatric poisoning, household , fatalities (PubMed Search)
Children less than 5 years of age account for the majority of poisoning exposures in the United States. As expected, accessible household items are the most frequently reported exposures and include cosmetics and personal care products, household cleaning substances, medications, and foreign bodies. Opioids are responsible for the highest incidence of hospitalizations followed by benzodiazepines, sulfonylureas, and cardiovascular drugs (beta & calcium channel blockers, and centrally acting antiadrenergic agents). Rise in buprenorphine use has led to significant increases in pediatric exposures. The most common sources of prescription medications were pills found on the ground, in a purse or bag, night stand, or pillbox. The 2015 American Association of Poison Centers Annual report lists 28 fatalities in children less than 5 year of age. Fatalities occurred from exposures to the following: narcotics (9), disc and button batteries (5), carbon monoxide (4), and other substances (10).
Highlighted AAPC cases include:
Poison prevention education of patients prescribed opioids or other highly toxic "one pill killers" who have young children in their household is recommended and could be potentially life saving.
2015 Annual Report of the American Association of Poison Centers' National Poison Data System: 33rd Annual Report. Mowrey JB, et al. Clinical Toxicology, 54:10.924-1109.
Emergency Hospitalizations for Unsupervised Prescription Medication Ingestions by Young Children, Lovegrove MC, et al. Pediatrics. 2014,134 (4) e1009-e1016 .
The Underrecognized Toll of Prescription Opioid Abuse on Young Children. Bailey JE, et al. Ann of Emerg Med. April 2009:53(4): 419-24. doi:10.1016/j.annemergmed.2008.07.015.Epub 2008 Sep 6.
Keywords: adult clonidine overdose (PubMed Search)
Clinical signs and symptoms of clonidine overdose include CNS depression, bradycardia, and miosis. Other effects include early hypertension, followed by hypotension and respiratory depression, especially in children.
Although clonidine overdose in children is well described, frequency of clinical signs/symptoms in adults is not well characterized.
Recently, a retrospective study was performed in a hospital in Australia looking at clonidine overdose in adults.
Among isolated clonidine overdose, patients experienced:
Isbister GK et al. Adult clonidine overdose: prolonged bradycarida and central nervous system depression, but not severe toxicity. Clin Toxicol 2017;55:187-192.
Keywords: Dilantin, Ataxia (PubMed Search)
Phenytoin is a first line anticonvulsant agent for most seizure disorders with the exception of absence and toxin-induced seizures. It has erratic gastrointestinal absorption with peak serum levels occurring anywhere from 3-12 hours following a single oral dose. 90% of circulating phenytoin is bound to albumin but only the unbound free fraction is active to cross cell membranes and exert pharmacological effect. Measured serum phenytoin levels reflect the total serum concentration of both the free and protein bound portions. Therapeutic range is between 10-20 mg/L. Free phenytoin levels are not often measured but are normally between 1-2 mg/L. Individuals with decreased protein binding (elderly, malnourished, hypoalbuminemia, uremia, and competing drugs) may have clincial toxicity despite a normal total phenytoin level. Toxicity consists of predominantly ocular and neurologic manifestations involving the vestibular and cerebellar systems:
|Plasma level, µg/mL||Clinical manifestations|
|10-20||Occasional mild nystagmus|
|30-40||Ataxia, slurred speech, extrapyramindal effects|
|>50||Coma, rare seizures|
Treatment of overdose is primarily supportive with serial drug level testing and neurologic exams. There is no evidence that gastrointestinal decontamination improves outcome. Routine cardiac monitoring is not necessary for overdose following oral ingestions. Cardiac toxicity is rarely seen and only with parenteral administration.
Phenytoin posisoning. Craig S. Neurocrit Care. 2005;3(2): 161-70.
Severe oral phenytoin overdose does not cause cardiovascular morbidity. Wyte CD, et al. Annals of EM. 1997; 20(5). 508-512.
Cardiac Monitoring after phenytoin overdose. Evers M, et al. Heart & Lung. 1997; 26:325-328.
Keywords: EDS, Excited Delirium (PubMed Search)
Excited delirium syndrome (EDS) is a life-threatening condition caused by a variety of factors including drug intoxication. EDS is defined as altered mental status, hyperadrenergic state, and combativeness or aggressiveness. It is characterized by tolerance to significant pain, tachypnea, diaphoresis, severe agitation, hyperthermia, non-compliance or poor awareness to direction from police or medical personnel, lack of fatigue, superhuman strength, and inappropriate clothing for the current environment. These patients are at high risk for sudden death. Toxins associated with this syndrome include:
Ketamine at 4mg/kg dose can be given by intramuscular route and has been demonstrated to be safe and effective treatment for EDS.
Top 10 Facts You Need to Know About Synthetic Cannabinoids: Not So Nice Spice Kemp, Ann M. et al. The American Journal of Medicine , Volume 129 , Issue 3 , 240 - 244.
Synthetic cannabinoid drug use as a cause or contributory cause of death. Labay, LM. et al. Forensic Science International , Volume 260 , 31 - 39.
Sudden Death Due To Acute Cocaine Toxicity—Excited Delirium in a Body Packer. Sheilds, LB, Rolf CM, et al. J Forensic Sci, 2015. 60: 1647–1651.
Excited Delirium and Sudden Death: A Syndromal Disorder at the Extreme End of the Neuropsychiatric Continuum. Mash, DC.Frontiers in Physiology. 2016; 7:435.
