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The Poison Review

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Flagellate dermatitis — when the shiitake hits the fan
Flagellate dermatitis 3.5 out of 5 stars Shiitake dermatitis recorded by French Poison Control Centers — new case series with clinical observations. Boels D et al. Clin Toxicol 2014 Jul;52:625-628. Abstract Just when you thought it was safe to go back to Whole Foods . . . I must admit — I had not idea that eating raw shiitake mushrooms can cause a “very spectacular and uncomfortable” toxic dermatitis. This authors retrospectively reviewed all cases reported to French Poison Control Centers from the years 2000 through 2013 related to consumption of shiitake mushrooms. They identified 15 cases that presented...
Source: The Poison Review - June 30, 2014 Category: Toxicology Authors: Leon Tags: Medical dermal toxicity flagellate dermatitis shiitake mushroom skin Source Type: news

Must-read: getting started in online emergency medicine education and FOAMed
4 out of 5 stars Five Strategies to Effectively Use Online Resources in Emergency Medicine. Thoma B et al. Ann Emerg Med 2014 Jun 21 [Epub ahead of print] Reference FOAM (Free Open Access Meducation) was born, legend has it, in 2012 during an international conference in Dublin, as Dr. Mike Cadogan  stared into the dregs of a pint of Guinness wondering how to bring together the explosion of education-themed social media activity in the fields of emergency medicine and critical care. The bottom of his glass suggested an appropriate acronym. Since then, of course, the sheer volume of #FOAMed  material on the web has ex...
Source: The Poison Review - June 28, 2014 Category: Toxicology Authors: Leon Tags: Best of TPR Medical FOAM FOAMed FOAMtox online education strategy Source Type: news

Does cannabis cause acute coronary syndromes?
2 out of 5 stars Is recent cannabis use associated with acute coronary syndromes? An illustrative case series. Casier I et al. Acta Cardiol 2014 Apr;69:131-136. Abstract Tetrahydrocannabinol (THC) has a number of well-documented effects on the cardiovascular system: increased heart rate increased blood pressure decreased peripheral vascular resistance orthostatic hypotension THC may also be associated in rare cases with induction of ventricular arrhythmias. In addition, smoking marijuana may decreased oxygen delivery to the myocardium because of elevated carboxyhemoglobin levels. This paper presents 3 cases in which, t...
Source: The Poison Review - June 25, 2014 Category: Toxicology Authors: Leon Tags: Medical cannabis cardiotoxicity coronary disease marijuana tetrahydrocannabinol THC Source Type: news

Overdose and death from pediatric chloral hydrate sedation
Chloral hydrate 4 out of 5 stars Pediatric Chloral Hydrate Poisonings and Death Following Outpatient Procedural Sedation. Nordt SP et al. J Med Toxicol 2014 Jun;10:219-222. Abstract The medical use of chloral hydrate goes back to the 19th century. It is still used occasionally today for pediatric pre-procedural sedation. The risks inherent in this practice are illustrated in this excellent short article. The authors present a series of 3 cases of chloral hydrate overdose, —including 1 fatality — that all occurred within a 4-month period: A 4-year-old girl was prescribed 900 mg chloral hydrate by her dentist, to be ta...
Source: The Poison Review - June 24, 2014 Category: Toxicology Authors: Leon Tags: Medical chloral hydrate overdose death fatality pediatric sedation Source Type: news

An unusual complication of injecting paraffin oil to enhance body sculpting
3 out of 5 stars Severe hypercalcaemia, nephrocalcinosis, and multiple paraffinomas caused by paraffin oil injections in a young bodybuilder. Gyldenløve M et al. Lancet 2014 Jun14;383:2098 Reference This short case report describes a 23-year-old male bodybuilder who presented with scrotal pain. The patient also admitted to shortness of breath and chest tightness. Workup for infection and nephrolithiasis was negative. Laboratory tests revealed anemia, renal insufficiency, and severe hypercalcemia (free calcium approximately twice normal.) Physical examination revealed multiple dense nodules in the skin and subcutaneous t...
Source: The Poison Review - June 20, 2014 Category: Toxicology Authors: Leon Tags: Medical body building body sculpting calcium CYP27B1 hypercalcemia mineral oil paraffin oil vitamin D Source Type: news

