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Saturday with SMACC: Evidence-Based Education — What Works
Victoria Brazil Evidence-Based Education — What Works– from Social Media and Critical Care on Vimeo. From SMACC Gold: Victoria Brazil asks what educational modalities and interventions are effective in medical education, what does “effectiveness” really mean and how do we measure it. Here are links to some of the studies and resources she mentions: The Great Dr. Fox Lecture: A Vintage Academic Hoax Hunt et al: Pediatric resident resuscitation skills improve after “rapid cycle deliberate practice” training Best Evidence Medical Education (BEME) Collaboration BondVH: virtual hospital app (Sou...
Source: The Poison Review - October 11, 2014 Category: Toxicology Authors: Leon Tags: Medical dr. myron l. fox lecture medical education SMACC victoria brazil Source Type: news

More than you ever wanted to know about synthetic cannabinoids
This article is not really readable, but I’m not sure it was meant to be read. Rather, it’s a reference paper with (by my count) 228 citations through the year 2014. It will be invaluable for anyone surveying the medical literature on synthetic cannabinoids The authors’ goals was to review comprehensively the pharmacology and toxicology of various chemicals found in synthetic cannabinoid products such as “Spice,” “K2,” and “Crazy Clown.” Their extensive literature search identified 215 relevant articles. Because of the multiple substances covered and mix of laboratory, ...
Source: The Poison Review - October 9, 2014 Category: Toxicology Authors: Leon Tags: Medical crazy clown K2 literature review spice synthetic cannabinoid Source Type: news

TPR Podcast Episode #6: I’m tripping and I can’t get down
TPR Podcast Episode 6: I’ve Tripped and I Can’t Get Down Written by Theresa Kim, MD   Outline   1)     Synthetic cathinones 2)     Piperazine compounds 3)     Gamma-hydroxybutyric acid (GHB) 4)     25C-NBOMe     This month’s podcast was inspired by the New York Times article “A Year After Drug Deaths, the Electric Zoo Music Festival Tries Again” which covered designer drug related deaths associated with summer music festivals     Synthetic Cathinones   Derivatives of the Catha edulis (khat) plant’s psychoactive alkaloid (cathinone) o   examples: mephedrone, methedrone, MD...
Source: The Poison Review - October 7, 2014 Category: Toxicology Authors: LeonThe Poison Review Tags: Podcast Source Type: news

Rosary pea ingestion: no testing needed
A. precatorius seeds 2.5 out of 5 stars A Case of Abrin Toxin Poisoning, Confirmed via Quantitation of L-Abrine (N-Methyl-L-Tryptophan) Biomarker. Wooten JV et al. J Med Toxicol 2014 Feb 13 [Epub ahead of print] Abstract The decorative rosary pea or jequirity pea (Abrus precatorius) contains the toxin abrin, a protein that inhibits the function of mRNA, leading to impaired protein synthesis and cell death. The mechanism is quite similar to that of the toxin ricin, found in castor beans. This case report describes a 22-month-old girl who ingested approximately 20 rosary peas. She appeared asymptomatic until she started vom...
Source: The Poison Review - October 4, 2014 Category: Toxicology Authors: Leon Tags: Medical abrin jequirity pea rosary pea Source Type: news

Must-listen podcast: anti-NMDA receptor encephalitis
  < As part of its “Best Case Ever” series, the Emergency Medicine Cases podcast has a superb discussion by Dr. David Carr of anti-NMDA receptor encephalitis, a relatively new but important diagnosis that is generally under-recognized and often missed. To listen to it, click here. The reason this diagnosis is of interest to toxicologists is that during the early psychotic stage of the disease patients may be treated with a neuroleptic agent. During later stages when movement disorders and autonomic instability supervene, it is easy to misdiagnose the condition as neuroleptic malignant syndrome. The tele...
Source: The Poison Review - September 29, 2014 Category: Toxicology Authors: Leon Tags: Medical anti-NMDA receptor encephalitis Source Type: news

Tox on the web: narcotic noodles, intranasal narcan, and much more!
The Antidote: A long piece in the  The New Yorker by Ian Frazier describes the epidemic of overdoses from both prescription opiate analgesics and heroin, how that epidemic affects the New York City borough of Staten Island, and the potential role of intranasal naloxone in reducing the number of deaths. A little superficial regarding the origins of the epidemic and the medical use of naloxone, but well worth reading nevertheless. It is superb at portraying the human dimension of what Frazier justifiably calls an “iatrogenic disaster.” By the way, the versatile Frazier is the author of one of the funniest parodi...
Source: The Poison Review - September 29, 2014 Category: Toxicology Authors: Leon Tags: Medical ian frazier intranasal naloxone medical overtreatment mind-altering plants narcan opium noodles tox on the web Source Type: news

