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ACEP Toxicology Section Antidote App (free)
This simple but very useful app, from the Toxicology Section of the American College of Emergency Physicians, provides basic information about uses and dosing of basic antidotes used in toxicology. Version 1.1 covers approximately 50 different antidotes from A (acetylcysteine) to T (thiamine). Of course, clinical judgment is still required when considering these treatments, and most situations requiring use of the antidotes listed would justify consultation with a poison center. For example, one of the potential indications listed for hyperbaric oxygen (HBO) therapy in carbon monoxide (CO) poisoning is myocardial ischemia....
Source: The Poison Review - March 27, 2015 Category: Toxicology Authors: Leon Tags: Medical ACEP american college of emergency physicians android antidotes app iOS Source Type: news

Review: 23 patients with laboratory-confirmed MDPV exposure
Methylenedioxypyrovalerone (MDPV) 3.5 out of 5 stars Acute Methylenedioxypyrovalerone Toxicity. Fruberg BA et al. J Med Toxicol 2014 Dec 3 [Epub ahead of print] Abstract This is an impressive paper, but for reasons the authors thoroughly discuss in their limitations sections, there is somewhat less here than meets the eye. The authors retrospectively reviewed patients seen over a 2-year period at 10 different hospitals who were entered into the ToxIC Registry and coded under a term consistent with “bath salt” exposure. Cases were eligible for the study if they had blood and/or urine laboratory confirmation p...
Source: The Poison Review - March 25, 2015 Category: Toxicology Authors: Leon Tags: Medical bath salts MDPV methylenedioxyphyrovalerone ToxIC registry Source Type: news

Non-controlled and over-the-counter drugs of abuse
  2.5 out of 5 stars Abuse of Medications That Theoretically Are Without Abuse Potential. Reeves RR et al. South Med J 2015 Mar;108:151-157. Abstract This review of noncontrolled prescription and over-the-counter drugs that can be and have been abused for non-medical or recreational purposes is rather sketchy and anecdotal (as the authors admit,) but nevertheless contains some useful information. Classes of drugs discussed include: Cold & Cough products: pseudoephedrine, ephedrine, oxymetazoline, dextromethorphan Anticholinergics: diphenhydramine, benztropine, trihexyphenidyl (Artane) Antipsychotics: quetiapine,...
Source: The Poison Review - March 24, 2015 Category: Toxicology Authors: Leon Tags: Medical cough/cold preparations dextromethorphan medication abuse otc over-the-counter Source Type: news

Tox Tunes #94: Cocaine Blues (David Bromberg)
Along comes Sally with her nose all tore The doctor says she can’t sniff no more He says that cocaine’s for horses, it’s not for men He says it’s gonna kill me but he don’t say when During the American folk music revival that started in the 1930s and continued into the 1960s and 70s, many musicians rediscovered the rich vein of drug themes that ran through the history of blues and country songs. I first heard Luke Jordan’s “Cocaine Blues” through David Bromberg’s excellent cover version. Jordan (1882-1952) made several recordings for Victor Records in Charlotte NC and ...
Source: The Poison Review - March 23, 2015 Category: Toxicology Authors: Leon Tags: Medical cocaine blues david bromberg luke jordan tox tunes Source Type: news

Keef Kat, Boddahfinger, and other marijuana edibles — how should they be regulated
3 out of 5 stars Half-Baked — The Retail Promotion of Marijuana Edibles. MacCoun RF, Mello MM. N Engl J Med 2015 Mar 12;372:989-991. Full Text This Perspective piece — from authors at the Stanford Schools of Law and Medicine — discusses problems raised by the increasing availability of marijuana edibles in some states. Often, these products are manufactured in forms that are enticing to children (such as cookies, candy bars, and gummy bears) and packaged to look like familiar consumer products. It have written about this problem previously in several columns for Emergency Medicine News — to read them, click here...
Source: The Poison Review - March 20, 2015 Category: Toxicology Authors: Leon Tags: Medical FDA food and drug administration marijuana edibles schedule I drug THC Source Type: news

Sympathomimetic toxidrome: is it scorpion envenomation or methamphetamine?
Centruroides sculpturatus 2.5 out of 5 stars Methamphetamine Ingestion Misdiagnosed as Centruroides sculpturatus Envenonmation. Strommen J, Shirazi F. Case Rep Emerg Med Epub 2015 Jan 14. Full Text Native to the American southwest and Mexico, Centruroides sculpturatus is the most venomous scorpion in North America. Its venom contains a variety of toxins, including α-toxins that inhibits deactivation of voltage-gated sodium channels causing excitation of both the sympathetic and parasympathetic autonomic systems. In addition, the venom causes catecholamine release. Sympathetic effects usually predominate. Patients oft...
Source: The Poison Review - March 10, 2015 Category: Toxicology Authors: Leon Tags: Medical anascorp antivenom centruroides sculpturatus methamphetamine scorpion sting sympathomimetic toxidrome Source Type: news

