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Tox Tunes #99: Casey Jones (Grateful Dead)
The critical response to the final 3 performances of the Grateful Dead’s “Fare Thee Well” tour has been decidedly mixed. In the New York Times, Jon Pareles reported that “Even with a handful of the Dead’s inevitable stumbles, the music was strong.” On the other hand, Greg Kot’s review in the Chicago Tribune was headlined “Grateful Dead pay slack tribute to legacy.” This time around, as the Times cleverly notes, its “as much about today as yesterday, more hashtags than hash, less Summer of Love than summer of ‘likes.'” Some fans are coming not in psych...
Source: The Poison Review - July 5, 2015 Category: Toxicology Authors: Leon Tags: Medical casey jones grateful dead tox tunes Source Type: news

Tox Tunes #98: Truckin’ (The Grateful Dead)
Surprisingly, “Tox Tunes” has featured only one Grateful Dead song so far. This weekend seemed a good time to catch up, as the remnants of The Dead play their farewell concerts at Soldier Field in Chicago in the biggest festival the Windy City has seen since smaccUS. There are, of course, a number of drug references in the song, which relates the autobiography of the band through the early 1970s. On January 31, 1970, 19 members of the band and its touring party — including their live-in street chemist and sound engineer Owsley Stanley — were arrested in New Orleans for possession of marijuana: Sitting and s...
Source: The Poison Review - July 3, 2015 Category: Toxicology Authors: Leon Tags: Medical grateful dead tox tunes truckin' Source Type: news

Recommendations for starting hemodialysis in salicylate toxicity
3.5 out of 5 stars Extracorporeal Treatment for Salicylate Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup. Juurlink D et al. Ann Emerg Med 2015 May 8 [Epub ahead of print] Abstract Aspirin is an especially dangerous poison for a number reasons: • It’s easy to purchase over-the-counter in large quantities • Even after a life-threatening acute ingestion of salicylate, a patient can present looking deceptively stable only to deteriorate catastrophically several hours later • In chronic salicylate toxicity, the diagnosis can be easily missed Ask many toxicologists about the poisons the...
Source: The Poison Review - July 1, 2015 Category: Toxicology Authors: Leon Tags: Medical aspirin enhanced elimination extracorporeal treatment extrip hemodialysis indications salicylate toxicity Source Type: news

Tox Tunes #97: Resurrection Mary (Ian Hunter)
Combining Chicago lore, poisons, and a ghost, this is the perfect “Tox Tune” to post the weekend before smaccUS descends on the Windy City. “Resurrection Mary,” which appeared on Ian Hunter’s 1996 album The Artful Dodger, recounts the famous Chicago ghost story involving about a vanishing hitchhiker who is periodically sited near the Resurrection Cemetery in southwest suburban Justice. Legend has it that the hitchhiker is the ghost of a young girl killed by an automobile in the late 1920s or early 1930s while trying to get away from her boyfriend. As recounted by Wikipedia: Since the 1930s,...
Source: The Poison Review - June 21, 2015 Category: Toxicology Authors: Leon Tags: Medical Chicago ian hunter resurrection mary tox tunes Source Type: news

Looking back: the first FOAMed meeting in the U.S.
This photograph, from November 2010, documents what was to my knowledge the first #FOAMed get-together on U.S. soil. Gathered that evening at a tapas restaurant in San Francisco during the “Essentials of EM” conference were (from left to right): Anton Helman (Emergency Medicine Cases)  Chris Nickson (Life in the Fast Lane) Scott Weingart (EMCrit) Michelle Lin (Academic Life in Emergency Medicine) Leon Gussow (The Poison Review) It is truly amazing to realize that only four-and-a-half years later, 2000 foamheads from around the world are descending on Chicago for the 3-day festival of life and learning calle...
Source: The Poison Review - June 20, 2015 Category: Toxicology Authors: Leon Tags: Medical FOAM FOAMed FOAMtox smaccus Source Type: news