No, Craigslist is not a research tool
This study aimed to get preliminary information about perceptions of “dab” users related to the product, and whether “dab” is associated with increased risk of THC tolerance or withdrawal. Interesting questions, but unfortunately the methods used were, let’s say, less than scientifically rigorous. The authors posted ads on “Craigslist” in 12 U.S. cities, asking for volunteers to fill out a questionnaire and offering a chance for cash prizes in return. There was no checking for reliability of responses or duplicate entries, and volunteers were not provided any specific definitions o...
Source: The Poison Review - June 18, 2014 Category: Toxicology Authors: Leon Tags: Medical bho butane hash oil dab glass marijuana shatter tetrahydrocannabinol THC wax Source Type: news

Must-read: the approval of Zohydro, and more tox on the web
Must-read of the week: Stephen S. Hall’s article “How Much Does It Hurt?” in the current edition of  New York magazine gives the best explanation I’ve seen of how the Food and Drug Administration ended up approving the extended-release hydrocodone product ZohydroER, even though their scientific advisory committee recommended against approval by a vote of 11-2. According to the article, Dr. Robert Rappaport, Director of the FDA’s Anesthesia, analgesia, and Addiction Products section, “reminded that advisory committee that it had to consider the Zohydro application within the narrow regu...
Source: The Poison Review - June 16, 2014 Category: Toxicology Authors: Leon Tags: Medical ayahuasca FDA new york magazine zohydro Source Type: news

Review: marijuana and health
3 out of 5 stars Adverse Health Effects of Marijuana Use. Volkow ND et al. N Engl J Med 2014 Jun 5;370:2219-2227. No abstract available This review article by Dr. Nora Volkow and her colleagues at the National Institute on Drug Abuse is in most respects a rather fair and balanced look at the potential adverse effects of marijuana use. Among the potential negative effects discussed are: impaired driving ability impaired brain development during childhood and adolescence impaired school performance with increased risk of dropping out marijuana addiction and withdrawal The authors reasonably state that other often-mention...
Source: The Poison Review - June 14, 2014 Category: Toxicology Authors: Leon Tags: Medical adverse health effects marijuana Review THC Source Type: news

Inter-species case series: seizures associated with a novel synthetic cannabinoid
3.5 out of 5 stars ‘Crazy Monkey’ Poisons Man and Dog: Human and canine seizures due to PB-22, a novel synthetic cannabinoid. Gugelmann H et al. Clin Toxicol 2014 Jun 6 [Epub ahead of print] Abstract This amazing case report (or inter-species case series) comes from the California Poison Control System and UC-SF. A 22-year-old man brings his dog to the veterinarian because of possible seizure activity. While at the veterinary clinic, the man has a witnessed tonic-clonic generalized seizure lasting 1 minute. A friend reported that the (human) patient had recently smoked material labelled “Crazy MonkeyR...
Source: The Poison Review - June 10, 2014 Category: Toxicology Authors: Leon Tags: Medical crazy monkey pb-22 qupic toxic seizures UR-144 Source Type: news

Taste test: would a child find e-cigarette nicotine liquids appealing?
Calls to poison centers regarding ingesting e-cigarette nicotine liquid have increased radically in recent years. There is clearly enough nicotine in a vial of this liquid to constitute a lethal dose for a toddler. Nicotine is a potent cholinergic neurotoxin. When you consider that the industry is at present unregulated and that many containers are not child-proof — as well as the candy and fruit flavors many of these products come in — it is somewhat surprising that no cases of serious toxicity have yet been reported. Recently, the Food and Drug Administration announced that they would begin regulating these products....
Source: The Poison Review - June 9, 2014 Category: Toxicology Authors: Leon Tags: Medical e-cigarette lethal dose nicotine liquid pediatric exposure Source Type: news