Review: cobalt toxicity and artificial metal hips
4.5 out of 5 stars Systemic toxicity related to metal hip prostheses. Bradberry SM et al. Clin Toxicol 2014;52:837-847. Abstract As TPR has reported before, cobalt poisoning can cause hypothyroidism, cardiomyopathy, and neurotoxicity. Neurological manifestations include: optic nerve damage and retinopathy with reduced visual acuity bilateral nerve deafness and tinnitus polyneuropathy (sensory and motor) cognitive impairment and memory loss A number of papers and case reports have described clinical cobalt toxicity related to metal-on-metal hip prostheses or revision of a failed ceramic prosthesis with metal parts. Al...
Source: The Poison Review - September 25, 2014 Category: Toxicology Authors: Leon Tags: Medical cardiomyopathy cobalt toxicity hip replacement hypothyroidism neurotoxicity prosthesis Source Type: news

Avoid couchlock! Four things to know about cannabis pharmacology
  With medical marijuana now legal in 23 states and the District of Columbia — and recreational weed available in Colorado and Washington State — knowing the pharmacokinetics of THC has never been more important, both for consumers and the physicians who must counsel and treat them. Recently, the New York Times’ Pulitzer Prize-winning columnist Maureen Dowd got into trouble in Denver when she overdosed on a cannabis candy bar and experienced 8 hours of paranoia and couchlock. My recent Emergency Medicine News column describing 4 things Maureen should have known about weed before venturing to the “mi...
Source: The Poison Review - September 18, 2014 Category: Toxicology Authors: Leon Tags: Medical cannabis edibles marijuana overdose pharmacokinetcis pharmacokinetics Source Type: news

Tox on the Web: sarin, lithium, strychnine, and much more!
  Toxicologist as Man on Couch with Laptop: This video shows a short presentation by Larissa Laskowski a first year fellow at the NYC Poison Control Center, describing the work of Eliot Higgins and the Brown Moses blog. Higgins — an unemployed finance worker several years ago with no knowledge about weapons of warfare — started blogging about the use of different weapons in Syria, and posting online videos appearing on sites such as YouTube that demonstrated use of these weapons. He is now an acknowledge expert in the field. His work led to the identification of sarin as the agent used in the Ghouta chemical at...
Source: The Poison Review - September 18, 2014 Category: Toxicology Authors: Leon Tags: Medical albert hoffman brown moses eliot higgins lithium LSD nicotine sarin strychnine syria toledo ohio tox on the web toxic algae Source Type: news

Case Report: Synthetic Cannabinoid K2 and Myocardial Infarction
This article describes 16-year-old male who presented to hospital with 1 day of substernal chest pressure associated with nausea, vomiting, and dyspnea that started 2 hours after he smoked the synthetic cannabinoid K2. Workup revealed elevated ST segments in the inferolateral leads and elevated troponin that peaked at 8.29 ng/ml (normal 0-0.3 ng/ml). Echocardiogram and cardiac catheterization were unremarkable. Urine drug screen was positive only for opiates and benzodiazepines, both of which the patient received in the hospital before the specimen was obtained. Specimens for additional toxicology tests were sent to an out...
Source: The Poison Review - September 17, 2014 Category: Toxicology Authors: Leon Tags: Medical coronary syndrome K2 myocardial infarction synthetic cannabinoid Source Type: news

Conservative treatment for asymptomatic body packers?
Body packer 2 out of 5 stars Asymptomatic body packers should be treated conservatively. Glovinski PV et al. Dan Med J 2013 Nov;60:A4723 Abstract Kudos to the authors for putting their general conclusion in the title. Unfortunately, there’ s less here than meets the eye. This is a retrospective review of 57 patients suspected of body packing, seen at Hvidovre Hospital in Denmark. However, actual body packing was confirmed in only a little over half of these cases, meaning this is really a study of only 29 patients. All confirmed body packers were admitted, given a laxative and “monitored using a scope.”...
Source: The Poison Review - September 10, 2014 Category: Toxicology Authors: Leon Tags: Medical body packers CT imaging Source Type: news

Do pediatric patients require endoscopy after ingesting a laundry pod?
3 out of 5 stars Laundry Detergent Pod Ingestions: Is There a Need for Endoscopy? Smith E et al. J Med Toxicol 2014 Sep;10(3):286-91 Abstract The authors never answer their title question definitively, but you wouldn’t expect that they’d be able to on the basis of this small case series and the limited data published to date. Ingestion of laundry detergent pod (LDP) ingredients can present with manifestations affecting a number of systems: Gastrointestinal Pulmonary Neurological Metabolic The paper presents 3 cases of pediatric LDP ingestion in patients ages 13 months to 3 years. Presenting signs and sympt...
Source: The Poison Review - September 8, 2014 Category: Toxicology Authors: Leon Tags: Medical caustic ingestion esophageal stricture laundry pod detergent Source Type: news