Protonix (pantoprazole) can cause a false positive urine screening test for THC
3.5 out of 5 stars 13-Year-Old Girl With Recurrent, Episodic, Persistent Vomiting: Out of the Pot and Into the Fire. Felton D et al. Pediatrics 2015 Mar 2 [Epub ahead of print] Abstract The package insert for Protonix (pantoprazole) states: There have been reports of false positive urine screen tests for tetrahydrocannabinol (THC) in patients receiving protein pump inhibitors. The source of these reports have not been clear, and no cases have previously been reported in the literature. This paper describes a 13-year-old girl who presented to hospital with an episode of recurrent cyclic vomiting syndrome, who was diagnose...
Source: The Poison Review - March 6, 2015 Category: Toxicology Authors: Leon Tags: Medical cannabis false-positive marijuana pantoprazole protonix THC urine drug screen Source Type: news

Intravenous lipid emulsion in oral overdoses: what is the optimal dosing?
This article is an attempt to arrive at a rational dosing schedule for LE in oral overdoses. The authors consider a number of factors: Very high doses of lipid emulsion have been associated with adverse effects, including acute respiratory distress syndrome The FDA recommends a maximum dose of 12.5 mL/kg/day when LE is used for nutritional support The antidotal action of LE may depend on both the “lipid sink” effect and direct cardiac inotropy Both of the above effects require creation of a moderately lipemic plasma Combining these considerations with pharmacologic calculations, the authors make the followi...
Source: The Poison Review - March 5, 2015 Category: Toxicology Authors: Leon Tags: Medical dosing intralipid lipid emulsion lipid rescue therapy Source Type: news

TPR Podcast Episode #8: Pearls from NACCT
Discussion of Dr. Millard Bass’ JAMA article “Sudden Sniffing Death” (SSD) SSD occurs after sniffing, bagging, or huffing a volatile hydrocarbon inhalant Hypothesis: death results from sensitization of the myocardium to catecholamines, resulting in cardiac arrhythmias   Capsaicin for Cannabinoid Hyperemesis Syndrome Initial idea to use capsaicin in the treatment of cannabinoidhyperemesis syndrome (CHS) stemmed from: Symptomatic relief from hot showers or baths often reported by patients Realization that TRPV1 receptor is activated by both hot temperatures and capsaicin Case reports from California and Ne...
Source: The Poison Review - March 1, 2015 Category: Toxicology Authors: LeonThe Poison Review Tags: Podcast cannabinoid hyperemesis syndrome capsaicin cream clenbuterol NACCT phenibut sudden sniffing death syndrome tpr podcast Source Type: news

Is lipid emulsion therapy effective in calcium-channel-blocker and beta-blocker overdose?
2 out of 5 stars Role of intravenous lipid emulsions in the management of calcium channel blocker and β-blocker overdose: 3 years experience of a university hospital. Sebe A et al.  Postgrad Med 2015 Feb;127:119-124. Abstract The authors of this study, from Cukurova University School of Medicine in Turkey, retrospectively reviewed patients admitted to their hospital who were treated with lipid rescue therapy (LRT) for refractory hypotension, heart block, or cardiac arrest following overdose from a calcium-channel-blocker (CCB) or a beta-blocker (BB). They identified 15 patients(9 CCB, 6 BB.) There were two cardiac arre...
Source: The Poison Review - February 28, 2015 Category: Toxicology Authors: Leon Tags: Medical beta blocker overdose calcium channel blocker overdose intralipid lipid emulsion lipid rescue therapy Source Type: news

Tox on the web: 12 students hospitalized at Wesleyan College after “Molly” overdose
Four students arrested at Wesleyan College after “Molly” overdoses: Last weekend a dozen students and visitors at Wesleyan University in Middletown, Connecticut were hospitalized after apparently ingesting a drug or drugs labelled as “Molly.” Two victims were in critical condition and were medevacked to Hartford Hospital, the only Level 1 Trauma Center in the region. By mid-week, these two patients were still in hospital but reported to be improving. Four students have been arrested in connection with this incident. As @forensictoxguy pointed out on his blog “The Dose Makes The Poison,̶...
Source: The Poison Review - February 27, 2015 Category: Toxicology Authors: Leon Tags: Medical activated charcoal cleanse designer drug detox guy weinberg intralipid lipid rescue therapy mdma molly tox talk wesleyan Source Type: news

Excellent review of lipid rescue therapy
3.5 out of 5 stars Intravenous Lipid Emulsion in the Emergency Department: A Systematic Review of Recent Literature. Cao D et al. J Emerg Med 2014 Dec 19 [Epub ahead of print] Abstract This excellent comprehensive review of lipid rescue therapy (LRT) is vitiated only by the unavoidable fact that available clinical evidence  is so inconclusive. As the authors point out, published literature consists mostly of case reports and small case series. The vast majority of these reported cases have good outcomes and reflect positive effects from ILE, but the evidence is marred by multiple confounding variables (such as concurren...
Source: The Poison Review - February 25, 2015 Category: Toxicology Authors: Leon Tags: Medical intralipid lipid emulsion lipid rescue therapy lipid sink Review Source Type: news

