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W-18, a synthetic opiate 100 times more potent than fentanyl
W-18 Last August, Canadian police seized 110 illegal fentanyl pills at a home in Alberta province. Yesterday, Global News reported that some of the pills have tested positive for an extremely potent opioid called W-18. This is certainly a disturbing development, since W-18 is a μ-receptor agonist 100 times more potent than fentanyl. According to B.C. Centre for Disease Control, W-18 is one of a series of 32 synthetic opioids discovered in the 1980s at the University of Alberta. W1 thru W19 are pure μ-receptor agonists; W20 thru W32 are agonist-antagonists (as is buprenorphine.)  W-18 seems to be the most powerful agonis...
Source: The Poison Review - February 4, 2016 Category: Toxicology Authors: Leon Tags: Best of TPR Medical fentanyl opiate opioid w-18 Source Type: news

Coronary artery vasospasm induced by cocaine (maybe)
2.5 out of 5 stars Cocaine-Induced Coronary Artery Vasospasm. Almaddah N, Ajayi TO. N Engl J Med 2016 Feb 4;374:e5 Full Text with video In a series of amazing studies that are now about three decades old, Richard Lange and his colleagues at Parkland Hospital in Dallas investigated the cardiovascular effects of administering intranasal cocaine to patients to patients during cardiac catheterization for routine workup of chest pain. In an initial study, the group demonstrated that cocaine produced coronary artery vasoconstriction that was relieved by nitroglycerin and exacerbated by smoking a cigarette and also by ad...
Source: The Poison Review - February 4, 2016 Category: Toxicology Authors: Leon Tags: Medical cardiovascular effects cocaine coronary artery vasospasm Source Type: news

Tox Tunes #105: How Can a Poor Man Stand Such Times and Live (Ry Cooder)
Well the doctor comes around with a face all bright, And he says in a little while you’ll be all right. All he gives is a humbug pill, A dose of dope and a great big bill — Tell me how can a poor man stand such times and live? “How Can a Poor Man Stand Such Times and Live” was written by Blind Alfred Reed (1880-1956), who recorded it about a month after the stock market crash in 1929 that heralded the Great Depression. This great cover by Ry Cooder features a first-rate band including the legendary Flaco Jiménez on accordion. This cut was taken from a 1987 concert at The Catalyst in Santa Cruz. Th...
Source: The Poison Review - February 1, 2016 Category: Toxicology Authors: Leon Tags: Medical blind alfred reed flaco jimenez how can a poor man stand such times and live ry cooder tox tunes Source Type: news

Saturday with SMACC: Strayer on how to use opioids (and how not to use opioids)
The 3rd (and final) release of registrations for the 2016 Social Media and Critical Care (SMACC) conference in Dublin (June 13-16) will take place on February 3 at 09:00 Sydney time — or 4 pm Tuesday February 2 Chicago time. The 2nd release early December sold out in just one hour (!) after being posted,  so if you’re interested in attending plan accordingly. The program and registration details for the conference can be accessed at the smaccDUB website. To get a taste of what’s in store for Dublin, here’s a talk from last year’s smaccCHICAGO — Reuben Strayer’s excellent talk o...
Source: The Poison Review - January 31, 2016 Category: Toxicology Authors: Leon Tags: Medical addiction dublin epidemic opiate opioid SMACC smaccdub social media and critical care Source Type: news

Cannabis psychopharmacology: it’s more complex than you might imagine
Yarygin/shuttershock.com 3.5 out of 5 stars The Cannabis sativa Versus Cannabis indica Debate: An Interview with Ethan Russo, MD. Cannabis and Cannabinoid Research 2016 Jan;1:44-46 Full Text This short interview with Ethan Russo MD should be of interested to toxicologists and other clinicians who might counsel patients on issues regarding medical marijuana. It contains some interesting information about the different biologically active chemicals contained in cannabis plants, and their effects. These chemicals include: Δ9-tetrahydrocannabinol (THC) – main psychoactive chemical in Cannabis cannabinol – bre...
Source: The Poison Review - January 29, 2016 Category: Toxicology Authors: Leon Tags: Medical cannabidiol cannabinol cannabis cannabis indica cannabis sativa marijuana myrcene pinene THC Source Type: news

Extracorporeal treatment for digoxin toxicity: just say no
3 out of 5 stars Extracorporeal treatment for digoxin poisoning: systematic review and recommendations from the EXTRIP Workgroup. Mowry JB et al. Clin Toxicol 2016 Feb;54:103-14. Abstract “Forced diuresis, and hemodialysis are ineffective in enhancing the elimination of digoxin because of its large volume of distribution (4-10 L/kg), which makes it relatively inaccessible to these techniques.” Goldfrank’s Toxicologic Emergencies (Tenth Edition, 2015) That one sentence from the latest edition of Goldfrank’s tells you all you need to know about the use of extracorporeal treatment (ECTR)  in digoxin...
Source: The Poison Review - January 28, 2016 Category: Toxicology Authors: Leon Tags: Medical digoxin toxicity extracorporeal treatment extrip Fab fragment hemodialysis hemoperfusion Source Type: news