Illustrated case report of phenol exposure
Phenol 3.5 out of 5 stars Phenol Toxicity Following Cutaneous Exposure to Creolin®:A Case Report. Vearrier D et al. J Med Toxicol 2015 Jun;11:227-231. Abstract This paper is worth looking at for the excellent color photographs of the partial thickness skin burns induced by exposure to Creolin®, which contains carbolic acid (phenol), sodium hydroxide, and isopropanol. A 9-year-old girl was brought to the emergency department because of respiratory distress and unresponsiveness. Symptoms came on quickly and started within 4 minutes of the mother pouring 8 oz Creolin® over the patients hair in an attempt to get rid of hea...
Source: The Poison Review - June 18, 2015 Category: Toxicology Authors: Leon Tags: Medical coagulative necrosis creolin phenol surface burn Source Type: news

Case series: 11 hospital workers symptomatic after ingesting “synthetic marijuana” brownies
3 out of 5 stars Cluster of Acute Toxicity from Ingestion of Synthetic Cannabinoid-Laced Brownies. Obafemi AI et al. J Med Toxicol 2015 May 13 [Epub ahead of print] Abstract This case series describes 11 patients brought to hospital after inadvertently ingesting brownies laced with the synthetic cannabinoid AM-2201. All 11 patients were hospital workers who ingested brownies brought to work by a staff member. In each patient, symptoms started within an hour of ingestion and generally resolved within 2 to 4 hours (although two persons felt tired and dizzy for up to 10 hours post-ingestion.) The most common neurological ma...
Source: The Poison Review - June 16, 2015 Category: Toxicology Authors: Leon Tags: Medical acute toxicity AM-2201 ingestion synthetic cannabinoid Source Type: news

Podcast: Managing the crashing tox patient with ECMO
As I wrote about in a recent column for Emergency Medicine News, extracorporeal membrane oxygenation (ECMO) may be the next big thing in managing the severely ill, crashing overdose patient in whom usual therapy is not working. On the new podcast posted today at the EDECMO website, Steve Aks and I got together over Skype with Joe Bellezzo, Zack Shinar, and Scott Weingart to discuss the potential benefits, as well as the potential risks and complications, involved in using ECMO in the sickest tox patients. Some of the topics we discuss: What overdose patients might benefit most from ECMO? What vascular access is needed fo...
Source: The Poison Review - June 16, 2015 Category: Toxicology Authors: Leon Tags: Medical ECMO edecmo extracorporeal membrane oxygenation podcast poisoning toxicology Source Type: news

Dramatic recent increase in cases and deaths associated with use of synthetic cannabinoids
4 out of 5 stars Increase in Reported Adverse Health Effects Related to Synthetic Cannabinoid Use —United States, January-May 2015. MMWR 2015 Jun 12;64:618-619. Full Text I have to say that this report shocked me some. Although I was aware of an increased number of news reports of incidents related to synthetic cannabinoids, I really had no idea the increased number of cases involving exposures reported to poison centers with major adverse effects and death were so dramatic. As this report points out: “Synthetic cannabinoids include various psychoactive chemicals or a mixture of such chemicals that are sprayed ont...
Source: The Poison Review - June 13, 2015 Category: Toxicology Authors: Leon Tags: Medical CDC national poison data system spice mmwr synthetic cannabinoid Source Type: news

How lipid rescue therapy works: it’s more than just a sink
This study, from Guy Weinberg’s lab at the University of Illinois, used a rat model of bupivacaine toxicity, along with and computational analysis, to investigate the mechanisms by which lipid rescue therapy (LRT) might act in treating overdose from local anesthetics and other cardiotoxic drugs. This is a very complex paper, and I have to admit that I found reading through the experimental protocol rough going. However, the authors findings are important and convincing. The results suggest that — as the title of the paper indicates — there are several modalities that provide benefit: LRT accelerated removal of d...
Source: The Poison Review - June 10, 2015 Category: Toxicology Authors: Leon Tags: Medical antidote bupivacaine intralipid lipid emulsion lipid rescue therapy local anesthetic triglyceride Source Type: news

“Rick and Jerry”: a salute
At the Emergency Physicians Monthly website, Mel Herbert posted a lovely tribute to Rick Bukata and Jerry Hoffman as they pass off the lead anchoring duties on Emergency Medicine Abstracts to a new generation of medical educators. I think Mel’s piece captures the impact and influence of the Abstracts perfectly. When I started listening to the monthly tapes in the mid-1980s, I found them to be a revelation. Certainly, a critical approach to analyzing medical literature was not taught at all in medical school, although it is certainly one of the most important skills a physician can have. Other packages that tried ...
Source: The Poison Review - June 8, 2015 Category: Toxicology Authors: Leon Tags: Medical emergency medicine abstracts jerry hoffman rick bukata Source Type: news