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2.5 out of 5 stars Evaluation of Residual Toxic Substances in the Stomach Using Upper Gastrointestinal Endoscopy for Management of Patients With Oral Drug Overdose on Admission. Miyauchi M et al. Medicine 2015 Jan;94:e463 Abstract Despite many flaws, this paper has some interesting data that the authors use to come to exactly the wrong conclusion. The authors studied patients presenting with oral non-liquid drug overdose. Using endoscopy they classified the contents of the stomach as: 1) tablet/food phase; 2) soluble/fluid phase; and 3) reticular/empty phase.(I’m not clear on the precise meaning of a “tablet/f...
Source: The Poison Review - February 24, 2015 Category: Toxicology Authors: Leon Tags: Medical gastric empyting gastric lavage gastrointestinal decontamination Source Type: news

Sundays with SMACC: Sonowars 2014
SonoWars from Social Media and Critical Care on Vimeo. At the SMACC Gold conference last March in Australia, an epic Sonowars contest pitted the Northern Hemisphere against the Southern Hemisphere. Representing the North were Matt Dawson and Mike Mallin from the Ultrasound Podcast. Meeting the bell for the lands down under were James Rippey and Adrian Goudie from Ultrasound Village and The Sono Cave. The battle is both amusing and informative. The entire session lasts about 90 minutes. If time is limited, start watching at 56:00, where Dr. Rippey builds a heart out of clay to teach echocardiographic anatomy, and Dr. Malli...
Source: The Poison Review - February 22, 2015 Category: Toxicology Authors: Leon Tags: Medical SMACC Chicago SMACC Gold sonowars Source Type: news

Treating severe drug-induced hyperthermia with an ice-water bath
3 out of 5 stars Ice water submersion for rapid cooling in severe drug-induced hyperthermia. Laskowski LK et al. Clin Toxicol 2015 Mar;53:181-184. Abstract There is still debate about the optimal method of cooling severely hyperthermic patients, such as those with core temperature > 104oF (40oC) who are exhibiting changes in mental status. Some common techniques include ice packs to the groin and axillae, cooling blankets, along with convection (evaporation) techniques such as cool sprays and fans. There is little debate, however, about the proposition that the faster these extremely hyperthermic patients are cooled th...
Source: The Poison Review - February 21, 2015 Category: Toxicology Authors: Leon Tags: Medical active cooling drug-induced hyperthermia ice-water bath Source Type: news

Do medical toxicologists use physostigmine to treat anticholinergic toxidrome?
2.5 out of 5 stars The Use of Physostigmine by Toxicologists in Anticholinergic Toxicity. Watkins JW et al. J Med Toxicol 2014 Dec 16 [Epub ahead of print] Abstract Physostigmine is a carbamate that reversibly inhibits acetylcholinesterase, the enzyme that breaks down acetylcholine (ACh). By so doing, it increases the levels of ACh in synapses, serving as an antidote for drugs and agents causing anticholinergic syndrome. Unlike neostigmine, physostigmine crossed the blood-brain-barrier and has both peripheral and central effects. Decades ago, physostigmine was routinely used with some frequency to treat overdose with ...
Source: The Poison Review - February 18, 2015 Category: Toxicology Authors: Leon Tags: Medical anticholinergic toxidrome physostigmine ToxIC registry Source Type: news

Hemodialysis in acute methanol poisoning: is there really good evidence?
3.5 out of 5 stars Recommendations for the Role of Extracorporeal Treatments in the Management of Acute Methanol Poisoning: A Systematic Review and Consensus Statement. Roberts DM et al. Crit Care Med 2015 Feb;43:461-472. Abstract The Extracorporeal Treatment in Poisoning (EXTRIP) Workgroup was established to provide evidence-based guidance on the use of hemodialysis and other methods of extracorporeal treatment in various toxic exposures. The workgroup has published previous papers giving their recommendations regarding poisoning by acetaminophen, lithium, carbamazepine, barbiturate, tricyclic antidepressants, and thall...
Source: The Poison Review - February 17, 2015 Category: Toxicology Authors: Leon Tags: Medical evidence-based recommendations extracorporeal treatment extrip hemodialysis methanol toxic alcohol Source Type: news

Must-read: another adverse effect associated with tramadol
4 out of 5 stars Tramadol and Hypoglycemia: One More Thing to Worry About. Nelson LS, Juurlink DN. JAMA Intern Med 2015 Feb 1;175(2):194-5 Reference Hypoglycemia associated with use of tramadol has been noted previously in scattered case reports, after both overdose and therapeutic ingestion, involving patients with and without diabetes. In this month’s issue of JAMA Internal Medicine, Fournier et al. presented a large case-control study comparing patients started on tramadol for pain with similar patients started on codeine. They found that the tramadol patients had a significantly increased risk of hospitalizati...
Source: The Poison Review - February 10, 2015 Category: Toxicology Authors: Leon Tags: Medical adverse effect hypoglycemia tramadol ultram Source Type: news