Tox on the Web: deadly French drug trial, fatal food, and more!
    Must-read post about the catastrophic phase 1 French drug trial: In a superb must-read post at the Forbes magazine website,  David Kroll discusses what we know about the disastrous drug safety trial in France that left 1 subject dead and 4 others with varying degrees of neurological damage.The drug in question — named BIA 10-2474 — is an inhibitor of the enzyme fatty acid amide hydrolase (FAAH) that was being developed as a new oral analgesic. As Kroll explains: What’s so important about FAAH? Our bodies make several fatty acid amides that include anandamide, a natural stimulator of the cannabinoi...
Source: The Poison Review - January 23, 2016 Category: Toxicology Authors: Leon Tags: Medical bia 10-2474 fatty acid amide hydrolase inhibitor litvenenko polonium-210 putin tox on the web Source Type: news

Happy Birthday, Wilbur Scoville! (1865-1942)
Pass the Carolina Reaper! (Source: The Poison Review)
Source: The Poison Review - January 22, 2016 Category: Toxicology Authors: Leon Tags: Medical Source Type: news

Definitive paper on phenytoin/phosphenytoin-associated purple glove syndrome
Purple glove syndrome (fda.gov) 4.5 out of 5 stars Purple Glove Syndrome after Phenytoin or Fosphenytoin Administration: Review of Reported Cases and Recommendations for Prevention. Garbovsky LA et al. J Med Toxicol 2015 Dec;11:445-459. Abstract Purple glove syndrome (PGS) is an uncommon adverse drug reaction to parenteral administration of phenytoin or fosphenytoin marked by severe progressive soft tissue discoloration, swelling and pain in the distal extremity into which the drug was infused. This extremely well done and comprehensive paper will tell you all you need to know (well, probably more than you need to know) ...
Source: The Poison Review - January 22, 2016 Category: Toxicology Authors: Leon Tags: Medical adverse drug reaction dilantin phenytoin phosphenytoin purple glove syndrome soft tissue Source Type: news

Review of synthetic cannabinoids out-of-date as soon as it’s published
3 out of 5 stars A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Tait RJ et al. Clin Toxicol 2016 Jan;54:1-13. Abstract This paper review clinical literature related to use of synthetic cannabinoids (SCs) through the end of 2015. Although it seems comprehensive, and cites 108 references, it is of course already at least 18 months out-of-date. The number of cases involving exposure to SC surged during 2015. For example, although the authors of this paper identified 22 deaths associated with SCs, according to CDC data in the first 6 months of 2015 alone ...
Source: The Poison Review - January 20, 2016 Category: Toxicology Authors: Leon Tags: Medical K2 spice synthetic cannabinoids systematic review Source Type: news

Must-read: combination acetaminophen-opioid formulations should be abandoned
4 out of 5 stars The prescription paradox of acetaminophen safety. Dart RC, Green JL. Pharmacoepidemiol Drug Saf 2015 Dec 29 [Epub ahead of print] Reference Last week, we pointed out that the American College of Medical Toxicology (ACMT) had issued a position statement on prescribing opioids that had missed a good opportunity to call for abandoning use of pharmaceutical products that combined strong opioids such as hydrocodone with acetaminophen. I just discovered that a recent editorial by Richard Dart and Jody Green from the Rocky Mountain Poison and Drug Center agree with my take on this matter. They point out that a re...
Source: The Poison Review - January 13, 2016 Category: Toxicology Authors: Leon Tags: Medical acetaminophen adverse effects hepatotoxicity opioid Source Type: news

Tox Tunes #104: Oxycontin Blues (Steve Earle)
This is from Steve Earle’s 2007 CD Washington Square Serenade. The lyrics are simple and stark: Well my daddy worked in the coal mine Till the company shut it down Then he sat around and drank his self blind Till we put him back underground Now nothing grows on this mountain And what’s a poor boy to do Except to wander these hills forgotten With the oxycontin blues Of course, in the nearly decade since this song came out, we’ve become all too aware that the “oxycontin blues” is an problem that has spread far beyond the coal region and Appalachia. Thanks to reader @kimvie for suggesting this ...
Source: The Poison Review - January 11, 2016 Category: Toxicology Authors: Leon Tags: Medical oxycontin blues Steve Earle tox tunes Source Type: news

Saturday with SMACC: Tox Dogmalysis
The 4th annual Social Media and Critical Care (SMACC) conference will take place in Dublin (Ireland, not California) later this year from June 13 through June 16. I’m really looking forward to it, both because last year’s meeting in Chicago was so much fun, and because the last day of the Dublin conference — June 16 —coincides with Bloomsday, the day James Joyce’s novel Ulysses takes place and the occasion every year for a huge festival in Dublin. The first two releases of tickets to SMACC Dublin sold out quickly. The third and last batch of tickets will be available in early February and are expecte...
Source: The Poison Review - January 10, 2016 Category: Toxicology Authors: Leon Tags: Medical benzodiazepine poisoning beta blocker Bryan Hayes calcium cocaine chest pain digoxin poisoning flumazenil hyperkalemia SMACC SMACC Chicago tox dogmalysis Source Type: news