Tox Tunes #88: Junco Partner (Professor Longhair)
http://www.youtube.com/watch?v=DG6gPe1plWQ   Professor Longhair (Henry “Roy” Byrd, 1918-1980) combined classic New Orleans rhythm and blues piano with Afro-Cuban funk to produce music that was exciting and utterly original. Many years ago, I was working in a research lab in New York City, living in a West Village studio that rented for $78 a month. (Yes, it was that long ago.) I hated killing rabbits for their prostaglandin, and it was sort of a bleak time. But during that period I came across an oddly compelling record — New Orleans Piano by Professor Longhair. It was magical, and taught me that the ...
Source: The Poison Review - September 8, 2014 Category: Toxicology Authors: Leon Tags: Medical henry byrd junco partner junko partner professor longhair tox tunes Source Type: news

Saturday with SMACC: The Art and Science of Fluid Responsiveness
Haney Mallemat – The Art and Science of Fluid Responsiveness from Social Media and Critical Care on Vimeo. From SMACC Gold: In a great talk, Haney Mallemat from the University of Maryland discusses the limitations of static indices of fluid responsiveness such as blood pressure and respiratory-induced changes in inferior vena cava diameter. He argues persuasively that dynamic indices — such as change in stroke volume with passive leg raise — are more accurate and precise, although measurement is technically more difficult.   (Source: The Poison Review)
Source: The Poison Review - September 7, 2014 Category: Toxicology Authors: Leon Tags: Medical dynamic indices fluid responsiveness haney mallemat SMACC ultrasound Source Type: news

Must-read: consider hemodialysis in cases of massive acetaminophen overdose
4 out of 5 stars Extracorporeal treatment of acetaminophen poisoning: Recommendations from the EXTRIP workgroup. Gosselin S et al. Clin Toxicol 2014 Aug 18:1-12. [Epub ahead of print] Abstract These recommendations come from the Extracorporeal Treatments in Poisoning (EXTRIP) workgroup, a project established to provide some guidance on the use of hemodialysis and other techniques in toxicology cases, an area where high-quality evidence simply does not exist. Although there has been some disagreement among toxicologists about the value of this effort, I have found the papers that come from EXTRIP extremely interesting a...
Source: The Poison Review - September 6, 2014 Category: Toxicology Authors: Leon Tags: Medical acetaminophen enhanced elimination extracorporeal treatment extracorporeal treatments in poisoning workgroup extrip massive overdose N-acetylcysteine paracetamol tylenol Source Type: news

Synthetic cannabinoid XLR-11 and driving
XLR-11 3 out of 5 stars Driving Under the Influence of Synthetic Cannabinoid Receptor Agonist XLR-11. Lemos NP. J Forensic Sci  2014 Aug 3. doi: 10.1111/1556-4029.12550. [Epub ahead of print] Abstract XLR-11 is one of the many different synthetic cannabinoid compounds found in samples of smokeable herbs sometimes sold as “Spice” or “Legal Marijuana.” Exposure to XLR-11 has been associated with cases of acute kidney injury. This case report describes a 22-year-old male who appeared “really high on weed” after being involved in a traffic accident. The man admitted to using “Blueb...
Source: The Poison Review - September 4, 2014 Category: Toxicology Authors: Leon Tags: Medical driving synthetic cannabinoid xlr-11 Source Type: news

Severed snake head bites, kills chef in China
Indonesian spitting cobra USA Today reports that a chef in China died recently after being bitten by the decapitated head of an Indonesian spitting cobra, possibly Naja sputatrix. Chef Peng Fan beheaded the snake in preparation for making traditional cobra soup at his restaurant in Guangdong province. Ten to twenty minutes later, when he was disposing of the head, it bit him. “We did not know what was happening” one diner said, “but could hear screams coming from the kitchen.”  The chef was dead before medical help could arrive. Cobra venom is predominantly neurotoxic and cardiotoxic. Death could ...
Source: The Poison Review - September 1, 2014 Category: Toxicology Authors: Leon Tags: Medical chef China fatal injury peng fan spitting cobra Source Type: news

Tox Tunes #87: Cocaine Blues (Bob Dylan 1961)
http://www.youtube.com/watch?v=x8a6eRME6po   This version of “Cocaine Blues” by a very young Bob Dylan was recorded in 1961, possibly shortly before he left Minnesota for New York City. It’s hard to believe that this was over half a century ago.   Related posts: Cocaine Blues (Dave Van Ronk) Cocaine Blues (Roy Hogsed) Cocaine Blues (Nick Drake) Cocaine Blues (Townes Van Zandt) Cocaine Blues (Luke Jordan) Cocaine Habit Blues (Memphis Jug Band) Cocaine Blues (Keith Richards) (Source: The Poison Review)
Source: The Poison Review - August 31, 2014 Category: Toxicology Authors: Leon Tags: Medical bob dyland cocaine blues tox tunes Source Type: news