The New Yorker on use of psilocybin to treat cancer patients
Recommended long-read of the week is Michael Pollan’s New Yorker article “The Trip Treatment,” a look at research being done at several medical centers — including New York University and Johns Hopkins — into the use of the psychedelic drug psilocybin to ameliorate anxiety and depression in cancer patients. Similar work had been started half a century ago, but was essentially abandoned after the image of psychedelics became tainted by the excesses of the 1960s, and the Controlled Substances Act of 1970 made it virtually impossible to obtain the drug even for research purposes. Part of the research...
Source: The Poison Review - February 9, 2015 Category: Toxicology Authors: Leon Tags: Medical cancer New Yorker oncology psilocybin psychedlics Source Type: news

News flash: dead overdose victims can have drugs in the GI tract
1.5 out of 5 stars Retained drugs in the gastrointestinal tracts of deceased victims of oral drug overdose. Livshits Z et al. Clin Toxicol 2014 Dec 30:1-6 [Epub ahead of print] Abstract This is certainly one of the more bizarre medical papers I’ve seen for quite some time. The main objective of the study was to determine the presence of “undigested or partially digested” tablets found at autopsy in the GI tracts of oral drug overdose fatalities. Why would they be interested in this question? Apparently to argue that aggressive gastrointestinal decontamination may have benefit even late after oral ingesti...
Source: The Poison Review - February 6, 2015 Category: Toxicology Authors: Leon Tags: Medical activated charcoal cadaver study gastric emptying gastric lavage gastrointestinal decontamination ingestion intoxication overdose whole bowel irrigation Source Type: news

Colorado’s experience with medical effects of legalizing marijuana
3 out of 5 stars The Implications of Marijuana Legalization in Colorado. Monte AA et al. JAMA 2015 Jan 20;313:241-2. No abstract available This brief article, from the Department of Emergency Medicine at the University of Colorado and the Rocky Mountain Poison and Drug Center, gives a concise summary of the medical consequences following Colorado’s legalization of marijuana. Although Colorado changed its state constitution in 2000 to allow medical marijuana, such use did not really become common until October 2009, when a U.S. Department of Justice memorandum indicated that the DOJ would not prosecute medical marij...
Source: The Poison Review - February 5, 2015 Category: Toxicology Authors: Leon Tags: Medical cannabis cannabis hyperemesis syndrome colorado marijuana medical marijuana recreational marijuana Source Type: news

NEJM discussion of ethylene glycol poisoning misses crucial points
2 out of 5 stars Case 4-2015: A 49-Year-Old Man with Obtundation Followed by Agitation and Acidosis. Cooper CM, Baron JM. N Engl J Med 2015 Jan 29;372:465-473. Reference This episode of the Journal‘s “Case Records of the Massachusetts General Hospital” series is the latest of their amazing inept discussions of medical toxicology cases. Yet again, the discussants do not include a medical toxicologist or emergency physician. Given the level of toxicological awareness evidenced by this case presentation, it’s fortunate that the patient did well. A unresponsive 49-year-old man was found outside with a ...
Source: The Poison Review - February 3, 2015 Category: Toxicology Authors: Leon Tags: Medical case records of the massachusetts general hospital ethylene glycol poisoning fomepizole management medical toxicology new england journal of medicine Source Type: news

The Bud Light Commercial Too Toxic for the Super Bowl
//www.youtube.com/watch?v=cYIN-b8qjmo In case you missed it when TPR posted this clip on previous Super Bowl Sundays, here is the toxicology-themed Bud Light commercial that was banned from the air during Super Bowl XLI in 2007. (Source: The Poison Review)
Source: The Poison Review - February 1, 2015 Category: Toxicology Authors: Leon Tags: Medical apology bot 3000 bud light fish poisoning fugu super bowl tetrodotoxin Source Type: news

Tox Tunes #93: Lithium (Evanescence)
As with the Nirvana song of the same title, the lyrics are not completely clear as to whether the singer is describing the experience of the drug, or using it as a metaphor for emotional ambivalence. (We should note that in fact Nirvana’s “Lithium” never mentions the drug in its lyrics.) I thought of this song after reviewing the new paper from the EXTRIP workgroup paper on extracorporeal treatment of lithium toxicity. (Source: The Poison Review)
Source: The Poison Review - January 26, 2015 Category: Toxicology Authors: Leon Tags: Medical evanescence lithium tox tunes Source Type: news

Saturdays with SMACC: Hinds & May debate cricoid pressure
At the 2014 smaccGOLD conference in Australia, two motorsport enthusiasts, Drs. Brent May (@DocBrent) and John Hinds (@DocJohnHinds) engaged in a very amusing debate about the efficacy of cricoid pressure in managing airways. Taking the pro side, Dr. May argued that applying cricoid pressure is superior (or at least non-inferior) to not doing so in preventing aspiration. Dr. Hinds’ position was that  . . . well, it’s best summed up in this graphic: The combatants were introduced by Minh Le Cong (@ketaminh). By the way, SMACC is giving away several free student registrations to the smaccUS Chicago conference t...
Source: The Poison Review - January 24, 2015 Category: Toxicology Authors: Leon Tags: Medical brent may cricoid pressure debate john hinds SMACC Source Type: news

