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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ACEP Toxicology Section Antidote App (free)
This simple but very useful app, from the Toxicology Section of the American College of Emergency Physicians, provides basic information about uses and dosing of basic antidotes used in toxicology. Version 1.1 covers approximately 50 different antidotes from A (acetylcysteine) to T (thiamine). Of course, clinical judgment is still required when considering these treatments, and most situations requiring use of the antidotes listed would justify consultation with a poison center. For example, one of the potential indications listed for hyperbaric oxygen (HBO) therapy in carbon monoxide (CO) poisoning is myocardial ischemia....
Source: The Poison Review - March 27, 2015 Category: Toxicology Authors: Leon Tags: Medical ACEP american college of emergency physicians android antidotes app iOS Source Type: news

Review: 23 patients with laboratory-confirmed MDPV exposure
Methylenedioxypyrovalerone (MDPV) 3.5 out of 5 stars Acute Methylenedioxypyrovalerone Toxicity. Fruberg BA et al. J Med Toxicol 2014 Dec 3 [Epub ahead of print] Abstract This is an impressive paper, but for reasons the authors thoroughly discuss in their limitations sections, there is somewhat less here than meets the eye. The authors retrospectively reviewed patients seen over a 2-year period at 10 different hospitals who were entered into the ToxIC Registry and coded under a term consistent with “bath salt” exposure. Cases were eligible for the study if they had blood and/or urine laboratory confirmation p...
Source: The Poison Review - March 25, 2015 Category: Toxicology Authors: Leon Tags: Medical bath salts MDPV methylenedioxyphyrovalerone ToxIC registry Source Type: news

Non-controlled and over-the-counter drugs of abuse
  2.5 out of 5 stars Abuse of Medications That Theoretically Are Without Abuse Potential. Reeves RR et al. South Med J 2015 Mar;108:151-157. Abstract This review of noncontrolled prescription and over-the-counter drugs that can be and have been abused for non-medical or recreational purposes is rather sketchy and anecdotal (as the authors admit,) but nevertheless contains some useful information. Classes of drugs discussed include: Cold & Cough products: pseudoephedrine, ephedrine, oxymetazoline, dextromethorphan Anticholinergics: diphenhydramine, benztropine, trihexyphenidyl (Artane) Antipsychotics: quetiapine,...
Source: The Poison Review - March 24, 2015 Category: Toxicology Authors: Leon Tags: Medical cough/cold preparations dextromethorphan medication abuse otc over-the-counter Source Type: news

Tox Tunes #94: Cocaine Blues (David Bromberg)
Along comes Sally with her nose all tore The doctor says she can’t sniff no more He says that cocaine’s for horses, it’s not for men He says it’s gonna kill me but he don’t say when During the American folk music revival that started in the 1930s and continued into the 1960s and 70s, many musicians rediscovered the rich vein of drug themes that ran through the history of blues and country songs. I first heard Luke Jordan’s “Cocaine Blues” through David Bromberg’s excellent cover version. Jordan (1882-1952) made several recordings for Victor Records in Charlotte NC and ...
Source: The Poison Review - March 23, 2015 Category: Toxicology Authors: Leon Tags: Medical cocaine blues david bromberg luke jordan tox tunes Source Type: news

Keef Kat, Boddahfinger, and other marijuana edibles — how should they be regulated
3 out of 5 stars Half-Baked — The Retail Promotion of Marijuana Edibles. MacCoun RF, Mello MM. N Engl J Med 2015 Mar 12;372:989-991. Full Text This Perspective piece — from authors at the Stanford Schools of Law and Medicine — discusses problems raised by the increasing availability of marijuana edibles in some states. Often, these products are manufactured in forms that are enticing to children (such as cookies, candy bars, and gummy bears) and packaged to look like familiar consumer products. It have written about this problem previously in several columns for Emergency Medicine News — to read them, click here...
Source: The Poison Review - March 20, 2015 Category: Toxicology Authors: Leon Tags: Medical FDA food and drug administration marijuana edibles schedule I drug THC Source Type: news

Sympathomimetic toxidrome: is it scorpion envenomation or methamphetamine?
Centruroides sculpturatus 2.5 out of 5 stars Methamphetamine Ingestion Misdiagnosed as Centruroides sculpturatus Envenonmation. Strommen J, Shirazi F. Case Rep Emerg Med Epub 2015 Jan 14. Full Text Native to the American southwest and Mexico, Centruroides sculpturatus is the most venomous scorpion in North America. Its venom contains a variety of toxins, including α-toxins that inhibits deactivation of voltage-gated sodium channels causing excitation of both the sympathetic and parasympathetic autonomic systems. In addition, the venom causes catecholamine release. Sympathetic effects usually predominate. Patients oft...
Source: The Poison Review - March 10, 2015 Category: Toxicology Authors: Leon Tags: Medical anascorp antivenom centruroides sculpturatus methamphetamine scorpion sting sympathomimetic toxidrome Source Type: news