Saturday with SMACC: Resuscitation Dogmalysis
Reid, Cliff — Resuscitation Dogmalysis from Social Media and Critical Care on Vimeo. From SMACC Gold 2014: Cliff Reid demonstrates that everything you thought you knew about treating critically ill patients may not be true. (Source: The Poison Review)
Source: The Poison Review - August 31, 2014 Category: Toxicology Authors: Leon Tags: Medical dogmalysis resuscitation SMACC Gold Source Type: news

Treating digoxin toxicity: is less more?
3 out of 5 stars Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Chan BSH, Buckley NA. Clin Toxicol 2014 Aug 4 [Epub ahead of print] Abstract This long detailed paper seems to be a manifesto masquerading as a review article. It is quite informative and well worth reading. But I’d keep in mind that the authors appear to have a (not so) hidden agenda: to decrease the dose of digoxin-specific antibody fragments administered in most cases of acute and chronic digoxin toxicity. The authors state their objective up front: To review the pharmacology, efficacy, effectiveness, indications, safety an...
Source: The Poison Review - August 29, 2014 Category: Toxicology Authors: Leon Tags: Medical digibind digifab digoxin specific antibody fragments digoxin toxicity Source Type: news

Hydrogen peroxide ingestion: can bedside ultrasound help?
http://www.youtube.com/watch?v=ed6mpRKmx14 3 out of 5 stars Young Woman With Epigastric Pain and Vomiting. Manning EP et al. Ann Emerg Med 2014 Sep;64:330. Full Text This brief case is part of the Annals of Emergency Medicines‘s series “Image of the Month.” A 23-year-old woman develops epigastric pain and vomiting after investing a cleaning agent. Abdominal exam was unremarkable. a CT of the abdomen demonstrated gas in the portal veins. The cleaning agent was hydrogen peroxide, which causes injury by two mechanisms: 1) corrosive tissue injury, and 2) gas formation. A previous case report indicated that...
Source: The Poison Review - August 29, 2014 Category: Toxicology Authors: Leon Tags: Medical bedside emergency ultrasound gas in portal vein hydrogen peroxide ingestion overdose Source Type: news

Blowguns, poison darts, and tajem
This interesting short film illustrates the meticulous care that goes into making a poison dart blowgun. The poison mentioned in the video — tajem — is made from latex obtained from the bark of a specific tree. I was not able to find out details about how it acts, but it appears to be cardiotoxic and produce fatal arrhythmias. One source mentions that there are several natural antidotes. Hunting with tajem-tipped poison darts is practiced by the Penan people in Borneo. (Source: The Poison Review)
Source: The Poison Review - August 27, 2014 Category: Toxicology Authors: Leon Tags: Medical blowgun cardiotoxicity pen an people poison darts Source Type: news

Blowguns, poison darts, and tajem poison
This interesting short film illustrates the meticulous care that goes into making a poison dart blowgun. The poison mentioned in the video — tajem — is made from latex obtained from the bark of a specific tree. I was not able to find out details about how it acts, but it appears to be cardiotoxic and produce fatal arrhythmias. One source mentions that there are several natural antidotes. Hunting with tajem-tipped poison darts is practiced by the Penan people in Borneo. (Source: The Poison Review)
Source: The Poison Review - August 27, 2014 Category: Toxicology Authors: Leon Tags: Medical blowgun cardiotoxicity pen an people poison darts Source Type: news

Body packers: can CT determine the number of drug packets?
Body packer 2.5 out of 5 stars Sensitivity and specificity of CT scanning for determining the number of internally concealed packages in ‘body-packers.’ Asha SE et al. Emerg Med J 2014 Feb 19. doi: 10.1136/emermed-2013-203389. [Epub ahead of print] Abstract Although the abdominal CT scan has been shown to be relatively accurate for determining the presence or absence of drug packets in suspected body packers, there is no good data as whether or not the test is accurate in determining the number of such packets. The abstract of this paper suggests that the authors — from Sydney’s St. George Hospital — ...
Source: The Poison Review - August 26, 2014 Category: Toxicology Authors: Leon Tags: Medical body packer CT mule radiography Source Type: news

CPC: salicylate toxicity
Discussion of salicylate toxicity misses several key points Pearl: falsely normalized anion gap in salicylate overdose Excellent guidelines for managing salicylate overdose Salicylate toxicity can present with a normal-anion-gap metabolic acidosis Salicylate toxicity: the great masquerader       (Source: The Poison Review)
Source: The Poison Review - August 25, 2014 Category: Toxicology Authors: Leon Tags: Medical aspiring poisoning case records of the massachusetts general hospital salicylate toxicity Source Type: news

