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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

What’s better for amatoxin poisoning: silibinin or leprechaun luck?
Amanita phalloides 2 out of 5 stars Survival Following Investigational Treatment of Amanita Mushroom Poisoning: Thistle or Shamrock? Gores KM et al. Chest 2014 Oct 1 [Epub ahead of print] Abstract Amatoxins are potent RNA inhibitors, shutting down protein synthesis and producing hepatonecrosis and, occasionally, renal injury. There is not generally accepted treatment for amatoxin-induced hepatotoxicity aside from supportive care, early multi dose activated charcoal, and liver transplant if indicated. There are, however, a number of unproven therapies that have been used and advocated in the past. This case report, from th...
Source: The Poison Review - November 18, 2014 Category: Toxicology Authors: Leon Tags: Medical amanita phalloides amatoxin milk thistle mushroom poisoning silibinin Source Type: news

Crayola toxicology: life-threatening causes of bluish vomiting
This article does serve to remind us of 3 important not-to-miss ingestions on the differential when a patient shows up barfing blue. Unfortunately, the authors misses an obvious mnemonic: Cerulean Blue Puke = Copper sulfate, Boric acid, Paraquat. Related posts: Green urine Propofol causes green urine An elderly woman with purple urine (Source: The Poison Review)
Source: The Poison Review - November 14, 2014 Category: Toxicology Authors: Leon Tags: Medical blue vomit boric acid copper sulfate crayola toxicology emesis paraquat Source Type: news

Snorting bupropion
2.5 out of 5 stars An 11-year review of bupropion insufflation exposures in adults reported to the California Poison Control System. Lewis JC et al. Clin Toxicol 2014 Nov;52:969-972. Abstract The abuse of bupropion by pulverizing and snorting the medication has been described at least as far back as 2002. Bupropion inhibits re-uptake of dopamine and norepinephrine, but apparently has little or no effect on serotonin. It is abused for its psychotropic effects that resemble those of amphetamine and cocaine.. A hallmark of overdose with sustained-release or extended-release bupropion formulations is delayed onset of seizures...
Source: The Poison Review - November 13, 2014 Category: Toxicology Authors: Leon Tags: Medical burpropion delayed seizures overdose toxicity Wellbutrin Zyban Source Type: news

Methoxphenidine: a designer dissociative drug
3 out of 5 stars Acute toxicity associated with the recreational use of the novel dissociative psychoactive substance methoxphenidine. Hofer KE et al. Clin Toxicol 2014 Oct 28 [Epub ahead of print] Abstract Methoxphenidine  (MXP) is a dissociative drug with actions apparently similar to those of phencyclidine (PCP), ketamine, and methoxetamine (MXE). It is often sold as a “research chemical” and labelled as “Not for Human Consumption.” The pharmacology and toxicology of MXP has not been well studied. Anecdotal reports on some drug forums describe anterograde amnesia and prolonged duration of effe...
Source: The Poison Review - November 12, 2014 Category: Toxicology Authors: Leon Tags: Medical case report designer drug dissociative ketamine methoxetamine pcp phencyclidine Source Type: news

Ban the Words: should the phrase “should be considered” be banished from the toxicology literature?
Interventions such as gastric lavage and whole bowel irrigation are labor intensive and associated with significant adverse effects. In addition, they have never been proven to improve clinical outcomes. Are we now at a point where we can stop discussing them, easing them into a dignified retirement along with ipecac-induced emesis? Many texts and review articles suggest that these interventions “should be considered” in selected toxicology cases. Should this phrase be banned from the literature? I will be hosting a Twitter chat with @EM_News tomorrow from noon – 1 pm EST to talk about my November column ...
Source: The Poison Review - November 10, 2014 Category: Toxicology Authors: Leon Tags: Medical ban the words Emergency Medicine News gastric lavage whole bowel irrigation Source Type: news

Saturday with SMACC: Weingart on sepsis in New York City
In this brilliant talk from smaccGOLD last March in Australia, Scott Weingart talks about lessons from the STOP Sepsis Collaborative project in New York City based on their experience with 15,000 severe sepsis patients. In brief, the Collaborative achieved a 22% reduction of in-patient mortality in these patients by relatively simple measures that did not involve early goal-directed therapy or fancy invasive monitoring. The key steps in their protocol involved: early recognition of the septic patient source control reasonable but not massive fluid administration inotropes early antibiotics meticulous intubation (if indica...
Source: The Poison Review - November 9, 2014 Category: Toxicology Authors: Leon Tags: Medical Paul Marik Scott Weingart septic shock SMACC Chicago smaccGold STOP sepsis collaborative Source Type: news