Protonix (pantoprazole) can cause a false positive urine screening test for THC
3.5 out of 5 stars 13-Year-Old Girl With Recurrent, Episodic, Persistent Vomiting: Out of the Pot and Into the Fire. Felton D et al. Pediatrics 2015 Mar 2 [Epub ahead of print] Abstract The package insert for Protonix (pantoprazole) states: There have been reports of false positive urine screen tests for tetrahydrocannabinol (THC) in patients receiving protein pump inhibitors. The source of these reports have not been clear, and no cases have previously been reported in the literature. This paper describes a 13-year-old girl who presented to hospital with an episode of recurrent cyclic vomiting syndrome, who was diagnose...
Source: The Poison Review - March 6, 2015 Category: Toxicology Authors: Leon Tags: Medical cannabis false-positive marijuana pantoprazole protonix THC urine drug screen Source Type: news

Intravenous lipid emulsion in oral overdoses: what is the optimal dosing?
This article is an attempt to arrive at a rational dosing schedule for LE in oral overdoses. The authors consider a number of factors: Very high doses of lipid emulsion have been associated with adverse effects, including acute respiratory distress syndrome The FDA recommends a maximum dose of 12.5 mL/kg/day when LE is used for nutritional support The antidotal action of LE may depend on both the “lipid sink” effect and direct cardiac inotropy Both of the above effects require creation of a moderately lipemic plasma Combining these considerations with pharmacologic calculations, the authors make the followi...
Source: The Poison Review - March 5, 2015 Category: Toxicology Authors: Leon Tags: Medical dosing intralipid lipid emulsion lipid rescue therapy Source Type: news

TPR Podcast Episode #8: Pearls from NACCT
Discussion of Dr. Millard Bass’ JAMA article “Sudden Sniffing Death” (SSD) SSD occurs after sniffing, bagging, or huffing a volatile hydrocarbon inhalant Hypothesis: death results from sensitization of the myocardium to catecholamines, resulting in cardiac arrhythmias   Capsaicin for Cannabinoid Hyperemesis Syndrome Initial idea to use capsaicin in the treatment of cannabinoidhyperemesis syndrome (CHS) stemmed from: Symptomatic relief from hot showers or baths often reported by patients Realization that TRPV1 receptor is activated by both hot temperatures and capsaicin Case reports from California and Ne...
Source: The Poison Review - March 1, 2015 Category: Toxicology Authors: LeonThe Poison Review Tags: Podcast cannabinoid hyperemesis syndrome capsaicin cream clenbuterol NACCT phenibut sudden sniffing death syndrome tpr podcast Source Type: news

Is lipid emulsion therapy effective in calcium-channel-blocker and beta-blocker overdose?
2 out of 5 stars Role of intravenous lipid emulsions in the management of calcium channel blocker and β-blocker overdose: 3 years experience of a university hospital. Sebe A et al.  Postgrad Med 2015 Feb;127:119-124. Abstract The authors of this study, from Cukurova University School of Medicine in Turkey, retrospectively reviewed patients admitted to their hospital who were treated with lipid rescue therapy (LRT) for refractory hypotension, heart block, or cardiac arrest following overdose from a calcium-channel-blocker (CCB) or a beta-blocker (BB). They identified 15 patients(9 CCB, 6 BB.) There were two cardiac arre...
Source: The Poison Review - February 28, 2015 Category: Toxicology Authors: Leon Tags: Medical beta blocker overdose calcium channel blocker overdose intralipid lipid emulsion lipid rescue therapy Source Type: news

Tox on the web: 12 students hospitalized at Wesleyan College after “Molly” overdose
Four students arrested at Wesleyan College after “Molly” overdoses: Last weekend a dozen students and visitors at Wesleyan University in Middletown, Connecticut were hospitalized after apparently ingesting a drug or drugs labelled as “Molly.” Two victims were in critical condition and were medevacked to Hartford Hospital, the only Level 1 Trauma Center in the region. By mid-week, these two patients were still in hospital but reported to be improving. Four students have been arrested in connection with this incident. As @forensictoxguy pointed out on his blog “The Dose Makes The Poison,̶...
Source: The Poison Review - February 27, 2015 Category: Toxicology Authors: Leon Tags: Medical activated charcoal cleanse designer drug detox guy weinberg intralipid lipid rescue therapy mdma molly tox talk wesleyan Source Type: news