Castor bean ingestion: do they kill?
2.5 out of 5 stars Castor bean seed ingestions: A state-wide poison control system’s experience. Thornton SL et al. Clin Toxicol 2014 Apr;52(4):265-8. Abstract Castor beans (Ricinus communis) contain ricin,  a toxin that inhibits ribosomal function, impairing protein synthesis. It is often called the most powerful plant poison — able to kill in extremely small doses. When ingested, especially if chewed, castor beans can cause gastrointestinal symptoms: abdominal pain, nausea, vomiting, diarrhea and volume depletion. But despite the widespread presence of R. communis as a shrub and decorative plant, there has ...
Source: The Poison Review - June 6, 2014 Category: Toxicology Authors: Leon Tags: Medical castor bean ricin ricinus communis Source Type: news

Memo to Maureen Dowd – peak effect of ingested marijuana is delayed up to 3 hours
If only Maureen Dowd had seen this report from KCNC (CBS4) in Denver before seriously misjudging her dose of a marijuana-chocolate-caramel edible. As she described yesterday in the New York Times: But then I felt a scary shudder go through my body and brain. I barely made it from the desk to the bed, where I lay curled up in a hallucinatory state for the next eight hours. I was thirsty but couldn’t move to get water. Or even turn off the lights. I was panting and paranoid, sure that when the room-service waiter knocked and I didn’t answer, he’d call the police and have me arrested for being unable to handle my candy....
Source: The Poison Review - June 5, 2014 Category: Toxicology Authors: Leon Tags: Medical bad trip denver edible pot marijuana Maureen Dowd overdose THC Source Type: news

Rubbing alcohol toxicity
3.5 out of 5 stars Isopropanol poisoning. slaughter RJ et al. Clin Toxicol 2014 May 9 [Epub ahead of print] Abstract This comprehensive and well done review article will tell you perhaps more than you wanted to know about isopropyl alcohol poisoning. This is, frankly, not the sexiest topic in medical toxicology, since isopropanol ingestion generally responds to supportive care and rarely causes death. However, for those who want to get granular on the subject, this is now the go-to paper. Some key points: Isopropanol is rapidly absorbed, mostly in the first 30 minutes after ingestion. Isopropanol toxicity typically pres...
Source: The Poison Review - May 31, 2014 Category: Toxicology Authors: Leon Tags: Medical isopropanol isopropyl alcohol Review rubbing alcohol Source Type: news

Tox Tunes #83: Gimme a Pigfoot and a Bottle of Beer (Bessie Smith)
http://www.youtube.com/watch?v=HBzkXFFcBik Bessie Smith (1894-1937) was one of the greatest blues singers on the jazz age. On this cut, recorded in 1933, this plea for fun, a trotter, and a bottle of beer turns distinctly druggier in the last verse: Gimme a reefer and a gang o’ gin Slay me, ’cause I’m in my sin Slay me, ’cause I’m full of gin For more Bessie Smith, listen to her version of W.C. Handy’s St. Louis Blues, with Louis Armstrong on cornet. This sublime cut is one of the great recordings in American musical history: http://www.youtube.com/watch?v=3rd9IaA_uJI (Source: The Poison Review)
Source: The Poison Review - May 25, 2014 Category: Toxicology Authors: Leon Tags: Medical bessie smith gimme a pigfoot and a bottle of beer tox tunes Source Type: news

Counties in California sue manufacturers of opioid analgesics
This week, two counties in California sues five manufacturers of opioid analgesics, accusing them of carrying out a “campaign of deception” to boost sales of their products. According to a report in the Los Angeles Times: In sweeping language reminiscent of the legal attack against the tobacco industry, the lawsuit alleges the drug companies have reaped blockbuster profits by manipulating doctors into believing the benefits of narcotic painkillers outweighed the risks, despite “a wealth of scientific evidence to the contrary.” The effort “opened the floodgates” for such drugs and “...
Source: The Poison Review - May 25, 2014 Category: Toxicology Authors: Leon Tags: Medical lawsuit opiates opioid analgesics pain as fifth vital sign Source Type: news