Tox Tunes #96: Champagne and Reefer (Rolling Stones and Buddy Guy)
This is a great version of Muddy Waters’ song “Champagne and Reefer” by the Stones and Buddy Guy. Those who will be in Chicago for SMACCus may want to stop into Buddy Guy’s Legends, a club that is virtually downtown and where Buddy himself sometimes shows up to play. Related post: Tox Tunes #32: Champagne and Reefer (Muddy Waters) (Source: The Poison Review)
Source: The Poison Review - June 8, 2015 Category: Toxicology Authors: Leon Tags: Medical Source Type: news

Tox Tunes #96: Champagne and Reefer (rolling Sontes and Buddy Guy)
This is a great version of Muddy Waters’ song “Champagne and Reefer” by the Stones and Buddy Guy. Those who will be in Chicago for SMACCus may want to stop into Buddy Guy’s Legends, a club that is virtually downtown and where Buddy himself sometimes shows up to play. Related post: Tox Tunes #32: Champagne and Reefer (Muddy Waters) (Source: The Poison Review)
Source: The Poison Review - June 8, 2015 Category: Toxicology Authors: Leon Tags: Medical Source Type: news

Episode #9: TPR Podcast on hemodialysis in poisonings
Episode 9: EXTRIP Review   Written by Theresa Kim, MD   Outline EXTRIP Guideline Methodology Methanol Theophylline Lithium Acetaminophen   EXTRIP Guideline Methodology Extracorporeal treatments (ie. hemodialysis, hemoperfusion) are commonly used in poisonings despite lack of formal human trials Goal of the EXTRIP workgroup was to form an international collaboration among experts from nephrology, toxicology, critical care, pharmacology, and over 30 professional societies to form consensus recommendations and suggestions based on available research and expert opinion Clinical evidence ranked using GRADE syst...
Source: The Poison Review - June 1, 2015 Category: Toxicology Authors: LeonThe Poison Review Tags: Podcast Source Type: news

Tox Tunes #95: Dead Flowers (Townes Van Zandt)
The Rolling Stones’ original version of “Dead Flowers” was on their 1971 Sticky Fingers album, along with a number of other songs definitely or possibly about drugs, including “Brown Sugar,” “Moonlight Mile,” and “Sister Morphine.” The song was written in the late 1960s, when Keith Richards was hanging out with the country-rock musician Gram Parsons. Although fans debate whether or not the term “dead flowers” refers to poppies, the other reference to heroin is unmistakable: I’ll be in my basement room With a needle and a spoon I much prefer Townes Van ...
Source: The Poison Review - June 1, 2015 Category: Toxicology Authors: Leon Tags: Medical dead flowers rolling stones townes van zandt tox tunes Source Type: news

Poisoned patients treated with ECMO: 10 cases from the ToxIC Registry
3 out of 5 stars Extracorporeal Membrane Oxygenation (ECMO) for Severe Toxicological Exposures: Review of the Toxicology Investigators Consortium (ToxIC) Wang GS et al. J Med Toxicol 2015 May 27 [Epub ahead of print] Abstract The Toxicology Investigators Consortium (ToxIC) Case Registry — established in 2010 — is a database containing information from cases of known or suspected poisoning at multiple centers that were cared for at the bedside by board-certified or eligible medical toxicologists. In 2013, it comprised 38 toxicology groups and 69 separate institutions. The authors of this study retrospectively reviewed 4...
Source: The Poison Review - May 30, 2015 Category: Toxicology Authors: Leon Tags: Medical ECMO extracorporeal membrane oxygenation ToxIC registry toxicology investigators consortium Source Type: news

Keys to the safe use of naloxone
4 out of 5 stars Reducing the harm of opioid overdose with the safe use of naloxone: a pharmacologic review. Kim HK, Nelson LS. Expert Opin Drug Saf 2015 Apr 12:1-10 [Epub ahead of print] Abstract This review of naloxone comes down strongly on the side of “less is more,” and argues that when reversing opiate overdose a starting dose of 2 mg — or even 0.4 mg — is unnecessary and risks precipitating acute opiate withdrawal syndrome (OWS). Although some clinicians will not agree with all the authors’ opinions, they are well thought out and worth considering. Some key points: Naloxone’s duration o...
Source: The Poison Review - May 28, 2015 Category: Toxicology Authors: Leon Tags: Medical antidote naloxone narcan opiate overdose opioid intoxication Source Type: news