Excellent review of lipid rescue therapy
3.5 out of 5 stars Intravenous Lipid Emulsion in the Emergency Department: A Systematic Review of Recent Literature. Cao D et al. J Emerg Med 2014 Dec 19 [Epub ahead of print] Abstract This excellent comprehensive review of lipid rescue therapy (LRT) is vitiated only by the unavoidable fact that available clinical evidence  is so inconclusive. As the authors point out, published literature consists mostly of case reports and small case series. The vast majority of these reported cases have good outcomes and reflect positive effects from ILE, but the evidence is marred by multiple confounding variables (such as concurren...
Source: The Poison Review - February 25, 2015 Category: Toxicology Authors: Leon Tags: Medical intralipid lipid emulsion lipid rescue therapy lipid sink Review Source Type: news

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2.5 out of 5 stars Evaluation of Residual Toxic Substances in the Stomach Using Upper Gastrointestinal Endoscopy for Management of Patients With Oral Drug Overdose on Admission. Miyauchi M et al. Medicine 2015 Jan;94:e463 Abstract Despite many flaws, this paper has some interesting data that the authors use to come to exactly the wrong conclusion. The authors studied patients presenting with oral non-liquid drug overdose. Using endoscopy they classified the contents of the stomach as: 1) tablet/food phase; 2) soluble/fluid phase; and 3) reticular/empty phase.(I’m not clear on the precise meaning of a “tablet/f...
Source: The Poison Review - February 24, 2015 Category: Toxicology Authors: Leon Tags: Medical gastric empyting gastric lavage gastrointestinal decontamination Source Type: news

Sundays with SMACC: Sonowars 2014
SonoWars from Social Media and Critical Care on Vimeo. At the SMACC Gold conference last March in Australia, an epic Sonowars contest pitted the Northern Hemisphere against the Southern Hemisphere. Representing the North were Matt Dawson and Mike Mallin from the Ultrasound Podcast. Meeting the bell for the lands down under were James Rippey and Adrian Goudie from Ultrasound Village and The Sono Cave. The battle is both amusing and informative. The entire session lasts about 90 minutes. If time is limited, start watching at 56:00, where Dr. Rippey builds a heart out of clay to teach echocardiographic anatomy, and Dr. Malli...
Source: The Poison Review - February 22, 2015 Category: Toxicology Authors: Leon Tags: Medical SMACC Chicago SMACC Gold sonowars Source Type: news

Treating severe drug-induced hyperthermia with an ice-water bath
3 out of 5 stars Ice water submersion for rapid cooling in severe drug-induced hyperthermia. Laskowski LK et al. Clin Toxicol 2015 Mar;53:181-184. Abstract There is still debate about the optimal method of cooling severely hyperthermic patients, such as those with core temperature > 104oF (40oC) who are exhibiting changes in mental status. Some common techniques include ice packs to the groin and axillae, cooling blankets, along with convection (evaporation) techniques such as cool sprays and fans. There is little debate, however, about the proposition that the faster these extremely hyperthermic patients are cooled th...
Source: The Poison Review - February 21, 2015 Category: Toxicology Authors: Leon Tags: Medical active cooling drug-induced hyperthermia ice-water bath Source Type: news

Do medical toxicologists use physostigmine to treat anticholinergic toxidrome?
2.5 out of 5 stars The Use of Physostigmine by Toxicologists in Anticholinergic Toxicity. Watkins JW et al. J Med Toxicol 2014 Dec 16 [Epub ahead of print] Abstract Physostigmine is a carbamate that reversibly inhibits acetylcholinesterase, the enzyme that breaks down acetylcholine (ACh). By so doing, it increases the levels of ACh in synapses, serving as an antidote for drugs and agents causing anticholinergic syndrome. Unlike neostigmine, physostigmine crossed the blood-brain-barrier and has both peripheral and central effects. Decades ago, physostigmine was routinely used with some frequency to treat overdose with ...
Source: The Poison Review - February 18, 2015 Category: Toxicology Authors: Leon Tags: Medical anticholinergic toxidrome physostigmine ToxIC registry Source Type: news

Hemodialysis in acute methanol poisoning: is there really good evidence?
3.5 out of 5 stars Recommendations for the Role of Extracorporeal Treatments in the Management of Acute Methanol Poisoning: A Systematic Review and Consensus Statement. Roberts DM et al. Crit Care Med 2015 Feb;43:461-472. Abstract The Extracorporeal Treatment in Poisoning (EXTRIP) Workgroup was established to provide evidence-based guidance on the use of hemodialysis and other methods of extracorporeal treatment in various toxic exposures. The workgroup has published previous papers giving their recommendations regarding poisoning by acetaminophen, lithium, carbamazepine, barbiturate, tricyclic antidepressants, and thall...
Source: The Poison Review - February 17, 2015 Category: Toxicology Authors: Leon Tags: Medical evidence-based recommendations extracorporeal treatment extrip hemodialysis methanol toxic alcohol Source Type: news