ACMT position statement on prescribing opioids: a missed opportunity
3 out of 5 stars Safety Issues Regarding Prescription Opioids. American College of Medical Toxicology J Med Toxicol 2016 Jan 5 [Epub ahead of print] No abstract available This “Position Statement” from the American College of Medical Toxicology (ACMT) covers 3 topics related to safety issues associated with use of prescription opioids. Unfortunately, some of the positions taken by the College are, to say the least, wishy-washy, and represent a missed opportunity to make some important points forcefully. The first topic addressed in this statement involves the use of medications that combine acetaminophen with a...
Source: The Poison Review - January 7, 2016 Category: Toxicology Authors: Leon Tags: Medical american college of medical toxicology opiates opioids position statement prescribing Source Type: news

The 6th Annual Alexander Awards: The Best Tox Reading of 2015
Alexander Gettler At the end of every year, TPR bestows the coveted Alexander Awards on the best long-form writing on toxicology topics that have appeared in the popular press during the preceding 12 months. To be eligible, an article must be open-access and freely available, not locked behind some paywall. The awards were named for Alexander Gettler (1883-1968,) the head of toxicology for the Office of the Chief Medical Examiner on the City of New York during the first half of the 20th century. Gettler has been called the “father of forensic toxicology in America.” His work was vividly described in Deborah Blu...
Source: The Poison Review - December 31, 2015 Category: Toxicology Authors: Leon Tags: Medical Alexander awards arsenic earth and fire erowid erowid.org marsh test opiates opioids spice spike synthetic cannabinoids Source Type: news

Carbon monoxide “myths”
2.5 out of 5 stars Myth busting in carbon monoxide poisoning. Hampson NB. Am J Emerg Med 2015 Nov 3 [Epub ahead of print] Abstract This short review, by the former medical director for the Virginia Mason Center for Hyperbaric Medicine in Seattle, sets out to debunk four “myths” associated with carbon monoxide (CO) exposure. Although nothing here will surprise most emergency physicians, the paper may be worth a quick look. The “myths” discussed are: The caboxyhemoglobin (COHb) level correlates with symptoms in acute CO poisoning: What really matters is CO in the cells and central nervous system, no...
Source: The Poison Review - December 24, 2015 Category: Toxicology Authors: Leon Tags: Medical carbon monoxide toxicity myths Source Type: news

TPR Podcast Episode #10: Synthetic cannabinoids, “Crazy Monkey,” and a man and his dog
Episode #10: The Rise of Synthetic Cannabinoids…and Crazy Monkeys Written by Theresa Kim, M.D.   Highlights According to reports from the CDC, an increasing number of calls to poison centers for synthetic cannabinoid exposure has been noted on a local as well as national level A report in the Morbidity and Morality Weekly (MMWR) published June 2015 cites a 330% increase monthly incidence nationwide from January 2015 to April 2015 A report in the MMWR published April 2015 cites 721 suspected cases including 9 deaths at the Mississippi Control Center from April 2 to May 3 Most commonly reported adverse effects T...
Source: The Poison Review - December 17, 2015 Category: Toxicology Authors: LeonThe Poison Review Tags: Podcast Source Type: news

TPR Podcast Episode #10: Synthetic cannabdinois, “Crazy Monkey,” and a man and his dog
Episode #10: The Rise of Synthetic Cannabinoids…and Crazy Monkeys Written by Theresa Kim, M.D.   Highlights According to reports from the CDC, an increasing number of calls to poison centers for synthetic cannabinoid exposure has been noted on a local as well as national level A report in the Morbidity and Morality Weekly (MMWR) published June 2015 cites a 330% increase monthly incidence nationwide from January 2015 to April 2015 A report in the MMWR published April 2015 cites 721 suspected cases including 9 deaths at the Mississippi Control Center from April 2 to May 3 Most commonly reported adverse effects T...
Source: The Poison Review - December 17, 2015 Category: Toxicology Authors: LeonThe Poison Review Tags: Podcast Source Type: news

Tox Tunes # 103: I’ll Never Smoke Weed with Willie Again (Toby Keith & Scott Emerick)
Yesterday we linked to a New York Magazine piece about Willie Nelson and his relationship with marijuana. As described in the article: . . . Nelson’s tolerance is supernatural. He can easily smoke 30 or 40 hits in a session and then play a flawless two-hour show. He does not always deploy this talent toward noble ends. He is famous for smoking new friends to oblivion and then challenging them to a few hands of high-stakes poker. Willie’s game is cash-only, and all debts must be settled at the table. Toby Keith’s song “I’ll Never Smoke Weed with Willie Again” apparently was written after one suc...
Source: The Poison Review - December 13, 2015 Category: Toxicology Authors: Leon Tags: Medical i'll never smoke weed with willie again toby keith tox tunes willie nelson Source Type: news