Hemodialysis in lithium poisoning: what is the evidence?
3.5 out of 5 stars Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup. Decker BS et al. Clin J Am Soc Nephrol 2015 Jan 12 [Epub ahead of print] Abstract The purpose of this review, from the Extracorporeal Treatments in Poisoning (EXTRIP) workgroup, was to give evidence-based recommendations related to use of hemodialysis and other extracorporeal modalities in the treatment of lithium toxicity. The goal of enhanced elimination in lithium poisoning is to avoid the syndrome of irreversible lithium-effectuated nerutoxicity (SILENT), which causes persistent cerebell...
Source: The Poison Review - January 24, 2015 Category: Toxicology Authors: Leon Tags: Medical extracorporeal treatment extrip hemodialysis indications lithium poisoning Source Type: news

Evidence does not support use of long-term opioid therapy for chronic pain
3.5 out of 5 stars The Effectivenss and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop. Chou R et al.  Ann Intern Med 2015 Jan 13 [Epub ahead of print] Abstract Although prescription opioids have been advocated and used for long-term treatment of chronic non-cancer pain, there is scant literature supporting such use. Most studies have been limited to a time period of 3 months or less. The purpose of this literature review was to assess the evidence pertaining to safety and effectiveness of long-term (> 1 year) opioid therapy fo...
Source: The Poison Review - January 22, 2015 Category: Toxicology Authors: Leon Tags: Medical chronic pain long-term opioids prescription analgesics Source Type: news

Tox Tunes #92: Born in Chicago (Paul Butterfield)
This is my favorite live version of Paul Butterfield’s blues classic “Born in Chicago” (written by Nick Gravenites.) It also features Rick Danko on bass and Blondie Chaplin on guitar. Although this visceral and gritty song does not specifically mention drugs, they are certainly alluded to in the lyrics: Well, my first friend went down When I was 17 year old Well, my first friend went down When I was 17 years old Well, there’s one thing I can say about that boy He gotta go Well, my second friend went down When I was 21 years of age Well, my second friend went down When I was 21 years of age Well, th...
Source: The Poison Review - January 19, 2015 Category: Toxicology Authors: Leon Tags: Medical blondie chaplin born in chicago paul butterfield rick danko tox tunes Source Type: news

Tox in the news: 72 die in Mozambique from poisoned beer
Mozambique In a very strange story that’s been developing all week, the Washington Post reported that at least 72 people died in Mozambique after consuming poisoned beer offered at a funeral gathering. Details are scarce and the poison (or poisons) has not yet been identified, but a limited clinical scenario can be gleaned from reading news coverage. Apparently, the funeral was an all-day affair. The beer was brewed in and served from a 210 liter container. People who drank the beer only in the morning were not affected. However, those who had the beer in the afternoon were sick by the next morning, with diarrhea ...
Source: The Poison Review - January 16, 2015 Category: Toxicology Authors: Leon Tags: Medical crocodile bile mozambique nyazema poisoned beer tox in the news Source Type: news

TPR Podcast Episode #7: Interview with Guy Weinberg about lipid rescue therapy
NOTE: The audio quality of this recording is understandable but definitely choppy and sub-optimal. However, the concepts discussed are so important that we are uploading the file for those who want to listen. We will also post a transcript of the discussion in the next few days. In this episode the TPR team interviews Dr. Guy Weinberg from the Department of Anesthesia at the University of Illinois Medical Center in Chicago. Dr. Weinberg, among his many other accomplishments, was instrumental in developing the modality of lipid rescue therapy in treating cardiotoxicity caused by parenteral injection of local anesthetics su...
Source: The Poison Review - January 14, 2015 Category: Toxicology Authors: LeonThe Poison Review Tags: Podcast Source Type: news

Whole bowel irrigation? Don’t just do something, stand there!
3.5 out of 5 stars Position paper update: Whole bowel irrigation for gastrointestinal decontamination of overdose patients. Thanacoody R et al. Clin Toxicol 2015 Jan;53:5-12. Abstract In 1997 the American Academy of Clinical Toxicology (AACT) and the Euroopean Association of Poisons Centre and Clinical Toxicologists (EAPCCT) published a position paper regarding the use of whole bowel irrigation (WBI) for gastrointestinal decontamination in the poisoned patient. The key conclusions were that no evidence existed showing that WBI improved clinical outcome, and that it should not be used routinely but “may be considered...
Source: The Poison Review - January 13, 2015 Category: Toxicology Authors: Leon Tags: Medical gastrointestinal decontamination overdose poisoning polyethylene glycol position paper whole bowel irrigation Source Type: news