NPR on Green Tobacco Sickness
As a supplement to yesterday’s post about green tobacco sickness, this is a report on the same topic from NPR’s “All Things Considered.” (Source: The Poison Review)
Source: The Poison Review - May 23, 2014 Category: Toxicology Authors: Leon Tags: Medical acute nicotine poisoning all things considered green tobacco sickness npr Source Type: news

Green tobacco sickness: down on the farm
This article is a good short review of the topic. The following video from the North Carolina Department of Labor is also a very good review, but does not deal specifically with GRS in children: http://www.youtube.com/watch?v=D6Fymvz2Zig To read my Emergency Medicine News column describing my own up-close-and-personal encounter with acute nicotine poisoning, click here.   (Source: The Poison Review)
Source: The Poison Review - May 22, 2014 Category: Toxicology Authors: Leon Tags: Medical green tobacco sickness nicotine toxicity pediatric Source Type: news

Make the diagnosis, Sherlock!
This is a case recently reported in the Medical Journal of Australia.  A 50-year-old woman presented with a read, painful, scaling rash on her hand an forearms, and around her eyes. She reported that sun exposure aggravated the dermal symptoms. She also gave a history of intermittent diarrhea. Examination revealed a scaly hyperpigmented lesion on her upper chest, in the distribution of a broad collar. The patient was a smoker and said she consumed half a bottle of gin daily. The skin manifestations did not respond to antibiotics or steroids. Click on the following questions to reveal the answers. Was is the diagnosis? ex...
Source: The Poison Review - May 22, 2014 Category: Toxicology Authors: Leon Tags: Medical dermatitis niacin deficiency pellagra Source Type: news

Episode #4: Poisoning and the diagnosis of brain death
Conclusion: unclear how long to wait before pronouncing brain death as many factors such as pharmacogenetics can alter normal metabolism   Summary Drug overdose can mimic brain death Be especially cautious in overdose involving the scary B’s: baclofen, barbiturate, benzodiazepine The 3-5 half life rule for drug clearance cannot be applied in the cases of overdose Half lives are measured at therapeutic levels Multiple other factors can alter metabolism in overdoses, such as pharmacogenetics, and cross reactivity with other ingestants Consult a toxicologist if there is any question regarding possible overdose in the ...
Source: The Poison Review - May 20, 2014 Category: Toxicology Authors: LeonThe Poison Review Tags: Podcast Source Type: news

From title on, this paper is a major fail
  1.5 out of 5 stars Intralipid therapy does not improve level of consciousness in overdoses with sedating drugs: A case series. Downes MA et al. Emerg Med Australas 2014 May 8. doi: 10.1111/1742-6723.12237. [Epub ahead of print] Abstract Frankly, I disliked everything about this paper. The authors did a retrospective chart review of patients at their institution who were given intralipid emulsion therapy (ILE) after presenting with a sedative drug overdose. Their goal was to determine if ILE improved the patients’ level of consciousness. Why did I hate this study? Let me count the ways: Title: The declarativ...
Source: The Poison Review - May 17, 2014 Category: Toxicology Authors: Leon Tags: Medical intralipid lipid emulsion therapy sedative overdose Source Type: news

Methanol poisoning disaster in Kenya, and other tox on the web
Walking Dead Man: KDFW-TV in Dallas-fort Worth  is reporting that the synthetic cannabinoid responsible for sending at least 140 people to hospital in D-FW and Austin was packaged with the labels “Dead Man Walking” and “Walking Dead Man.” Signs and symptoms included psychosis, aggressive behavior, blackouts, and hyperthermia. You can read TPR‘s coverage of this outbreak here. 25I-NBOMe in Virginia: The CBS affiliate WUSA-TV in Washington D.C. recently reported that they were seeing more cases of intoxication from the psychedelic phenethylamine 25I-NBOMe. In one weekend last month, 3 girls a...
Source: The Poison Review - May 14, 2014 Category: Toxicology Authors: Leon Tags: Medical 25I-NBOMe canthardin groopman kenya liquid nitrogen poisoning methanol narcotic new leaf opiate opioids sapwell spanish fly synthetic cannabinoid toxic cocktail walking dead man Source Type: news