Tox Tunes #86: Let’s Go Get Stoned (Big Mama Thornton)
http://www.youtube.com/watch?v=spkcAjt-TKU Big Mama Thornton (1926-1984) was a powerful rhythm and blues singer who recorded and/or wrote a number of songs that were big hits for other artists. “Let’s Go Get Stoned” — written by Nickolas Ashford, Valerie Simpson, and Josephine Armstead — went to the top of th eR&B charts when Ray Charles released his version in 1966. Thornton recorded Leiber and Stoller’s song “Hound Dog” in 1952. It was popular, but not the monster hit Elvis Presley had with the song in 1956. Thornton recorded her own song “Ball and Chain” in the ear...
Source: The Poison Review - August 25, 2014 Category: Toxicology Authors: Leon Tags: Medical big mama thornton let's go get stoned tox tunes Source Type: news

Saturday with SMACC: 17 Minutes
17 Minutes from Social Media and Critical Care on Vimeo. It’s been 5 months since I returned from Brisbane and Australia’s Gold Coast where I attended the 2014 SMACC Gold conference — by far the most inspiring and creative medical conference I’ve ever been to. This brilliant video presentation from one of the plenary sessions is a perfect example of how SMACC differs from most other professional meetings. I’ll say no more about it, except to mention that it’s a definite must-see. SMACC 2015 will take place June 23-25 next year and will be in my home town, Sweet Home Chicago! In addition to ...
Source: The Poison Review - August 23, 2014 Category: Toxicology Authors: Leon Tags: Medical 17 Minutes SMACC social media and critical care Tamara Hills Source Type: news

California counties sue makers of opioid analgesics
In May, two counties in California sued 5 pharmaceutical companies that make opioid analgesic medication, claiming that they waged a battle to create a “sea-change in medical and public perception” about the relative risks and benefits of these drugs by establishing a “deeply deceptive marketing campaign.” My Emergency Medicine News  column about this suit is online and can be read here. (Source: The Poison Review)
Source: The Poison Review - August 22, 2014 Category: Toxicology Authors: Leon Tags: Medical big pharma California law suit opiates opioid analgesics Source Type: news

Case series: 9 patients with acute kidney injury after smoking a synthetic cannabinoid
This article is a very complete and finely done description both of the clinical syndrome of AKI associated with use of synthetic cannabinoids, and the related public health investigation. [HT @DougBorys] Related posts: Four (really three) cases of acute kidney injury associated with us of synthetic cannabinoids MMWR: synthetic pot suspect in cases of kidney failure Blueberry “spice” in Wyoming linked to cases of renal failure (Source: The Poison Review)
Source: The Poison Review - August 22, 2014 Category: Toxicology Authors: Leon Tags: Medical acute kidney injury clown loyal renal toxicity spice synthetic cannabinoid Source Type: news

Methoxetamine: a ketamine analog that is NOT bladder friendly
3.5 out of 5 stars Methoxetamine — a novel recreational drug with potent hallucinogenic properties. Zawilska JB. Toxicol Lett 2014 Aug 13. pii: S0378-4274(14)01298-3. doi: 10.1016/j.toxlet.2014.08.011. [Epub ahead of print] Abstract Methoxetamine (MXE) is a structural analog of ketamine, with effects that are similar but more intense and longer-lasting. Street names include: MXE Mexxy  M-ket MEX Kmax Special M MA “Legal ketamine” Minx Jipper Roflcoptr Since chronic exposure to ketamine is known to cause ulcerative cystitis, MXE is sometimes touted as “bladder friendly.” However, lack of clini...
Source: The Poison Review - August 20, 2014 Category: Toxicology Authors: Leon Tags: Medical bladder toxicity genitourinary toxicity ketamine methoxetamine MXE Source Type: news

On the internet, nobody knows if it’s 25C-NBOMe (“N-bomb”)
This article uses both published scientific literature and discussions on Web bulletin boards and chat groups in an attempt to define the effects of this drug. The authors argue that since the internet is a crucial factor in marketing and disseminating novel psychoactive substances and since peer-reviewed articles about these substances are scarce, using unconfirmed anecdotal reports on sites like Bluelight and Drugs-Forum is justified. I don’t buy it. However, the authors do reference several medical papers about N-bomb. for example,  a recent article by Grautoff and Kahler described a 19-year-old man who suppose...
Source: The Poison Review - August 18, 2014 Category: Toxicology Authors: Leon Tags: Medical 25C-NBOME n-bomb Source Type: news

Tox Tunes #85: Goodnight, Irene (Jerry Lee Lewis and Van Morrison)
http://www.youtube.com/watch?v=wmvCAzLseu8 “Goodnight, Irene” was introduced by the folksinger and blues musician Lead Belly (Huddie Ledbetter, 1888-1949) and became a big hit for The Weavers in 1950. This fascinating song tells a somewhat murky story about unrequited passion and suicidal fantasies. The Weavers, however, left out the reference to opiates in Lead Belly’s original lyrics: I love Irene I swear I do I love her ’til the sea runs dry If Irene turns her back on me I’m gonna take morphine and die. Jerry Lee Lewis and Van Morrison keep this verse in their version. Lead Belly’s ...
Source: The Poison Review - August 18, 2014 Category: Toxicology Authors: Leon Tags: Medical drug references goodnight irene jerry lee lewis lead belly leadbelly morphine popular song the weavers tox tunes van morrison Source Type: news