Hallucinogenic stimulant PMMA found in “Superman” pills that killed 4 in Britain
The Guardian (U.K.) reported yesterday that the deaths of 4 men in Britain over the holidays were associated with a drug — purported to be MDMA (ecstasy) — that actually contained the hallucinogenic stimulant PMMA, a far more dangerous drug. The deaths all seemed to be related to a 5-sided pill that reproduced the famous Superman logo. PMMA is related to PMA, a drug so lethal it has been marketed under the name “Dr. Death.” Some data indicates that PMMA (para-methoxymethamphetamine) is metabolized to PMA (para-methamphetamine.) Both PMA and PMMA cause increased release of serotonin along with decreased re...
Source: The Poison Review - January 8, 2015 Category: Toxicology Authors: Leon Tags: Medical dr. death ecstasy mdma paramethoxyamphetamine paramethoxymethamphetamine pma PMMA serotonin syndrome superman Source Type: news

Pop Quiz: Tox in the News 2014
2014 was quite an interesting year for toxicology stories in the news. There was the bizarre death of a chef in China’s Guangdong province, the discovery that a chemical warfare agent may be commonly found in swimming pools, the case of multiorgan failure after playing a video game . . . and that’s not even including the crowning of the new record holder for world’s hottest pepper. (It’s the Carolina Reaper, grown by the PuckerButt Pepper Company.) My new column in Emergency Medicine News will test your knowledge of these current poisoning events. To take the quiz, click here. (Source: The Poison Review)
Source: The Poison Review - January 6, 2015 Category: Toxicology Authors: Leon Tags: Medical 2014 quiz toxicology in the news Source Type: news

Tetrodotoxin poisoning from dried “globefish”
This report presents 2 cases of tetrodotoxin poisoning seen at Hennepin County Medical Center in June, 2014. The patients, a 30-year-old man and his 33-year-old sister, both presented with symptoms typical of puffer fish poisoning that began 30 minutes after ingesting dried “globefish” originally purchased from a street vendor in New York City. Symptoms included: numbness around the mouth and tongue paresthesias and weakness in the extremities fatigue dyspnea Each patient is described as stating that “my teeth can’t feel themselves.” Physical exam findings, including strength and respirator...
Source: The Poison Review - January 6, 2015 Category: Toxicology Authors: Leon Tags: Medical fish poisoning globefish lagocephalus lunaris puffer fish seafood poisoning tetrodotoxin Source Type: news

The 5th Annual Alexander Awards: The Best Tox Reading of 2014
Alexander Gettler The distinguished Alexander Awards go to the best writings related to toxicology topics that have appeared in the previous year. To be eligible to win an Alexander, an article or paper must be freely available on the web, not locked up behind some paywall or subject to restricted access. The awards are named for Alexander Gettler (1883-1968,) the chief toxicologist with the Office of the Chief Medical Examiner of the City of New York during the first half of the 20th century. Gettler’s work was crucial in the development of modern forensic toxicology. In a must-read piece from New York magazine, Stev...
Source: The Poison Review - January 2, 2015 Category: Toxicology Authors: Leon Tags: Medical alexander award alexander gentler best toxicology reading 2014 Source Type: news

Death after injecting alpha-PVP
3 out of 5 stars Death due to intravenous use of α-pyrrolidinopentiophenone. Sellors K et al. Med J Aust 2014 Nov 17;201:601-3. Full Text  α-pyrrolidinopentiophenone (α-PVP) is a synthetic cathinone stimulant with structural similarities to MDPV. Like MDPV, α-PVP contains a pyrrolidine ring, a 5-sided nitrogen-containing component that enables the molecule to effectively block reuptake of dopamine and norepinephrine, with much weaker effects at the serotonin transporter. This dramatic case report describes a 44-year-old man who injected a product labelled “Smokin’ Slurries Scrubba” (α-PVP) intrave...
Source: The Poison Review - December 31, 2014 Category: Toxicology Authors: Leon Tags: Medical agitted delirium alphya-PVP death fatality MDPV Source Type: news

Nicotine poisoning from an asparagus look-alike
This report, from the University of Wisconsin in Madison, describes two patients who developed symptoms consistent with nicotinic poisoning after ingesting foraged B australis. Patient 1 was an 85-year-old woman developed nausea, vomiting, diarrhea, abdominal distress, and dizziness within 15 minutes of ingesting what she took to be “wild asparagus.” Patient 2, her 48-year-old daughter, developed similar symptoms plus vertigo within a similar time frame after ingestion. Each patient was described as having severe truncal ataxia and was not able to stand unassisted. The patients were treated with fluids, anti...
Source: The Poison Review - December 30, 2014 Category: Toxicology Authors: Leon Tags: Medical asparagus baptisia look alike nicotine toxicity Source Type: news

Deaths and severe toxicity at an electronic dance-music festival in NYC
This report — from the CDC and the New York City Department of Health — describes the full investigation into adverse medical events associated with the 3-day Labor Day weekend electronic dance-music (EDM) festival. (After the 2 deaths, the third day was cancelled.) The authors identified 22 adverse medical events requiring transfer to an emergency room. Nine cases were severe — defined as involving seizure, intubation, ICU admission, or death. Specimens for toxicology testing were available from 17 patients. The following were the key findings: Five patients were admitted to the ICU. One patient who died tested...
Source: The Poison Review - December 23, 2014 Category: Toxicology Authors: Leon Tags: Medical death ecstasy electronic dance-music festival fatality mdma methamphetamine methylone new york Source Type: news

