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The Poison Review

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Treating digoxin toxicity: is less more?
3 out of 5 stars Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Chan BSH, Buckley NA. Clin Toxicol 2014 Aug 4 [Epub ahead of print] Abstract This long detailed paper seems to be a manifesto masquerading as a review article. It is quite informative and well worth reading. But I’d keep in mind that the authors appear to have a (not so) hidden agenda: to decrease the dose of digoxin-specific antibody fragments administered in most cases of acute and chronic digoxin toxicity. The authors state their objective up front: To review the pharmacology, efficacy, effectiveness, indications, safety an...
Source: The Poison Review - August 29, 2014 Category: Toxicology Authors: Leon Tags: Medical digibind digifab digoxin specific antibody fragments digoxin toxicity Source Type: news

Hydrogen peroxide ingestion: can bedside ultrasound help?
http://www.youtube.com/watch?v=ed6mpRKmx14 3 out of 5 stars Young Woman With Epigastric Pain and Vomiting. Manning EP et al. Ann Emerg Med 2014 Sep;64:330. Full Text This brief case is part of the Annals of Emergency Medicines‘s series “Image of the Month.” A 23-year-old woman develops epigastric pain and vomiting after investing a cleaning agent. Abdominal exam was unremarkable. a CT of the abdomen demonstrated gas in the portal veins. The cleaning agent was hydrogen peroxide, which causes injury by two mechanisms: 1) corrosive tissue injury, and 2) gas formation. A previous case report indicated that...
Source: The Poison Review - August 29, 2014 Category: Toxicology Authors: Leon Tags: Medical bedside emergency ultrasound gas in portal vein hydrogen peroxide ingestion overdose Source Type: news

Blowguns, poison darts, and tajem
This interesting short film illustrates the meticulous care that goes into making a poison dart blowgun. The poison mentioned in the video — tajem — is made from latex obtained from the bark of a specific tree. I was not able to find out details about how it acts, but it appears to be cardiotoxic and produce fatal arrhythmias. One source mentions that there are several natural antidotes. Hunting with tajem-tipped poison darts is practiced by the Penan people in Borneo. (Source: The Poison Review)
Source: The Poison Review - August 27, 2014 Category: Toxicology Authors: Leon Tags: Medical blowgun cardiotoxicity pen an people poison darts Source Type: news

Blowguns, poison darts, and tajem poison
This interesting short film illustrates the meticulous care that goes into making a poison dart blowgun. The poison mentioned in the video — tajem — is made from latex obtained from the bark of a specific tree. I was not able to find out details about how it acts, but it appears to be cardiotoxic and produce fatal arrhythmias. One source mentions that there are several natural antidotes. Hunting with tajem-tipped poison darts is practiced by the Penan people in Borneo. (Source: The Poison Review)
Source: The Poison Review - August 27, 2014 Category: Toxicology Authors: Leon Tags: Medical blowgun cardiotoxicity pen an people poison darts Source Type: news

Body packers: can CT determine the number of drug packets?
Body packer 2.5 out of 5 stars Sensitivity and specificity of CT scanning for determining the number of internally concealed packages in ‘body-packers.’ Asha SE et al. Emerg Med J 2014 Feb 19. doi: 10.1136/emermed-2013-203389. [Epub ahead of print] Abstract Although the abdominal CT scan has been shown to be relatively accurate for determining the presence or absence of drug packets in suspected body packers, there is no good data as whether or not the test is accurate in determining the number of such packets. The abstract of this paper suggests that the authors — from Sydney’s St. George Hospital — ...
Source: The Poison Review - August 26, 2014 Category: Toxicology Authors: Leon Tags: Medical body packer CT mule radiography Source Type: news

CPC: salicylate toxicity
Discussion of salicylate toxicity misses several key points Pearl: falsely normalized anion gap in salicylate overdose Excellent guidelines for managing salicylate overdose Salicylate toxicity can present with a normal-anion-gap metabolic acidosis Salicylate toxicity: the great masquerader       (Source: The Poison Review)
Source: The Poison Review - August 25, 2014 Category: Toxicology Authors: Leon Tags: Medical aspiring poisoning case records of the massachusetts general hospital salicylate toxicity Source Type: news