Unlabeled amphetamine isomer in sports supplement “probably” caused hemorrhagic stroke
3.5 out of 5 stars Hemorrhagic Stroke Probably Caused by Exercise Combined With a Sports Supplement Containing β-Methylphenylethylamine (BMPEA): A Case Report. Cohen P et al. Ann Intern Med 2015 May 12 [Epub ahead of print] Reference Last month, the FDA sent letters to 5 companies that manufacture so-called “dietary” or “sports” supplements, warning them that their products were mislabeled because they contained an unlisted ingredient. That ingredient, β-methylphenylethylamine (BMPEA), is an isomer of amphetamine. Although the effects of BMPEA in humans have not been well studied, it has been ...
Source: The Poison Review - May 22, 2015 Category: Toxicology Authors: Leon Tags: Medical amphetamine beta-methylphenylethylamine BMPEA dietary supplement hemorrhagic stroke sports supplement Source Type: news

ED sedation with droperidol is relatively safe and effective
This study has shown that droperidol is relatively safe and effective for the management of violent and aggressive patients in the ED and that there was no increased risk of QT prolongation and torsades de points according to a large cohort of cases.” The “Editor’s Capsule Summary” that accompanies the article is even more emphatic*: How this is relevant to clinical practice Droperidol is safe even with the high doses used in this study. The authors note that the study does not rule out that droperidol may be associated with rare cases of torsades. But the agitated, delirious ED patient may be a dan...
Source: The Poison Review - May 20, 2015 Category: Toxicology Authors: Leon Tags: Best of TPR Medical black box warning droperidol FDA food and drug administration QT prolongation torsades de pointes Source Type: news

Lipid rescue therapy and ECMO in the poisoned patient — can they be used together?
3 out of 5 stars What are the adverse effects associated with the combined use of intravenous lipid emulsion and extracorporeal membrane oxygenation in the poisoned patient? Lee HM et al. Clin Toxicol 2015;53:145-150. Abstract Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is often used in the neonatal and pediatric intensive care units on children who are also receiving intravenous lipid emulsion (LE) for nutritional support. Complications reported in patients receiving both interventions include lipid agglutination, clogging, occurrence of blood clots, and cracking of parts of the ECMO circuit. There is inc...
Source: The Poison Review - May 16, 2015 Category: Toxicology Authors: Leon Tags: Medical antidote ECMO extracorporeal membrane oxygenation intralipid lipid emulsion lipid rescue therapy poisoned patient Source Type: news

Hemodialysis in metformin poisoning
3.5 out of 5 stars Extracorporeal Treatment fo Metformin Poisoning: Systematic Review and Recommendations From the Extracorporeal Treatments in Poisoning Workshop. Calello DP et al. Crit Care Med 2015 Apr 9 [Epub ahead of print]   Abstract Metformin is now the oral drug most commonly prescribed to treat non-insulin-dependent diabetes in the United States. The drug is large eliminated by the kidneys. Toxicity presents with severe lactic acidosis, and can occur when decreasing renal function causes accumulation of therapeutic doses, or in the case of acute deliberate overdose. According to some reports metformin poiso...
Source: The Poison Review - May 8, 2015 Category: Toxicology Authors: Leon Tags: Medical continuous renal replacement therapy extracorporeal treatment extrip glucophage hemodialysis metformin Source Type: news

Severe reactions to “Spice” on rise, some associated with drug MAB-CHMINACA
AB-CHMINACA 3 out of 5 stars In vitro and in vivo human metabolism of the synthetic cannabinoid AB-CHMINACA Erratico C et al. Drug Test Analysis 2015 Apr 12 [Epub ahead of print] Abstract The New York Times reported today on the recent dramatic increase in emergency department visits related to use of synthetic cannabinoids (call colloquially, but somewhat inaccurately, “Spice”). This phenomenon has been seen in many states, especially Mississippi, Pennsylvania, and New York. According to reports, patients often present with agitation, delirium, and hallucinations. Medical complications have included rhabdo...
Source: The Poison Review - April 25, 2015 Category: Toxicology Authors: Leon Tags: Medical CHMINACA spice synthetic cannabinoid Source Type: news