Prehospital Ketamine is a Safe and Effective Treatment for Excited Delirium in a Community Hospital Based EMS System, Scaggs, TR, Glass, DM, et al. Prehospital and Disaster Medicine. 2016 31(5), 563–569.
Keywords: Buprenorphine, Suboxone (PubMed Search)
The current opioid epidemic is considered the worst drug crisis in American history responsible for 50,000 deaths per year in the US from overdose of heroin and opioid prescription drugs. A 200% increase in the rate of overdose deaths involving opioids occurred between 2000 and 2014. The continued rise in opioid related deaths calls for an urgent need for treatment. Three types of medication-assisted therapies (MATs) are available for treating patients with opioid addiction:methadone, buprenorphine, and naltrexone. Suboxone a combination of buprenorphine and naloxone, is emerging as one of the best choices for the following reasons:
Rudd RA, Seth P, David F, Scholl L. Increase in Drug and Opioid-involved Overose Deaths -Unted States, 2010-2015. MMWR Morb Mortal Wkly Rep. ePub: 16 December 2016.
Jones HE. Practical Considerations for the Clinical Use of Buprenorphine. Science & Practice Perspectives. 2004;2(2):4-20.
Keywords: methadone overdose, hypoglycemia (PubMed Search)
Methadone overdose produces classic signs and symptoms of opioid intoxication - CNS and respiratory depression with pinpoint pupils. However, methadone overdose has also been associated with hypoglycemia – a relatively uncommon adverse effect.
Several case reports have been published over the past years. Recently, a case of refractory hypoglycemia was reported in a woman, without a history of diabetes, after ingesting 250 mL of methadone (18.2 mg/kg).
She required, in additional to naloxone infusion for respiratory depression, dextrose infusion (initially D10 then D20) for 54 hours.
Incidence of hypoglycemia has also been observed in patient with rapid methadone dose escalation as well as in cancer patient who were started on methadone for pain control with dose-depedent association.
In a mice study, methadone induced a dose dependent hypoglycemia - 20 mg/kg methadone resulted in decrease in average glucose level of 172 +/- 7 mg/dL to 55 +/- 6 mg/dL. This effect was reversed by naloxone administration. morphine, fentanyl, oxycodone and levorphanol did not produce hypoglycemia.
However, in the case report published in Clinical Toxicology Nov 2016, naloxone infusion did not effect the hypoglycemia.
Keywords: Urine Drug Sreen (PubMed Search)
Urine drug screens are most commonly performed by immunoassay technology utilizing monoclonal antibodies that recognizes a structural feature of a drug or its metabolites. They are simple to perform. provide rapid screening, and qualitative results on up to 10 distinct drug classes with good sensitivity but imperfect specificity. This can lead to false positive results and the need for confirmatory testing. UDS does not detect synthetic opiates or cannabinoids, bath salts (synthetic cathinones), and gamma-hydroybutyrate. Most common drug classes detected are the following:
Keywords: salicylate poisoning (PubMed Search)
A small retrospective study of an acute poisoning cohort attempted to identify risk factors for severe outcome in salicylate poisoning.
Severe outcomes were defined as
A multivariate analysis of 48 patients showed that older age and increased respiratory rate were independent predictors of severe outcomes when adjusted for salicylate level.
Initial salicylate acid level was not predictive of severe outcome.
Elevated lactic acid level was also a good predictor of severe outcome in univariate analysis but not in multivariate analysis.
Shively RM et al. Acute salicylate poisoning: risk factors for sever outcome. Clin Toxicol 2017 Jan 9:1-6. doi: 10.1080/15563650.2016.1271127. [Epub ahead of print]
Keywords: Lactic acidosis (PubMed Search)
Lactic acidosis is the most common cause of anion gap metabolic acidosis in all hospitalized patients. An elevated lactate level is an important marker of inadequate tissue perfusion causing subsequent shift to anaerobic metabolism and occuring in a variety of disease states such as sepsis. In patients with unexplained lactic acidosis without systemic hyoperfusion or seizure suspect the following toxins:
Understanding lactic acidosis in paracetamol (acetaminophen) poisoning. Shah, AD, Wood DM, et al. British Journal of Clinical Pharmacology 2011.71: 20–28.
Value of lactic acidosis in the assessment of the severity of acute cyanide poisoning. Baud FJ, et al. Crit Care Med. 2002;30(9):2044-50.
The Importance of the osmolality gap in ethylene glycol intoxication. Oostvogels R, et al. BMJ 2013 Dec 7;347:31-33.
Can Acute overdose metformin lead to lactic acidosis? Wilis BK, et al. Amer J Emerg Med. 2010;28:857.
Bench to bedside review: Severe lactic acidosis in HIV patients treated with nucleoside analogue reverse transcriptase inhibitors. Classens Y-E, et al. Critical Care. 2003;7(3):226-232.
A case of Kombucha Teas Toxicity. Kole A SH, Jones HD, et al. J Intensive care Med.2009:24(3) 205-7.
Keywords: cyanide toxicity, lactic acid (PubMed Search)
Smoke inhalation victims (house fires) are at risk of carbon monoxide (CO) and cyanide poisoning (CN). CO exposure/poisoning can be readily evaluated by CO - Oximetry but CN level can be obtained in majority of the hospital.
Lactic acid level is often sent to evaluate for CN poisoning.
In a manuscript published in 1991, N Engl J Med by Dr. FJ Baud is the source of this data.
CN blood levels were measured in 109 residetial fire victims in France prior to any treatment was initiated.
Baud FJ et al. Elevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med 1991;325:1761-6.