Tox on the Web: doomsday scams and more!
Apocalyptic Con Games: An article in The New York Times Magazine by C. J. Chivers sets out to find whether the purportedly extremely toxic and explosive compound “red mercury” actually exists. According to some reports, the Islamic State of Iraq and the Levant (ISIL or ISIS) has been trying to acquire samples in order to build a neutron bomb or other doomsday weapon. The author finds that “red mercury” is an urban myth, likely perpetuated by arms merchants in attempts to scam terrorists and other gullible potential customers to pay large amounts of money for a chimera. In the following interview o...
Source: The Poison Review - December 12, 2015 Category: Toxicology Authors: Leon Tags: Medical Alcohol driving marijuana opioid toxicity red mercury weapon of mass destruction weed willie nelson Source Type: news

Case series: agitation and hallucinations after exposure to 25B-NBOMe (“N-bomb”)
25B-NBOMe 3.5 out of 5 stars Case series: toxicity from 25B-NBOMe — a cluster of N-bomb cases. Gee P et al. Clin Toxicol 2015 Dec 1 [Epub ahead of print] Abstract The NBOMe series of drugs are substituted phenethylamines. They act as agonists at both the 5-HT2A serotonin receptors and the α-receptors. Because of these actions they can cause both hallucinations (5-HT2A effects) and the sympathomimetic toxidrome (α effects.) Since these drugs are so potent, they are often sold in the form of impregnated blotter paper and misrepresented as LSD. Street names include N-Bomb, Wizard, Smiles, and Blue Batman. “N-bom...
Source: The Poison Review - December 8, 2015 Category: Toxicology Authors: Leon Tags: Medical @%B-NBOMe case series hallucinogenic stimulant n-bomb phenethylamine psychedlic Source Type: news

Effect of lipid rescue therapy on laboratory tests
3 out of 5 stars Review of the effect of intravenous lipid emulsion on laboratory analyses. Grunbaum AM et al. Clin Toxicol 2015 Dec 1 [Epub ahead of print] Abstract Lipemic serum can interfere with laboratory measurements because of a number of factors: sample turbidity, partitioning, and cross-reactivity. Clinicians who are not aware of these effects can be misled by erroneous lab results in ways that may affect patient management. The Lipid Emulsion Therapy in Clinical Toxicology Workgroup was established by the American Academy of Clinical Toxicology to “review all appropriate evidence pertaining to the use o...
Source: The Poison Review - December 3, 2015 Category: Toxicology Authors: Leon Tags: Medical intralipid laboratory interference lipid emulsion lipid rescue therapy Source Type: news

Do labels accurately reflect THC content of medical marijuana edibles?
Atomazul/shutterstock.com 3.5 out of 5 stars Cannabinoid Dose and Label Accuracy in Edible Medical Cannabis Products. Vantrey R et al. JAMA 2015 Jun 23/30:2491-2493. Reference Titrating the dose of edible marijuana is difficult for a number of reasons, including differing rates of absorption and unpredictable metabolism involving active metabolites. In addition, some states that have legalized medical marijuana have not instituted stringent monitoring and regulation to assure that the dose listed on the package is consistent with the actual amount of THC and other cannabinoids in the product. The authors of this interesti...
Source: The Poison Review - December 3, 2015 Category: Toxicology Authors: Leon Tags: Medical cannabidiol cannabis marijuana edibles medical marijuana THC Source Type: news

Chronic pain is not acute pain: forget the numerical pain scale
4 out of 5 stars Intensity of Chronic Pain — The Wrong Metric? Ballantyne JC, Sullivan MD. N Engl J Med 2015 Nov 26;373:2098-9. Full Text This short but very important “Perspective” article argues that numerical pain scales are absolutely the wrong way to evaluate and monitor  chronic pain. The authors point out that: Opioids . . . have good short-term efficacy, but there is little evidence supporting their long-term benefit. They note that the “titrate to effect” method that can be successful in treating acute or end-of-life (e.g., cancer) pain may not be appropriate or effective in cases of c...
Source: The Poison Review - November 27, 2015 Category: Toxicology Authors: Leon Tags: Medical acute chronic pain pain scale Source Type: news

Kitchen Tox: beware of the durian
ThamKC/shutterstock.com 3 out of 5 stars Durian Induced Hyperkalaemia. Leo CLB et al. Med J Malaysia 2011 Mar;66:66-67. Full Text Durian, a spiky, coconut-sized fruit native to Malaysia and grown throughout southeast Asia, is known for its distinctive aroma that some have compared to ripe Limburger cheese. The Oxford Companion to Food notes that others have compared the smell of durian to “the civet cat, sewage, stale vomit, onions, and cheese; while one disaffected visitor to Indonesia declared that the eating of the flesh was not much different from having to consume used surgical swabs.” Anthony Bourdain...
Source: The Poison Review - November 18, 2015 Category: Toxicology Authors: Leon Tags: Medical durian hyperkalemia kitchen toxicology potassium Source Type: news