Sun Tzu and the Art of Focusing in Medical Toxicology
The philosophy expressed in Sun Tzu’s classic The Art of War has been applied to everything from military strategy to business management. But what does it have to teach practitioners of emergency medicine and medical toxicology? In my current column for Emergency Medicine News I discuss a very important lesson from the book that will completely change the way you read recommendations about gastric lavage and whole bowel irrigation still included in many textbook chapters and review articles. The read the column, click here. By the way, EM News will be hosting a Twitter Chat about the column to take place on Tuesday,...
Source: The Poison Review - November 7, 2014 Category: Toxicology Authors: Leon Tags: Medical gastric lavage should be considered sun tzu whole bowel irrigation Source Type: news

There is no real evidence on treating calcium channel blocker overdose
2.5 out of 5 stars Treatment of calcium channel blocker poisoning: A systematic review. St-Onge M et al. Clin Toxicol 2014 Nov;52:926-944. Abstract This systematic review is massive, intimidating, and all but unreadable. As a prelude to establishing a clinical guideline for treatment of calcium channel blocker (CCB) overdose, the 14 Canadian authors systematically searched and evaluated relevant literature. They initially identified 15,577(!) citations, from which two reviewers selected 216 for analysis. These included case reports, case series, animal trials, and observational studies. No eligible controlled trials were ...
Source: The Poison Review - November 7, 2014 Category: Toxicology Authors: Leon Tags: Medical calcium channel blocker overdose evidence systematic review therapy Source Type: news

Use of alkyl nitrite “poppers” can cause permanent visual impairment
Some poppers are sold as “Leather Cleaner” or “Acetone-free nail polish remover” 3.5 out of 5 stars Poppers maculopathy. Gruener AM et al. Lancet 2014;384:1606 Full Text This case report describes a 30-year-old man who developed central visual impairment after using alkyl nitrite “poppers” as a sexual aid. Eye exam revealed diminished visual acuity bilaterally, yellow foveal spots and damage to the retinal photoreceptors. Six months later, the visual impairment had not resolved. Previous cases of visual damaged associated with the use of alkyl nitrite poppers have been reported. (See,...
Source: The Poison Review - November 5, 2014 Category: Toxicology Authors: Leon Tags: Medical alkyl nitrite eye damage isobutyl nitrite isopropyl nitrite maculopathy poppers visual impairment Source Type: news

Position statement on bystander naloxone
4 out of 5 stars Position Statement: Expanding access to naloxone in the United States. Doyon S et al Clin Toxicol 2014 Oct 15 [Epub ahead of print] Reference This position statement was endorsed by the American Academy of Clinical Toxicology, the American College of Medical Toxicology, and the American Association of Poison control Centers. The authors start off by noting the marked increase in overdose deaths that have tripled over the last 30 years, and resulted in what the CDC calls an epidemic. They point out that in 2010 there were over 15,000 deaths from prescription opioid overdose. They also state — without cit...
Source: The Poison Review - November 5, 2014 Category: Toxicology Authors: Leon Tags: Medical bystander naloxone intranasal narcan narcotic opiate opioid overdose Source Type: news

Saturday with SMACC: Motorbike Mayhem
The lecture by John Hinds (@DocJohnHinds) last March at SMACC Gold in Brisbane was one of the most fascinating and unusual presentations I’ve ever seen at a medical conference. Hinds, a consultant anesthesiologist and intensivist at Craigavon Area Hospital in Northern Ireland, is also a motor bike racing enthusiast. His riveting account of the types of injuries that can occur in this sport — and how to manage them — should not be missed. To hear the lecture and access the slide set, click here. And that brings us to breaking, very exciting news. The brochure for SMACC CHICAGO has just been released, with just an ...
Source: The Poison Review - November 1, 2014 Category: Toxicology Authors: Leon Tags: Medical john hinds motor bike injury SMACC Gold smack chicago Source Type: news

Tox Tunes #89: Strange Brew (Cream)
http://www.youtube.com/watch?v=rGvfm7eEFSw   “Strange brew — killin’ what’s inside of you”   It always seemed to me that the subtext of this song was about drugs, although the lyrics don’t explicitly reference psychedelics or any other recreational pharmaceuticals. The song, found on Cream’s second album Disraeli Gears, is a reworking of Buddy Guy’s and Junior Wells’ version of an early blues song “Hey Lawdy Mama” that was in Cream’s early repertoire: http://www.youtube.com/watch?v=cj0_D5IGtfM Yesterday, Jack Bruce, Cream’s bass play...
Source: The Poison Review - October 26, 2014 Category: Toxicology Authors: Leon Tags: Medical cream disraeli gears eric clapton ginger baker jack bruce strange brew tox tunes Source Type: news

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