Even Dr. Oz can’t rebut John Oliver
Dr. Oz’s rebuttal yesterday to the letter from ten self-described “distinguished physicians” who demanded that Columbia Medical School cancel his faculty appointment was absolutely brilliant — recasting the narrative from the selling of snake oil to standing up for free speech and against the juggernaut agricultural-industrial complex. But there’s no rebuttal to John Oliver. See also Michael Specter’s New Yorker blog post on this issue, as well as his superb profile of Dr. Oz in the magazine. (Source: The Poison Review)
Source: The Poison Review - April 24, 2015 Category: Toxicology Authors: Leon Tags: Medical columbia dr. oz john oliver Source Type: news

Proton pump inhibitors increase risk of acute kidney injury
3 out of 5 stars Proton pump inhibitors and the risk of acute kidney injury in older patients: a population-based cohort study. Antoniou T et al. CMAJ Open 2015;Apr;3:E166-E171. Full Text Previous studies have suggested that use of proton pump inhibitors (PPIs) increases risk of acute interstitial nephritis, especially in elderly patients. Using information from  several large computerized databases containing medical information about patients in Ontario, Canada, the authors carried out a population-based cohort study of patients in Ontario aged 66 years and older who were newly prescribed  PPIs, compared with match...
Source: The Poison Review - April 23, 2015 Category: Toxicology Authors: Leon Tags: Medical acute kidney injury interstitial nephritis lansoprazole omeprazole proton pump inhibitor Source Type: news

Poisonous birds: what’s new
3 out of 5 stars Poisonous birds: A timely review. Ligabue-Braun R, Carlini CR. Toxicon 2015 Mar 31;99:102-108. Abstract It was just over two decades ago that Dumbacher et al published their landmark paper describing the presence of the alkaloid batrachotoxin (BTX, “frog poison”) in the skin and feathers of three species of Pitohui bird in New Guinea. This toxin binds to voltage-gated sodium channels maintaining them in the open position. This action causes depolarization of nerves and myocardial cells. This may serve the bird by acting as a “chemical defense” against large predators, or as a ...
Source: The Poison Review - April 21, 2015 Category: Toxicology Authors: Leon Tags: Medical batrachotoxin bird catharidin coturnism hoopoe pitohui bird poison quail rhabdomyolysis spur-winged goose toxicity Source Type: news

27 fatalities from laboratory-confirmed exposure to PMMA (“Dr. Death”)
4 out of 5 stars Deaths from exposure to paramethoxymethamphetamine in Alberta and British Columbia, Canada: a case series. Nicol JJE et al. CMAJ Open. 2015 Jan 13;3(1):E83-9 Full Text From June 2011 through April 2012, 27 deaths in the Canadian provinces of Albert and British Columbia were attributed to the hallucinogenic stimulant para-methoxy-N-methylamphetamine (PMMA) as the primary toxic agent based postmortem examination and toxicology results. PMMA is so dangerous that it is known on the street as “Death” and “Dr. Death.” This paper constitutes a retrospective review of those cases based on r...
Source: The Poison Review - April 18, 2015 Category: Toxicology Authors: Leon Tags: Best of TPR Medical alberta bath salt british columbia canada death dr. death ecstasy fatality hyperthermia mdma PMMA serotonin syndrome synthetic designer drug Source Type: news

Predicting delirium tremens in patients with alcohol withdrawal seizures
2 out of 5 stars Clinical predictors for delirium tremens in patients with alcohol withdrawal seizures. Kim DW et al. Am J Emerg Med 2015 Feb 23 [Epub ahead of print] Abstract Being able to predict which patients with alcohol withdrawal seizures will go on to develop delirium tremens (DTs) may lead to improved clinical outcomes and decreased morbidity and mortality.  The goal of this retrospective Korean study was to identify clinical and laboratory findings in emergency department (ED) patients with seizures attributed to alcohol withdrawal and would predict progression to delirium tremens. ED patients presenting to 4 te...
Source: The Poison Review - April 14, 2015 Category: Toxicology Authors: Leon Tags: Medical alcohol withdrawal seizures delirium tremens DT homocysteine platelet count Source Type: news