Tox Tunes #91: I Can’t Stand It (Memphis Jug Band)
What are you gonna do when your troubles get like mine Take a mouthful of sugar and drink a bottle of turpentine The Memphis Jug Band recorded in the 1920s and 1930s with an ever-changing lineup of musicians and instruments, usually including a liquor jug to provide the bass line. The 1960s blues-rock band Canned Heat obviously borrowed from this song for their own Turpentine Moan. Related post: Tox Tunes #20: Cocaine Habit Blues (Memphis Jug Band) (Source: The Poison Review)
Source: The Poison Review - December 22, 2014 Category: Toxicology Authors: Leon Tags: Medical i can't stand it memphis jug band tox tunes turpentine Source Type: news

Saturday with SMACC: Scott Weingart on Cutting Edge Intra-Arrest Care
The main theme of this extremely thought-provoking talk by Scott Weingart (@emcrit) is that CPR should not be limited to the cookbook algorithms taught in the American Heart Association’s ACLS course. Scott argues that ACLS teaches what can be done easily, not necessarily what’s needed to achieve an optimal outcome. He covers everything from the laryngeal mask airway to intra-arrest extracorporeal membrane oxygenation (ECMO.) You may not agree with all of Scott’s points, but this is a must-listen lecture. This talk was given at the 2014 SMACC Gold conference in Australia last March. I was there, and it w...
Source: The Poison Review - December 20, 2014 Category: Toxicology Authors: Leon Tags: Medical cardiopulmonary arrest Chicago cpr Medical conference resuscitation Scott Weingart SMACC Source Type: news

Surely the NEJM could do a better review of delirium tremens
2.5 out of 5 stars Recognition and Management of Withdrawal Delirium (Delirium Tremens). Schuckit MA. N Engl J Med 2014 Nov 27;371:2109-2113. No abstract available This is an amazingly inept paper, even by the traditionally low standards of the New England Journal‘s  “Review Article” section. It was written by a psychiatrist who — on the basis of this piece — seems not to deal with severe alcohol withdrawal or delirium tremens at all. At times, the author does not appear to appreciate the serious nature of DTs and the difficulty of treating the condition adequately. For instance, he states that ...
Source: The Poison Review - December 18, 2014 Category: Toxicology Authors: Leon Tags: Medical alcohol withdrawal delirium tremens DTs review article Source Type: news

Patient complains of bugs on her skin — could it be tox?
2.5 out of 5 stars Case 37-2014: A 35-Year-Old woman with Suspected Mite Infestation. Beach SR et al. N Engl J Med 2014 Nov 27;371:2115-2123. No abstract available This case — part of the Journal‘s “Case Records of the Massachusetts General Hospital” series — describes a 35-year-old woman had presented to the emergency department complaining of a parasitic skin infection: “During the 10 days before this presentation, she reported seeing white ‘granular balls,’ which she thought were mites or larvae, emerging from and crawling on her skin, sheets, and clothing and in her feces, apar...
Source: The Poison Review - December 13, 2014 Category: Toxicology Authors: Leon Tags: Medical amphetamine psychosis delusional parasitosis formication Source Type: news

Tox on the Web: deadly cocaine/fentanyl combination, the rising price of naloxone, and more
  Cocaine/Fentanyl Kills 3 in North Carolina: WTVD-ABC Eyewitness News in Raleigh, North Carolina reports that 3 people local Chatham County died over the weekend — and another 6 were taken to hospital — after using cocaine that had been surreptitiously adulterated with fentanyl. This is somewhat unusual, although many deaths in the past have been caused by fentanyl-laced heroin. A similar death occurred recently in Upstate New York. Naloxone Sticker Shock: The New York Times reported that with demand for intranasal naloxone increasing exponentially as take-home programs and use by police departments and oth...
Source: The Poison Review - December 8, 2014 Category: Toxicology Authors: Leon Tags: Medical cocaine fentanyl death. gastric lavage fatality robert hoffman tox on the web Source Type: news

Saturday SMACCdown: Should Real Airway Docs Use a Checklist?
In this verbal cage match from the 2014 SMACC Gold conference, Dr. Tim Leeuwenburg (@KangarooBeach) goes up against Dr. Minh Le Cong (@ketaminh) to debate the question: “Should real airway docs use checklists?” Very entertaining, and both sides make good points. Remember, SMACC Chicago takes place June 23-26, 2015. Many of the pre-conference workshops have already sold out, and registration for the conference itself has been brisk even at this early date. You can view the program and the amazing list of speakers lined up at the SMACC Chicago website. This is really the one conference in 2015 you won’t w...
Source: The Poison Review - December 7, 2014 Category: Toxicology Authors: Leon Tags: Medical checklist Le Cong Leeuwenburg patient safety SMACC Chicago SMACC Gold Source Type: news