Case series: pediatric coral snake bites
Eastern coral snake (Micrurus fulvisu) 3 out of 5 stars Coral Snake Bites and Envenomation in Children: A Case Series. Sasaki J et al. Pediatr Emer Care 2014 Apr;30:262-265. Abstract Of the approximately 4700 native venomous snake bites reported to U.S. poison centers each year, about 98% involve pit vipers (Crotalinae). The other 2% result from encounters with coral snakes (Elapidae). In contrast to bites from pit vipers, those from coral snakes typically cause minimal local tissue effects. However, coral snake envenomation can produce neurotoxicity — with delayed onset of up to 12 hours — and progress (rarely) to re...
Source: The Poison Review - May 9, 2014 Category: Toxicology Authors: Leon Tags: Medical coral snake bite eastern coral snake elapidae envenomation neurotoxicity Source Type: news

Good quick review of bupropion toxicity, but . . . whole bowel irrigation? Seriously??
2.5 out of 5 stars Bupropion Abuse and Overdose. Stall N et al. CMAJ 2014 Apr 28 [Epub ahead of print] No abstract available online This one-page précis is part of CMAJ‘s “Five Things To Know About _______” series. The key points include: Bupropion blocks reuptake of dopamine and norepinephrine, and also blocks the action of acetylcholine at nicotinic receptors. Burpropion is abused recreationally for its mild cocaine-like “high.” Routes of bupropion abuse include snorting, ingestion, and intravenous injection. Brupropion lowers the threshold for seizures, which may be delayed as long as ...
Source: The Poison Review - May 9, 2014 Category: Toxicology Authors: Leon Tags: Medical abuse bupropion overdose seizures Source Type: news

First case report of toxicity from ingestion of e-cigarette nicotine liquid
3 out of 5 stars Nicotine Poisoning in an Infant. Bassett RA et al. N Engl J Med 2014 May 7 [Epub before print] Full Text This short “letter to the editor” is, to my knowledge, the first reported case of toxicity from ingestion of e-cigarette nicotine liquid. A 10-month-old male ingested an unknown amount of nicotine-containing liquid compounded at a local “vape” shop. The liquid was labelled as containing 1.8% nicotine (18 mg/ml) as well as glycerin, propylene glycol, and oil of wintergreen (methyl salicylate). the child presented with vomiting, tachycardia, “grunting” respirations, an...
Source: The Poison Review - May 8, 2014 Category: Toxicology Authors: Leon Tags: Medical case report cholinergic toxicity e-cigarette nicotine toxicity Source Type: news

This makes it clear: stoned driving is indeed dangerous
http://www.youtube.com/watch?v=d6gLrnJxS8c This investigative report from KIRO-7 Eyewitness News in Seattle is a surprisingly good illustration of the effects of marijuana smoking on driving skills. It would have been even better if the piece was more clear on the concept of a “legal limit.” There are some people on the internet and in print arguing that driving under the influence of THC is no big deal, and that the effects on driving skills are minimal at most. This is just wrong, and goes against both common sense and medical evidence. A recent literature review in the BMJ showed that driving under the infl...
Source: The Poison Review - May 4, 2014 Category: Toxicology Authors: Leon Tags: Best of TPR Medical cannabis driving impairment legal limit marijuana THC Source Type: news

Texas emergency departments seeing rash of violent reactions to synthetic cannabinoids
    NBC 5 news in Dallas-Fort Worth reported on a rash of overdoses across Texas in people using synthetic cannabinoids. Over the last 2 days, about 40 patients have been seen in Dallas alone after apparently being exposed to these products. (Unfortunately, the report does not mention the name of the product(s) or how they were labelled.) Presenting signs and symptoms included tachycardia, agitation, violent aggression, hallucinations, and seizures. According to a report in the Dallas Morning News, most cases in Dallas were seen at the Baylor University Medical Center and Parkland Memorial Hospital. Additional c...
Source: The Poison Review - May 3, 2014 Category: Toxicology Authors: Leon Tags: Medical Dallas synthetic cannabinoids Texas Source Type: news