Risk of completed suicide after initial hospitalization for deliberate overdose
3.5 out of 5 stars Risk of Suicide Following Deliberate Self-poisoning. Finkelstein Y et al. JAMA Psychiatry 2015 Apr 1 [Epub ahead of print] Abstract The authors primary objective was to determine the risk of subsequent successful suicide in patients discharged from hospital after a first suicide attempt. They used multiple healthcare databases to identify patients hospitalized for first suicide attempt in Ontario, Canada from April 2002 through December 2010. Subjects identified were followed through the end of 2011. For each subject a control patient without history of self-poisoningt was selected, matched for age, gend...
Source: The Poison Review - April 11, 2015 Category: Toxicology Authors: Leon Tags: Medical overdose risk self-poisoning suicide Source Type: news

Less is more: fatal C. difficile colitis after empiric antibiotics
Aspiration pneumonitis 4 out of 5 stars Antibiotics “Just-In-Case” in a Patient With Aspiration Pneumonitis. Joundi RA et al. JAMA Intern Med 2015 Apr 1;175:489-490 Reference This very brief but very important case report contains more key points than most papers 10 times as long. The case describes a 50-year-old man with cerebral palsy and a known seizure disorder who had several witnessed tonic-clonic seizure episodes treated with a benzodiazepine. Subsequent chest x-ray revealed multiple bibasilar opacities consistent with aspiration. The patient was started on piperacillin-tazobactam. Although he showed si...
Source: The Poison Review - April 9, 2015 Category: Toxicology Authors: Leon Tags: Medical adverse drug event aspiration pneumonia aspiration pneumonitis clostridium difficile colitis Source Type: news

Factors associated with emergency department opioid-related adverse drug events
This study has a number of limitations, which the authors discuss candidly. For example, the study design would miss capturing a patient who received an opioid in the emergency department, was admitted, and died from respiratory depression on the floor. Nevertheless, this is a valuable reminder of the patient, provider, and systems factors that should raise red flags of caution when administering opioids in the emergency department. Worth reading.   (Source: The Poison Review)
Source: The Poison Review - April 8, 2015 Category: Toxicology Authors: Leon Tags: Medical adverse drug events dilaudid emergency department hydromorphone opiates opioids Source Type: news

“Flakka”: one of the most bizarre drugs yet
South Florida has recently seen a number of cases associated (at least by history) by exposure to a street drug called “Flakka”: In Lake Worth, a naked man brandishing a handgun stood on the roof of an apartment building, shouting “I feel delusional, and I’m hallucinating.” In Fort Lauderdale, a man tried to kick in the door of the local police station because he thought he was being chased by automobile seeking to do him harm. And 2 weeks ago, also in Fort Lauderdale, a man impaled himself on a spiked fence around a police station apparently in thrall to a paranoid delusion: It is no wonder ...
Source: The Poison Review - April 4, 2015 Category: Toxicology Authors: Leon Tags: Medical alpha-PVP bath salts flakka gravel Source Type: news

Do we know the best treatment for jellyfish stings?
2.5 out of 5 stars What is the Most Effective Treatment for Relieving the Pain of a Jellyfish Sting? Ostermayer DG, Koyfman A.  Ann Emerg Med 2015 Apr;65:432-433. Reference This short article manages to pack a maximum amount of confusion into a very small space. The authors perform a literature search to find evidence that would answer their title question, but come up with only a single relevant randomized controlled trial that included exclusively stings from a specific jellyfish, the bluebottle (Physalia). That study involved 96 subjects with apparent bluebottle stings, and compared immersion of the affected body part...
Source: The Poison Review - April 2, 2015 Category: Toxicology Authors: Leon Tags: Medical bluebottle jellyfish peeing physalia portuguese man of war sting treatment urine vinegar Source Type: news

3 die in Rochester NY after smoking cocaine/fentanyl combination
Several days ago, WHEC NBC news in Rochester NY reported that in the previous week at least 3 people in the area died after smoking a mixture of cocaine and fentanyl. There may have been as many as 4 additional recent deaths associated with this combination. Late last year, there were 3 similar deaths in North Carolina. HT: @VPharmER for the heads-up on this story. (Source: The Poison Review)
Source: The Poison Review - April 1, 2015 Category: Toxicology Authors: Leon Tags: Medical cocaine death fatality fentanyl rochester NY Source Type: news

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