Must-read: review of single-dose activated charcoal
wikipedia.org 4 out of 5 stars Activated charcoal for acute overdose: a reappraisal. Juurlink D. Br J Clin Pharmacol 2015 Sep 26 [Epub ahead of print] Abstract The British Journal of Clinical Pharmacology seems to be publishing a series of articles on basic management of the poisoned patient. Several weeks ago we reviewed (and highly recommended) Marco Sivilotti’s excellent discussion of flumazenil, naloxone and the coma cocktail. This current article looking at single-dose activated charcoal (SDAC) is similarly well done, and essential reading. The author points out that although most poisons bind to activated c...
Source: The Poison Review - November 17, 2015 Category: Toxicology Authors: Leon Tags: Best of TPR Medical gastric emptying management of poisoned patient Review single dose activated charcoal Source Type: news

Review: recreational marijuana use
Stanimir G. Stoev/Shutterstock.com 3 out of 5 stars Recreational cannabis use: Pleasures and pitfalls. Rella JG. Cleve Clin J Med 2015 Nov;82:765-72. Full Text This somewhat superficial but relatively well done review article gets extra credit for being available via open access. The author covers the history, pharmacology, toxicology, and acute and chronic effects of cannabis use, as well as withdrawal and the cannabinoid hyperemesis syndrome. My main problem with this paper involves the author’s casual use of references. For example, he states that previous literature had reported “a fivefold increased risk ...
Source: The Poison Review - November 10, 2015 Category: Toxicology Authors: Leon Tags: Medical recreational marijuana Review THC Source Type: news

Therapeutic plasma exchange in poisoned patients
1 out of 5 stars Therapeutic plasma exchange in poisoning: 8 years’ experience of a university hospital. Disel NR et al. Am J Emerg Med 2015 Oct;33:1391-1395. Abstract In therapeutic plasma exchange (TPE), blood is removed from the body, and plasma is separated from components such as RBCs, WBCs, and platelets. Those components are re-infused along with a replacement fluid such as fresh-frozen plasma or albumin. This procedure is usually used to removed pathological immunoglobulins in various conditions such as thrombotic thrombocytopenic purpura. There have been some case reports and small case series on the us...
Source: The Poison Review - November 8, 2015 Category: Toxicology Authors: Leon Tags: Medical apheresis plasma exchange poisoned patient toxicology Source Type: news

Use of flumazenil and naloxone in poisoned patients
4 out of 5 stars Flumazenil, naloxone and the ‘coma cocktail’ Sivilotti MLA Br J Clin Pharmacol 2015 Aug 7 [Epub ahead of print] Abstract This very smart paper reviews factors affecting the clinical use of two antidotes that reliably reverse  coma caused by two major classes of poisons: flumazenil for benzodiazepines, and naloxone for opiates. Both these antidotes are specific, rapid-acting, short-lived, and titratable. However, significant adverse effects have been associated with each of them. Unwise or overly aggressive administration of flumazenil can cause acute benzodiazepine withdrawal, agitation, seiz...
Source: The Poison Review - November 3, 2015 Category: Toxicology Authors: Leon Tags: Medical antidote benzodiazepine coma cocktail flumazenil naloxone opiate Source Type: news

Hemodialysis in lithium poisoning: there is no evidence. Full stop.
3.5 out of 5 stars Hemodialysis for lithium poisoning. Lavonas EJ, Buchanan J. Cochrane Database Sys Rev 2015 Sep 16 [Epub ahead of print] Abstract At a session at the ACEP Scientific Assembly last year, Jerry remarked: “Guidelines should regularly conclude that there is no evidence. Full stop.” I really like this Cochrane review of hemodialysis in lithium poisoning because [SPOILER ALERT] that is exactly what the authors conclude. They note that although hemodialysis undoubtedly increases clearance of lithium, there is no agreement as to whether this enhanced elimination actually improves clinical outcome. In...
Source: The Poison Review - September 29, 2015 Category: Toxicology Authors: Leon Tags: Medical cochrane review extracorporeal treatment hemodialysis lithium poisoning Source Type: news

Tox Tunes #102: Jake Leg Blues (The Mississippi Sheiks, 1930)
  “Jake Leg Blues”  by the Mississippi Sheiks is another song form the 1930s that describes the ravages wrought by Jamaica Ginger extract, an alcohol-containing patent medicine that was deliberately contaminated with the organophosphate compound tricresyl phosphate (TOCP) during prohibition. For a more complete description of this tragic episode of mass poisoning, and for references, see our previous post. “Limber leg” refers both to the leg weakness and foot drop caused by TOCP, and also to the impotence that affected many victims. The blog Vernacular:Shellac has a great post about Jake Leg...
Source: The Poison Review - September 28, 2015 Category: Toxicology Authors: Leon Tags: Medical jake leg mississippi sheiks organophosphate poisoning tocp tox tunes toxicological history Source Type: news