Iron poisoning: Tox on the Web
Academic Life in Emergency Medicine has a very nice review of iron toxicity by Mary A. Wittler and David Manthey from Wake Forest University Baptist Medical Center. Also, in a recent post at Life in the Fast Lane, Chris Nickson discusses “The Toddler with the Iron Gut” in a Q&A format. (Source: The Poison Review)
Source: The Poison Review - August 12, 2014 Category: Toxicology Authors: Leon Tags: Medical deferoxamine iron toxicity pediatric poisoning Source Type: news

Review of scorpion envenomation
Asian forest scorpion 3 out of 5 stars Scorpion Envenomation. Isbister GK, Bawaskar HS. N Engl J Med 2014 Jul 31;371:457-463. Reference With over 1700 species of scorpions found all over the world, this brief review article is much too short and unfocused to provide more than a superficial overview of its topic. The authors point out that most scorpion stings cause, at most, minor toxicity with pain and other local effects only. Most serious envenomations are associated with the Buthidae family, which include the genus Centruroides, several of which are found in North America and commonly cause neuromuscular excitation...
Source: The Poison Review - August 12, 2014 Category: Toxicology Authors: Leon Tags: Medical antivenom centruroides Review scorpion envenomaton Source Type: news

MIcrocystin: the hepatotoxin that shut down Toledo’s water supply
  Microcystin-LR 3.5 out of 5 stars The Toxicology of Microcystins. Dawson RM. Toxicon 1998;36:953-962. Abstract Just when you thought it was safe to go back to the faucet . . . While I was on vacation, the big toxicology story involved contamination of the water supply to Toledo Ohio. As a result almost half a million people in the area were warned not to drink — or even shower with — water from Lake Erie. The cause was a bloom of freshwater cyanobacteria, resulting from increased levels of phosphates and fertilizer. These cyanobacteria product microcystin, a heat-stable hepatotoxin. Microcystin can cause 3 clin...
Source: The Poison Review - August 8, 2014 Category: Toxicology Authors: Leon Tags: Medical acute liver failure algae cyanobacteria hepatoxicity microcystin toledo ohio Source Type: news

Nicotine liquid fatality — but was it from intravenous injection?
2.5 out of 5 stars Fatal Intravenous Injection of Electronic Nicotine Delivery System Refilling Solution. Thornton SL et al. J Med Toxicol 2014;10:202-204. Reference Well, any case report of a fatality following exposure to e-cigarette nicotine  refill liquid is interesting, but this one has problems. Lately, TPR has been whinging about the BuzzFeed-ificiation of the medical literature, especially with regard to titles of published papers. In this process, nuanced topics and cases are simplified to produce a misleading title that serves better as clickbait. This case report describes  29-year-old male who was found at ...
Source: The Poison Review - July 31, 2014 Category: Toxicology Authors: Leon Tags: Medical e-cigarette fatality nicotine liquid Source Type: news

N-Bomb: a potent psychedelic stimulant
3.5 out of 5 stars 2C-I-NBOMe, an “N-bomb” that kills with “Smiles”. Toxicological and legislative aspects. Nikolaou P et al. Drug Chem Toxicol 2014 May 1 [Epub ahead of print] Abstract Despite the confusing title, this is a well done comprehensive review of 2C-I-NBOMe, an extremely  potent hallucinogenic stimulant that has been associated with deaths and severe toxicity. The NBOMe structure drugs have a 2-methoxybenzyl group attached to the nitrogen of a 2C psychedelic phenethylamine:   This substitution gives the drug enhanced activity at the 5-HT2A  serotonin receptor, a main target of m...
Source: The Poison Review - July 29, 2014 Category: Toxicology Authors: Leon Tags: Medical 25I 2C-I-NBOME hallucinogenic stimulant n-bomb smiles substituted phenethylamine Source Type: news

Must-read: marketing vs. medicine in the case of Pradaxa (dabigatran)
4 out of 5 stars Dabigatran: how the drug company withheld important analyses. Cohen D. BMJ 2014 Jul 23;349:g4670. doi: 10.1136/bmj.g4670. Full Text As TPR has reported before, there has long been reason to doubt the claim that the anticoagulant dabigatran (Pradaxa) can be safely and effectively used for prevention of strokes in patients with non-valvular atrial fibrillation without laboratory monitoring. This must-read investigative report uses internal company documents released in association with a lawsuit — recently settled for $650 million — to suggest that Boehringer Ingelheim, the drug’s manufacturer, sup...
Source: The Poison Review - July 28, 2014 Category: Toxicology Authors: Leon Tags: Medical adverse drug event anticoagulant bleeding boehringer ingelheim dabigatran hemorrhage pradaxa Source Type: news