Review emphasizes the molecular pharmacology of “bath salts”
3.5 out of 5 stars Synthetic Cathinones (“Bath Salts”) Banks ML et al. J Emerg Med 2014 May;46:632-42. Abstract If you’re a structure geek like I am, this article is an interesting read as it walks you through the molecular details affecting the actions of bath salts. Bath salts are synthetic substituted forms of cathinone, which itself is a monoamine alkaloid built on a scaffolding made up of the phenethylamine molecule. They increase synaptic levels of norepinephrine, dopamine, and serotonin. The relative intensity of the effects on these 3 neurotransmitter determine such features as addiction potenti...
Source: The Poison Review - May 2, 2014 Category: Toxicology Authors: Leon Tags: Medical bath salts cathinones molecular structure review article Source Type: news

Street Drug Update: butane hash oil and “gravel” (alpha-PVP)
My latest “Toxicology Rounds” column in Emergency Medicine News discusses some new developments in the world of street drugs. (It occurs to me that this term is somewhat outdated, since some products such as “butane hash oil” or “wax” are now legal in certain states.) To read the column, click here. (Source: The Poison Review)
Source: The Poison Review - May 2, 2014 Category: Toxicology Authors: Leon Tags: Medical alpha-PVP bho butane hash oil butane honey oil dab gravel legal highs street drugs wax Source Type: news

Discussion of salicylate toxicity misses several key points
2 out of 5 stars Salicylate-induced pulmonary edema — a near-miss diagnosis. Yuklyaeva N et al. Am J Emerg Med 2014 May;32(5):490.e5-6. doi: 10.1016 Reference – no abstract available This is a potentially interesting case, but the discussion misses so many important points and is so clueless about some key issues that I find it impossible to recommend reading the paper. A 43-year-old woman in brought to the emergency department with confusion, agitation, and increasing shortness of breath. Chest x-ray showed pulmonary edema with a normal-size heart. Arterial blood gas showed the following: pH  7.49 PO2  60 PCO2...
Source: The Poison Review - April 29, 2014 Category: Toxicology Authors: Leon Tags: Medical anion gap hemodialysis metabolic acidosis respiratory alkalosis salicylate toxicity Source Type: news

Make the diagnosis, Sherlock!
  3.5 out of 5 stars Case 12-2014: A 59-Year-Old Man with Fatigue, Abdominal Pain, Anemia, and Abnormal Liver Function. Friedman LS et al. N Engl J Med 2014 Apr 17;370:1542-1550. Reference – no abstract available This is from the long-running series “Case Records of the Massachusetts General Hospital.” A 59-year-old man presents to an outpatient clinic with abdominal pain, dysgeusia, constipation, nausea, a new microcytic anemia with basophilic stippling, and behavioral changes. Hepatic transaminases were elevated. Symptoms increased markedly over the next several days. The following are key question...
Source: The Poison Review - April 29, 2014 Category: Toxicology Authors: Leon Tags: Medical basophilic stippling case records of the massachusetts general hospital lead toxicity new england journal of medicine Source Type: news

Tox Tunes #82: One Toke Over the Line (Lawrence Welk)
http://www.youtube.com/watch?v=t8tdmaEhMHE In a September 1970 speech at the Sahara Hotel in Las Vegas, vice President Spiro Agnew attacked the “creeping permissiveness” pervading American society and the influence of drugs that “threatens to sap our national strength.” He singled out some then popular songs that he identified as “latent drug culture propaganda.” One of the songs he had in mind was Brewer & Shipley‘s 1970 hit “One Toke Over the Line.” According to some reports, Agnew pressured the FCC to ban the song from radio airwaves. Ironically, the next year, ...
Source: The Poison Review - April 27, 2014 Category: Toxicology Authors: Leon Tags: Medical brewer & shipley lawrence walk one toke over the line tox tunes Source Type: news