Case report: seizures after exposure to 25B-NBOMe (N-Bomb)
Blue Batman pills (25C-NBOMe) 3 out of 5 stars Beware of blotting paper hallucinogens: severe toxicity with NBOMes. Isbister GK et al. Med J Aust 2015 Sep 21;203:266-267 Reference 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 the sympathomimetic toxidrome (α effects.) Since these drugs are so potent, they are often sold in the form of impregnated blotter paper and misrepresented as LSD. Street names include N-Bomb, Wizard, Smiles, and Blue Batman. This brief...
Source: The Poison Review - September 24, 2015 Category: Toxicology Authors: Leon Tags: Medical 25B-NBOMe hallucinogenic stimulant n-bomb Source Type: news

Tox Tunes #101: Alcohol and Jake Blues (Tommy Johnson, 1930)
One of the most interesting, and tragic, episodes of mass poisoning in U.S. history involves “jake paralysis“. The first depiction in the medical literature was in a June 1930 New England Journal of Medicine article, that described an epidemic of motor neuropathy that occurred in the midwestern and southern states. As I explained in the “Toxicology Rounds” column in Emergency Medicine News: Onset of this condition was usually heralded by lower leg muscular pain and tingling, rapidly followed by weakness that often also involved the upper extremities. Distal deep tendon reflexes were diminished. Sens...
Source: The Poison Review - September 21, 2015 Category: Toxicology Authors: Leon Tags: Medical jake leg jake walk limber leg neurotoxicity opidn organophosphate induced delayed neuropathy Tommy Johnson Source Type: news

Implications of obesity for pharmacology and toxicology
3.5 out of 5 stars A Review of the Toxicologic Implications of Obesity. Zuckerman M et al. J Med Toxicol 2015 Sep;11(3):342-54 Abstract The authors of this thought-provoking study propose that obese patients be considered a “special population” — similar to children, the elderly, and pregnant women — for matters of medical toxicology. Obesity — defined as a body mass index (BMI) > 30 kg/m2 — is associated with a number of pharmacokinetic and pharmacodynamic changes that can impact on toxicology: increased blood volume and cardiac output impaired respiratory function alterations in gastric emptying (...
Source: The Poison Review - September 19, 2015 Category: Toxicology Authors: Leon Tags: Medical medical toxicology obesity pharmacodynamics pharmacokinetics Source Type: news

Colchicine in acute gout: high-dose or low-dose or no-dose?
3.5 out of 5 stars Does Colchicine Improve Pain in an Acute Gout Flare? Turner J, Cooper D. Ann Emerg Med 2015 sep;66:260-1. Reference The 7th edition of Tintinalli’s Emergency Medicine (2011) has this to say about using colchicine to treat gout: Oral colchicine is typically administered in a dose of 0.6 milligrams/h until intolerable side effects (vomiting or diarrhea) or efficacy ensues. This “typical” dosing schedule goes back decades, and even when I was a medical student who didn’t know an Ewald tube from an Ewok it never made sense to me. The instructions might as well have been “Take ...
Source: The Poison Review - September 11, 2015 Category: Toxicology Authors: Leon Tags: Medical acute gout adverse events cochrane review colchicine toxicity dosing Source Type: news

Case report: use of ECMO in colchicine poisoning
Colchicum autumnale (Autumn crocus) 3.5 out of 5 stars Extracorporeal life support in the treatment of colchicine poisoning. Boisramé-Helms J et al. Clin Toxicol 2015;53:827-829. Abstract Colchicine toxicity occurs roughly in 3 phases. During the initial 24 hours, severe gastrointestinal symptoms — nausea, vomiting, and diarrhea — can cause hypotension and shock if fluid losses are not adequately replaced. During the second phase, severe toxicity can manifest with pancytopenia, sepsis, rhabdomyolysis, and renal failure. In addition, within days after ingestion, patients can develop cardiogenic shock and sudden cardia...
Source: The Poison Review - September 11, 2015 Category: Toxicology Authors: Leon Tags: Medical autumn crocus colchicine poisoning colchicum autumnale ECLS ECMO extracorporeal life support extracorporeal membrane oxygenation Source Type: news

Case report: veno-venous ECMO as a bridge to lung transplantation in paraquat poisoning
3 out of 5 stars Successful extracorporeal membrane oxygenation therapy as a bridge to sequential bilateral lung transplantation for a patient after severe paraquat poisoning. Tang X et al.  Clin Toxicol 2015 Aug 28 [Epub ahead of print] Abstract Conceptually, extracorporeal membrane oxygenation (ECMO) seems a perfect technique for treating some of the sickest toxicology patients,  buying time until failing vital functions can recover. With severe cardiotoxins — for example, calcium channel blockers, beta blockers or bupropion — veno-arterial ECMO can provide complete cardiopulmonary bypass, replacing both cardiac a...
Source: The Poison Review - September 9, 2015 Category: Toxicology Authors: Leon Tags: Medical ECMO extracorporeal membrane oxygenation lung transplantation paraquat poisoning Source Type: news