Bedside ultrasound in tox cases: an idea whose time has come?
Is there a role for point-of-care bedside ultrasound imaging in overdose cases? Quite possibly. My recent column in Emergency Medicine News discussed this question. To read it, click here. Related post: Ultrasound visualization of ingested tablets: good idea or wild-goose chase? (Source: The Poison Review)
Source: The Poison Review - July 23, 2014 Category: Toxicology Authors: Leon Tags: Medical calcium channel blockers salicylate toxicity toxicology cases ultrasound Source Type: news

Fatal caffeine overdose: useful paper despite BuzzFeed-worthy title
This article is classic example of scientific bait and switch, a deceptive tactic not dissimilar to the use of “click bait” by websites like BuzzFeed. The subtitle promises “Fatal Caffeine Intoxication: A Series of Eight Cases . . .” But by the end of the introduction this has been walked to back “eight fatal cases of caffeine intoxication-related deaths,” a concept that is hopelessly vague and undefined. The way the authors use the term, a man who gets hit by a truck leaving Starbucks after drinking two Vente cappuccinos could be considered a caffeine-related death. The authors’ a...
Source: The Poison Review - July 20, 2014 Category: Toxicology Authors: Leon Tags: Medical caffeine toxicity cardiotoxicity fatality Source Type: news

Two cases of laboratory-confirmed exposure to 25B-NBOMe
25I-NBOMe blotter paper 3 out of 5 stars Two cases of severe intoxication associated with analytically confirmed use of the novel psychoactive substances 25B-NBOMe and 25C-NBOMe. Tang MHY et al. Clin Toxicol 2014 Jun;52:561-565. Abstract The NBOMe series of drugs are substituted phenethylamines. They act as agonists at both the 5-HT2A receptors and the α-receptors. Because of these actions, they can cause both hallucinations (5-HT2A  effects) and sympathomimetic toxidrome (α effects.) Since these drugs are so potent, they are often sold in the form of impregnated blotter paper. This paper, from Hong Kong, describes ...
Source: The Poison Review - July 18, 2014 Category: Toxicology Authors: Leon Tags: Medical 25B-NBOMe 25C-NBOME 25I-NBOMe blotter paper hallucinogenics sympathomimetic toxidrome Source Type: news

Case report: guanfacine overdose
Intuniv (Guanfacine) 3 out of 5 stars Prolonged Bradycardia and Hypotension Following Guanfacine Extended Release Overdose. Walton J et al. J Child Adolesc Physcopharmacol 2014 Jul 10 [Epub ahead of print] Reference  Guanfacine is a central α2-agonist with a mechanism of action similar to that of clonidine. Originally marketed as an antihypertensive agent, it is now available as an extended-release preparation (Imtuniv) for treating children ages 6-17 with attention-deficit hyperactivity disorder (ADHD). It is thought the mechanism of action in that condition may involve stimulation of α2-receptors in the prefrontal c...
Source: The Poison Review - July 18, 2014 Category: Toxicology Authors: Leon Tags: Medical ADHD attention deficit hyperactivity disorder clonidine guanfacine Source Type: news

Review of cannabinoid hyperemesis syndrome
3 out of 5 stars A hot mess: A case of hyperemesis. Cheung E et al.  Can Fam Physician 2014 Jul;60:633-637. Full Text With medical marijuana now legal in 23 states plus the District of Columbia, and recreational marijuana legal in 2 states, it is essential that all emergency and primary care physicians become familiar with the adverse effects that can ensue from regular use of cannabis. One of the most striking and unexpected complications of chronic cannabis exposure is violent cyclic vomiting. This has been called “cannabinoid hyperemesis syndrome” (CHS). In this review article, the authors propose the foll...
Source: The Poison Review - July 17, 2014 Category: Toxicology Authors: Leon Tags: Medical cannabinoid hyperemesis syndrome cannabis cyclic vomiting marijuana THC Source Type: news

Tox Tunes #84: Pass the Dutchie (Musical Youth)
http://www.youtube.com/watch?v=dFtLONl4cNc The term “dutchie” now refers to a marijuana product, possibly a “blunt” made from a cigar such as a Dutch Masters. But it probably didn’t in 1982 when the British reggae band Musical Youth released this hit. The song is a cover of the Mighty Diamonds’ “Pass the Koutchie” — a “koutchie” being a pipe used to smoke marijuana. However, then Musical Youth’s version was released, the record company thought it unseemly for young teenagers to be singing about drugs, so the title was changed to “Pass the Dutchie...
Source: The Poison Review - July 13, 2014 Category: Toxicology Authors: Leon Tags: Medical magic diamonds musical youth pass the koutchie tox tunes Source Type: news