Must-read: another adverse effect associated with tramadol
4 out of 5 stars Tramadol and Hypoglycemia: One More Thing to Worry About. Nelson LS, Juurlink DN. JAMA Intern Med 2015 Feb 1;175(2):194-5 Reference Hypoglycemia associated with use of tramadol has been noted previously in scattered case reports, after both overdose and therapeutic ingestion, involving patients with and without diabetes. In this month’s issue of JAMA Internal Medicine, Fournier et al. presented a large case-control study comparing patients started on tramadol for pain with similar patients started on codeine. They found that the tramadol patients had a significantly increased risk of hospitalizati...
Source: The Poison Review - February 10, 2015 Category: Toxicology Authors: Leon Tags: Medical adverse effect hypoglycemia tramadol ultram Source Type: news

The New Yorker on use of psilocybin to treat cancer patients
Recommended long-read of the week is Michael Pollan’s New Yorker article “The Trip Treatment,” a look at research being done at several medical centers — including New York University and Johns Hopkins — into the use of the psychedelic drug psilocybin to ameliorate anxiety and depression in cancer patients. Similar work had been started half a century ago, but was essentially abandoned after the image of psychedelics became tainted by the excesses of the 1960s, and the Controlled Substances Act of 1970 made it virtually impossible to obtain the drug even for research purposes. Part of the research...
Source: The Poison Review - February 9, 2015 Category: Toxicology Authors: Leon Tags: Medical cancer New Yorker oncology psilocybin psychedlics Source Type: news

News flash: dead overdose victims can have drugs in the GI tract
1.5 out of 5 stars Retained drugs in the gastrointestinal tracts of deceased victims of oral drug overdose. Livshits Z et al. Clin Toxicol 2014 Dec 30:1-6 [Epub ahead of print] Abstract This is certainly one of the more bizarre medical papers I’ve seen for quite some time. The main objective of the study was to determine the presence of “undigested or partially digested” tablets found at autopsy in the GI tracts of oral drug overdose fatalities. Why would they be interested in this question? Apparently to argue that aggressive gastrointestinal decontamination may have benefit even late after oral ingesti...
Source: The Poison Review - February 6, 2015 Category: Toxicology Authors: Leon Tags: Medical activated charcoal cadaver study gastric emptying gastric lavage gastrointestinal decontamination ingestion intoxication overdose whole bowel irrigation Source Type: news

Colorado’s experience with medical effects of legalizing marijuana
3 out of 5 stars The Implications of Marijuana Legalization in Colorado. Monte AA et al. JAMA 2015 Jan 20;313:241-2. No abstract available This brief article, from the Department of Emergency Medicine at the University of Colorado and the Rocky Mountain Poison and Drug Center, gives a concise summary of the medical consequences following Colorado’s legalization of marijuana. Although Colorado changed its state constitution in 2000 to allow medical marijuana, such use did not really become common until October 2009, when a U.S. Department of Justice memorandum indicated that the DOJ would not prosecute medical marij...
Source: The Poison Review - February 5, 2015 Category: Toxicology Authors: Leon Tags: Medical cannabis cannabis hyperemesis syndrome colorado marijuana medical marijuana recreational marijuana Source Type: news

NEJM discussion of ethylene glycol poisoning misses crucial points
2 out of 5 stars Case 4-2015: A 49-Year-Old Man with Obtundation Followed by Agitation and Acidosis. Cooper CM, Baron JM. N Engl J Med 2015 Jan 29;372:465-473. Reference This episode of the Journal‘s “Case Records of the Massachusetts General Hospital” series is the latest of their amazing inept discussions of medical toxicology cases. Yet again, the discussants do not include a medical toxicologist or emergency physician. Given the level of toxicological awareness evidenced by this case presentation, it’s fortunate that the patient did well. A unresponsive 49-year-old man was found outside with a ...
Source: The Poison Review - February 3, 2015 Category: Toxicology Authors: Leon Tags: Medical case records of the massachusetts general hospital ethylene glycol poisoning fomepizole management medical toxicology new england journal of medicine Source Type: news

The Bud Light Commercial Too Toxic for the Super Bowl
//www.youtube.com/watch?v=cYIN-b8qjmo In case you missed it when TPR posted this clip on previous Super Bowl Sundays, here is the toxicology-themed Bud Light commercial that was banned from the air during Super Bowl XLI in 2007. (Source: The Poison Review)
Source: The Poison Review - February 1, 2015 Category: Toxicology Authors: Leon Tags: Medical apology bot 3000 bud light fish poisoning fugu super bowl tetrodotoxin Source Type: news

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