Is ED use of flumazenil safe?
2 out of 5 stars Lack of adverse effects from flumazenil administration: an ED observational study. Nguyen TT et al. Am J Emerg Med 2015 Jul 21 [Epub ahead of print] Abstract The use of the antidote flumazenil in patients with suspected benzodiazepine poisoning is controversial. The major concern is for inducing seizures in a patient who has a proconvulsant medication on board, is tolerant to benzodiazepines, or has an underlying seizure disorder. The goal of this single-hospital retrospective observational study was to “assess adverse events and clinical outcomes of flumazenil administration in known and suspected...
Source: The Poison Review - September 4, 2015 Category: Toxicology Authors: Leon Tags: Medical antagonist antidote benzodiazepine overdose flumazenil Source Type: news

Delayed seizure after exposure to a synthetic cannabinoid product
PB-22 3 out of 5 stars Delayed seizure-like activity following analytically confirmed use of previously unreported synthetic cannabinoid analogues. Schep LJ et al. Hum Exp Toxicol 2015 May;34:557-60. Abstract Exposure to s0-called synthetic cannabinoid products, which may consist of any of 100s of specific compounds — of a combination of these chemicals — have been associated with a wide range of signs and symptoms, including anxiety and agitation, drowsiness, vomiting, tachycardia, hallucinations, and seizures. Diagnoses associated with such exposure have included myocardial infarction, ischemia stroke, and acute kid...
Source: The Poison Review - September 1, 2015 Category: Toxicology Authors: Leon Tags: Medical 5F-PB-22 AM-2233 JWH-122 seizure spice synthetic cannabinoid Source Type: news

The first 100 “Tox Tunes”
On January 3, 2010, TPR launched “Tox Tunes,” a series of clips of songs about drug, toxins, and poisons starting with Keith Richards’ version of Reverent Gary Davis’s “Cocaine Blues.” Last week, we featured our one-hundredth tune, Amy Winehouse’s classic — and tragically ironic — song “Rehab.” To celebrate the 100-tunes milestone, we are listing all the selections with links to the original  posts. Enjoy! #1: Cocaine Blues (Keith Richards) #2: Sister Morphine (Marianne Faithfull) #3: Reefer Man (Cab Calloway) #4: Modern Times (Charlie Chaplin) #5: Who Put the Benz...
Source: The Poison Review - August 31, 2015 Category: Toxicology Authors: Leon Tags: Medical first hundred tox tunes Source Type: news

Management of body packers
This article from Hillingdon Hospital in London — located a mere 4 miles from Heathrow airport — was intended to evaluate the facility’s existing protocol for managing body packers. Although some details of their protocol are not justified or even well-described, in general they align with the trend towards conservative treatment of asymptomatic patients, with observation bowel cleansing agents — they used Picolax (sodium picosulfate with magnesium citrate) or Klean-Prep (polyethylene glycol.) Surgery was reserved for patients showing signs of toxicity from cocaine or heroin, or gastrointestinal obstruction, bu...
Source: The Poison Review - August 25, 2015 Category: Toxicology Authors: Leon Tags: Medical body packers cocaine Hillingdon Hospital management mules Source Type: news

Tox Tunes #100: Rehab (Amy Winehouse)
TPR started the series “”Tox Tunes” on January 3, 2010 with Keith Richards’ cover of Reverend Gary Davis classic “Cocaine Blues.” Our stated goal was to highlight selections “culled from the long tradition of popular songs about drugs, toxins, and poisoning.” Amy Winehouse’s “Rehab” — sometimes called the most ironic song in history — is our one-hundredth selection. Of course, Winehouse died of alcohol intoxication in July 2011; the coroner’s report listed her blood alcohol level as 416 mg/dL. As a look back, we will post a list of — and links to...
Source: The Poison Review - August 24, 2015 Category: Toxicology Authors: Leon Tags: Medical Alcohol amy winehouse ethanal rehab tox tunes Source Type: news

Make the Diagnosis, Sherlock!
A 24-year-old man is brought to the emergency room with altered mental status. He was found wearing only his undershorts and shouting “I am God!” A friend reports that 3 hours before presentation the patient had been seen smoking marijuana. Can you make the diagnosis? This case is part of the New England Journal of Medicine‘s “Interactive Medical Case” series. It is not behind the Journal‘s firewall and costs nothing to play. Subscribers can earn CME or MOC credit. To work through the case, click here. (Source: The Poison Review)
Source: The Poison Review - August 19, 2015 Category: Toxicology Authors: Leon Tags: Medical agitated delirium hyperthyroidism interactive medical case new england journal of medicine thyroid storm Source Type: news

Google Glass in toxicology: there may be less here than meets the eye(glasses)
Google Glass 3 out of 5 stars The Feasibility and Acceptability of Google Glass for Teletoxicology Consults. Chai PR et al. J Med Toxicol 2015 Aug 6 {Epub ahead of print] Abstract This paper takes up a fascinating subject — it has already received a fair amount of attention in the media — but I think there is somewhat less here than meets the eye. Google Glass is an optical head-mounted device (OHMD) that looks like a a pair of eyeglasses with an extra do-dad placed in front of one lens. This structure contains a camera and a display. The Glass is connected to the internet through a wi-fi network. In addition, the G...
Source: The Poison Review - August 18, 2015 Category: Toxicology Authors: Leon Tags: Medical consultation Google Glass head-mounted device medical toxicology Source Type: news