Acute respiratory distress syndrome following intralipid emulsion therapy
2.5 out of 5 stars Acute respiratory distress syndrome following verapamil overdose treated with intravenous lipid emulsion; A rare life-threatening complication. Martin C et al.  Ann Fr Anesth Reanim 2014 [Epub ahead of print] Reference This interesting French case report is a textbook example of how not to use intralipid emulsion therapy (ILE) in calcium-channel-block (CCB) overdose. It describes a 51-year-old woman who present to the emergency room 8 hours after ingesting forty 240 mg verapamil, a total of 9.6 grams. She was hypotensive and bradycardic, although alert and oriented. Initial echocardiography showed goo...
Source: The Poison Review - July 12, 2014 Category: Toxicology Authors: Leon Tags: Medical adverse drug reaction calcium channel blocker overdose intralipid emulsion therapy verapamil Source Type: news

Mussel Beach: Paralytic Shellfish Poisoning
3 out of 5 stars Paralytic Shellfish Poisoning: A Case Series. Hurley W et al. West J Emerg Med 2014 Jul;15:378-381. Full Text Paralytic shellfish poisoning (PSP)is caused by saxitoxin,  an alkaloid produced by certain marine dinoflagellates and released during algae blooms that produce a so-called “red tide.” (Actually, the water can be various colors, or even clear, during these blooms.) The toxin is then taken up and concentrated by filter-feeding mollusks, including oysters, clams and mussels. Like tetrodotoxin, saxitoxin is a sodium-channel blocker. It causes mostly neurotoxicity and gastrointestinal s...
Source: The Poison Review - July 11, 2014 Category: Toxicology Authors: Leon Tags: Medical dinoflagellate marine toxicity mollusks mussels neurotoxicity paralytic shellfish poisoning saxitoxin Source Type: news

TPR Podcast Episode #5: Don’t Harsh Our Mellow, Dude!
This study looked at the rates of registered medical marijuana users pre- and post-legalization of marijuana in Colorado and compared it to rates of positive urine and serum marijuana tests of Colorado drivers involved in a fatal motor vehicle crash o   It found a positive correlation: as the rates of marijuana users went up, the rates of fatal motor vehicle crashes in which drivers tested positive for marijuana went up as well Critique of the article: o   Urine tests can be positive for days-months after the last use so drivers who tested positive for marijuana were not necessarily under the influen...
Source: The Poison Review - July 11, 2014 Category: Toxicology Authors: LeonThe Poison Review Tags: Podcast Source Type: news

Retrospective review of nutmeg toxicity
2.5 out of 5 stars Nutmeg Poisonings: A Retrospective Review of 10 Years Experience from the Illinois Poison Center: 2001-2011. Ehrenpreis JE et al. J Med Toxicol 2014;10:148-151. Abstract Just when you thought it was safe to go back to the eggnog bowl . . . Nutmeg is the seed of the aromatic evergreen Myristica fragrans. It contains a number of volatile oils, some of which may be metabolized to monoamine oxidase inhibitors or amphetamine-like substances. Manifestations of nutmeg toxicity are quite similar to those of the anticholinergic syndrome, including dry mouth, flushing, tachycardia, tremor, urinary retention and...
Source: The Poison Review - July 10, 2014 Category: Toxicology Authors: Leon Tags: Medical anticholinergic syndrome myristica fragrans nutmeg Source Type: news

Tox on the web: intranasal naloxone, chloral hydrate toxicity, and more!
  Legalized recreational marijuana in Colorado – the first six months: NPR’s talk show On Point recently had an interesting discussion of Colorado’s experience with recreational marijuana. Guests included Alicia Caldwell, an editorial writer for the Denver Post, and Dr. Richard Zane, Chair of Emergency Medicine at the University of Colorado Medical Center. Dr. Zane pointed out that many of the patients who come to the emergency department after exposure to marijuana have ingested edible products. There are several reasons for this. First, the bioavailability and absorption of ingested THC is ext...
Source: The Poison Review - July 7, 2014 Category: Toxicology Authors: Leon Tags: Medical chloral hydrate toxicity colorado edibles intranasal naloxone marijuana prehospital Source Type: news

Quiz: How much do you know about heparin-induced thrombocytopenia?
3.5 out of 5 stars Heparin-induced thrombocytopenia. Lovecchio F. Clin Toxicol 2014 Jul;52:579-583. Abstract This is a good up-to-date review of heparin-induced thrombocytopenia (HIT). The following are some questions based on the discussion in the paper (click on each question to reveal the answer): When does HIT begin? expand(document.getElementById('ddet1087306517'));expand(document.getElementById('ddetlink1087306517')) Onset of HIT is generally within 5-10 days of heparin initiation, and is heralded by a 50% of greater decrease in the platelet count. What is the incidence of HIT? expand(document.getElementById('ddet1...
Source: The Poison Review - July 3, 2014 Category: Toxicology Authors: Leon Tags: Medical adverse drug reaction heparin heparin-induced thrombocytopenia platelet Source Type: news