Palytoxin: deadlier than fugu?
Palytoxin 3 out of 5 stars Hyperkalemia, Hyperphosphatemia, Acute Kidney Injury, and Fatal Dysrhythmias After Consumption of Palytoxin-Contaminated Goldspot Herring. Wu M: et al. Ann Emerg Med 2014 Dec;64:633-6. Abstract Palytoxin, a huge heat-stable molecule, is one of the most deadly of all the marine toxins. Fortunately, cases of severe palytoxin poisoning are relatively rare. This paper from Taiwan describes 4 patients from a single family who became symptomatic after eating fish soup made from the local catch. One person died. The presence of palytoxin was confirmed in samples of leftover fish. The following question...
Source: The Poison Review - December 5, 2014 Category: Toxicology Authors: Leon Tags: Medical fish poisoning Goldspot herring marine palytoxin Source Type: news

Best paper yet on screening suspected body packers
Body packer 4.5 out of 5 stars Body packing: a review of general background, clinical and imaging aspects. Bert FH et al. Radiol Med 2014 Oct 10 [Epub ahead of print] Abstract I’d say this is the best article on imaging suspected body packers we’re likely to see, but with the rapid evolution of radiological technology it will likely need to be updated every year or so. Nevertheless, it is the best review of the topic available, and has spectacular illustrations. The five authors rely on their experience as radiologists in major European cities, as well as published medical  literature, to review test character...
Source: The Poison Review - December 3, 2014 Category: Toxicology Authors: Leon Tags: Medical body packer body pusher cocaine drug smuggling heroin mule Source Type: news

Infants eliminate ethanol at rate comparable to that in adults
2.5 out of 5 stars Accidental Acute Alcohol Intoxication in Infants: Review and Case Report. Minera G, Robinson E.  J Emerg Med 2014;47:524-526 Abstract This case report describes a 9-week-old 9.5 kg boy who was brought to the emergency department when he was observed to be “acting strangely.”  He smelled of alcohol. History revealed that the grandmother had inadvertently prepared the infant’s formula with vodka instead of water. The child’s respiratory rate was 22/min and oxygen saturation 99% on room air. Fingerstick glucose was 167 mg/dL on admission and serum alcohol level was 330 mg/dL. Repe...
Source: The Poison Review - December 1, 2014 Category: Toxicology Authors: Leon Tags: Medical Alcohol ethanol elimination rate ethanol intoxication infant pediatric Source Type: news

Haff Time: fish-induced rhabdomyolysis
Buffalo fish (Ictiobus cyprinellus) 3 out of 5 stars Haff Disease: Rhabdomyolysis After Eating Buffalo Fish. Herman LL, Bies C. West J Emerg Med 2014 Sept;15:664-6. Abstract Haff Disease was first described in 1924 after an outbreak of acute muscle rigidity accompanied by dark  urine among patients living near the Königsberger Haff shores along the Baltic Coast.  Similar cases occurred in the following summers along the haff (a shallow lagoon.) Most victims gave a history of recently ingesting various fish — burbot, eel, pike, etc. Cases of rhabdomyolysis after ingesting fish were not reported in the United States u...
Source: The Poison Review - November 24, 2014 Category: Toxicology Authors: Leon Tags: Medical fish poisoning haff disease palytoxin rhabdomyolysis Source Type: news

Tox Tunes #90: Junco Partner (The Clash)
//www.youtube.com/watch?v=RZOPte4hlqE “Tox Tunes” has previously featured versions of “Junco Partner” by Dr. John and Professor Longhair. I love this reggae/punk take on the song from The Clash’s 1980 triple album Sandanista!. According to Dr. John, by the 1950s the song was known as an “anthem of the dopers, the whores, the pimps, the cons.” Joe Strummer of The Clash had already recorded “Junco Partner” with the previous band, the 101ers. By the way, the best use of the name “The Clash” in someone else’s song undoubtedly occurs in Richard Thompson&...
Source: The Poison Review - November 23, 2014 Category: Toxicology Authors: Leon Tags: Medical junco partner sandanista the clash tox tunes Source Type: news

Pop quiz: cardiac arrhythmia from an herbal medicine
3 out of 5 stars Life-threatening cardiovascular toxicity following ingestion of Chinese herbal medicine. Martinez A et al. Emerg Med Australas 2014 Oct;26:512-13. Abstract This case report describes a 46-year-old Chinese woman in Melbourne who presented with peri-oral and facial paresthesias, gastronintestinal disturbance (nausea, vomiting, diarrhea,  abdominal pain,) tachycardia and hypotension. She also had decreased level of consciousness and ventricular tachycardia. Symptoms started 30 minutes after ingesting a Chinese herbal medicine. The following is a pop quiz based on this presentation. Click on the question to r...
Source: The Poison Review - November 21, 2014 Category: Toxicology Authors: Leon Tags: Medical aconite cao wu cardiotoxicity Chinese herbal medicine chuan wu fu zi monkshood wolfsbane Source Type: news