The Greatest Tox Scene in Opera
http://www.youtube.com/watch?v=dCWxbfFIflE Mozart’s Cosi fan tutte has what is, beyond any argument, the greatest and funniest medical toxicology scene in all of opera. On this Saturday (April 26), the Metropolitan Opera Live in HD series will broadcast Cosi to theaters around the world,with James Levine conducting. As one who thinks that the 3 operas — The Marriage of Figaro, Don Giovanni, and Cosi fan tutte — written by Mozart and his librettist Lorenzo Da Ponte represent the greatest works of art in the history of the human race, I can’t wait. In anticipation, I am rerunning this post from several ye...
Source: The Poison Review - April 24, 2014 Category: Toxicology Authors: Leon Tags: Medical Cosi Fan Tutte lorenzo da ponte Mozart opera Source Type: news

More about phenibut
3.5 out of 5 stars Phenibut (β-Phenyl-GABA): A Tranquilizer and Nootropic Drug. Lapin I. CNS Drug Rev 2001;7:471-481. Abstract Since posting about phenibut yesterday, I wondered how much medical literature existed describing its pharmacology and toxicology. This paper — not included in the  the initial accepted manuscript of O’Connell et al but referenced in the Wikipedia entry on phenibut — is the most complete discussion I found. However,  phenibut was first synthesized and used medically in the Soviet Union half a century ago and there undoubtedly is considerable literature published in Russian that I can...
Source: The Poison Review - April 22, 2014 Category: Toxicology Authors: Leon Tags: Medical dietary supplement GABA agonist phenibut Source Type: news

Toxicity from phenibut, a legal over-the-counter baclofen analogue
3 out of 5 stars Phenibut, the appearance of another potentially dangerous product in the Univted States. O’Connell CW et al. Am J Med 2014 Apr 5 [Epub ahead of print] Reference This short case report describes a 25-year-old man who was brought to the emergency department after being found with decreased mental status and responsiveness. On arrival at the hospital, his vital signs were stable and pulse oximetry 100% on room air. He was minimally responsive to painful stimuli. Neurological exam was non-focal and head CT unremarkable. A roommate reported that the patient had been taking 1.5 grams of “Phenibut...
Source: The Poison Review - April 22, 2014 Category: Toxicology Authors: Leon Tags: Medical baclofen GABA agonist legal high noofen phenibut sedative Source Type: news

Tox Tunes #81: Junko Partner (Dr. John)
http://www.youtube.com/watch?v=BqfH_1xCSME This is a great version of the blues standard from Dr. John‘s 1972 album Gumbo. The song has been covered by everyone from Professor Longhair to The Clash. The liner notes call this song “the anthem of the dopers, the whores, the pimps, the cons”: Lee Allenwails on this one, how many tenor choruses does he have, four? I love it! The song was first made popular by James Wayne’s hit on the “Sittin’ In” (Bob Shad’s) label. But it was a New Orleans classic; the anthem of the dopers, the whores, the pimps, the cons. It was a song they s...
Source: The Poison Review - April 20, 2014 Category: Toxicology Authors: Leon Tags: Medical dr. john junco partner junko partner tox tunes Source Type: news

Rocky Mountain Poison Center Staff Discuss Legalized Pot in Colorado
Dr. Eric Lavonas,  associate director of the Rocky Mountain Poison and Drug Center, discussed the situation with legalized cannabis in Colorado on 710KNUS in Denver. He noted that the 3 main problems emergency departments have been dealing since legalization have been psychotic reactions from persons not accustomed to the potency of the marijuana that’s on the market, the severe vomiting that some users experience, and children who inadvertently ingest cannabis edibles (candy, brownies cookies, etc) and show up with altered behavior. Dr. Lavonas also touched on the problem of users “stacking” doses of ed...
Source: The Poison Review - April 19, 2014 Category: Toxicology Authors: Leon Tags: Medical al bronstein cannabis colorado denver edible eric lavonas marijuana rocky mountain poison center Source Type: news