Ten cases of suspected palytoxin poisoning
This report describes the investigation by the Alaska Section of Epidemiology into at least 10 cases of palytoxin poisoning over a 2 year period. The index case, a middle-aged man, presented to the emergency department complaining of a “bitter metallic taste,” fever, weakness, headache, cough, as well as arthralgias and myalgias. Approximately 7-8 hours before presentation, live zoanthid coral was placed in his home aquarium. On presentation, he was tachycardic (135/min,) tachypnic, and febrile (103oF.) Two other persons who lived with the index case presented with milder symptoms. The authors point out that th...
Source: The Poison Review - August 15, 2015 Category: Toxicology Authors: Leon Tags: Medical aquarium colonial coral palytoxin zoanthid Source Type: news

Candiru: a catfish that’s small, eel-like, and penetrates the urethra
3.5 out of 5 stars Candiru — A Little Fish With Bad Habits: Need Travel Health Professionals Worry? A Review. Bauer IL J Travel Med 2013 Mar-Apr;20:119-124. Abstract Don’t know how I missed this paper when it was published 2 years ago. The author searched medical literature to answer the pressing question: Is there really a catfish native to the Amazon River that can swim up — and become embedded in — a man’s urethra? TPR has posted on this subject before. The candiru (Vandellia cirrhosa) — a tiny eel-like catfish — is a blood-sucking parasite that preys on larger fish, following the stream of water a...
Source: The Poison Review - August 12, 2015 Category: Toxicology Authors: Leon Tags: Medical candiru catfish penis urethral penetration urology Source Type: news

Early metabolic acidosis and coma in massive acetaminophen overdose
3.5 out of 5 stars Coma and Severe Acidosis: Remember to Consider Acetaminophen. Villano JH et al. J Med Toxicol 2015 July 8 [Epub ahead of print] Reference This paper, from UC-San Diego, contains an excellent case discussion that makes numerous important points about a patient who presents with decreased mental status and high-anion-gap metabolic acidosis. The patient was a 28-year-old male who was brought to the emergency department because he was found to be unresponsive in his jail cell 16 hours after being arrested for murder. Initial evaluation revealed tachycardia (111/min,) mild hypothermia (95.5oF,) and a depresse...
Source: The Poison Review - August 7, 2015 Category: Toxicology Authors: Leon Tags: Medical acetaminophen overdose APAP elevated anion gap metabolic acidosis Source Type: news

Review: liquid nicotine toxicity
2.5 out of 5 stars Liquid Nicotine Toxicity. Kim JW, Baum CR. Pediatr Emer Care 2015;31:517-524. Abstract This review of liquid nicotine toxicity is part of the continuing medical education series in Pediatric Emergency Care. While there are a few good clinical nuggets buried in this review, they are surrounded by so many distracting and unnecessary epidemiological facts that the whole paper — though relatively short — is a chore to read. In addition, some of the “facts” are wrong. For example:: A study found that the proportion of calls that poison control centers received regarding e-cigarettes and cigare...
Source: The Poison Review - July 30, 2015 Category: Toxicology Authors: Leon Tags: Medical e-cigarettes electronic cigarettes liquid nicotine toxicity Source Type: news

Venlafaxine abuse
2.5 out of 5 stars Venlafaxine as the ‘baby ecstasy’? Literature overview and analysis of web-based misusers’ experiences. Francesconi G et al. Hum Psychopharmacol Clin Exp 2015 Jul;30:255-261.  Abstract In 2003, Sattar et al published a case report of venlafaxine abuse in a 38-year-old man. The patient had been prescribed 225-mg extended-release venlafaxine daily. He found that increasing his dose by 50% — to 337.5-mg per day — initially produced a “sudden, amphetamine-like ‘high'” that he did not re-experience even after increasing the dose to 450-mg. He subsequently discovered ...
Source: The Poison Review - July 30, 2015 Category: Toxicology Authors: Leon Tags: Medical abuse effexor overdose venlafaxine Source Type: news

Case series: anxiety and agitation following exposure to the synthetic cannabinoid ADB-PINACA
3 out of 5 stars A Common Source Outbreak of Severe Delirium Associated with Exposure to the Novel Synthetic Cannabinoid ADB-PINACA. Schwartz MD et al. J Emerg Med 2015 May;48:573-80. Abstract As noted in a recent survey of synthetic cannabinoid exposures in the New England Journal of Medicine, the synthetic cannabinoid (SC) ADB-PINACA was associated with outbreaks in August and September 2013, both in Brunswick GA (22 cases) and Denver CO (> 220 exposures). This paper reports on 7 cases from the outbreak in Georgia. All patients tested positive for ADB-PINACA or its metabolic ADB-PINACA-5-Pentoic Acid in plasma a...
Source: The Poison Review - July 29, 2015 Category: Toxicology Authors: Leon Tags: Medical ADB-PINACA agitation anxiety black mamba case series crazy clown delirium synthetic cannabinoid Source Type: news