Tox Tunes #86: Let’s Go Get Stoned (Big Mama Thornton)
http://www.youtube.com/watch?v=spkcAjt-TKU Big Mama Thornton (1926-1984) was a powerful rhythm and blues singer who recorded and/or wrote a number of songs that were big hits for other artists. “Let’s Go Get Stoned” — written by Nickolas Ashford, Valerie Simpson, and Josephine Armstead — went to the top of th eR&B charts when Ray Charles released his version in 1966. Thornton recorded Leiber and Stoller’s song “Hound Dog” in 1952. It was popular, but not the monster hit Elvis Presley had with the song in 1956. Thornton recorded her own song “Ball and Chain” in the ear...
Source: The Poison Review - August 25, 2014 Category: Toxicology Authors: Leon Tags: Medical big mama thornton let's go get stoned tox tunes Source Type: news

Saturday with SMACC: 17 Minutes
17 Minutes from Social Media and Critical Care on Vimeo. It’s been 5 months since I returned from Brisbane and Australia’s Gold Coast where I attended the 2014 SMACC Gold conference — by far the most inspiring and creative medical conference I’ve ever been to. This brilliant video presentation from one of the plenary sessions is a perfect example of how SMACC differs from most other professional meetings. I’ll say no more about it, except to mention that it’s a definite must-see. SMACC 2015 will take place June 23-25 next year and will be in my home town, Sweet Home Chicago! In addition to ...
Source: The Poison Review - August 23, 2014 Category: Toxicology Authors: Leon Tags: Medical 17 Minutes SMACC social media and critical care Tamara Hills Source Type: news

California counties sue makers of opioid analgesics
In May, two counties in California sued 5 pharmaceutical companies that make opioid analgesic medication, claiming that they waged a battle to create a “sea-change in medical and public perception” about the relative risks and benefits of these drugs by establishing a “deeply deceptive marketing campaign.” My Emergency Medicine News  column about this suit is online and can be read here. (Source: The Poison Review)
Source: The Poison Review - August 22, 2014 Category: Toxicology Authors: Leon Tags: Medical big pharma California law suit opiates opioid analgesics Source Type: news

Case series: 9 patients with acute kidney injury after smoking a synthetic cannabinoid
This article is a very complete and finely done description both of the clinical syndrome of AKI associated with use of synthetic cannabinoids, and the related public health investigation. [HT @DougBorys] Related posts: Four (really three) cases of acute kidney injury associated with us of synthetic cannabinoids MMWR: synthetic pot suspect in cases of kidney failure Blueberry “spice” in Wyoming linked to cases of renal failure (Source: The Poison Review)
Source: The Poison Review - August 22, 2014 Category: Toxicology Authors: Leon Tags: Medical acute kidney injury clown loyal renal toxicity spice synthetic cannabinoid Source Type: news

Methoxetamine: a ketamine analog that is NOT bladder friendly
3.5 out of 5 stars Methoxetamine — a novel recreational drug with potent hallucinogenic properties. Zawilska JB. Toxicol Lett 2014 Aug 13. pii: S0378-4274(14)01298-3. doi: 10.1016/j.toxlet.2014.08.011. [Epub ahead of print] Abstract Methoxetamine (MXE) is a structural analog of ketamine, with effects that are similar but more intense and longer-lasting. Street names include: MXE Mexxy  M-ket MEX Kmax Special M MA “Legal ketamine” Minx Jipper Roflcoptr Since chronic exposure to ketamine is known to cause ulcerative cystitis, MXE is sometimes touted as “bladder friendly.” However, lack of clini...
Source: The Poison Review - August 20, 2014 Category: Toxicology Authors: Leon Tags: Medical bladder toxicity genitourinary toxicity ketamine methoxetamine MXE Source Type: news

On the internet, nobody knows if it’s 25C-NBOMe (“N-bomb”)
This article uses both published scientific literature and discussions on Web bulletin boards and chat groups in an attempt to define the effects of this drug. The authors argue that since the internet is a crucial factor in marketing and disseminating novel psychoactive substances and since peer-reviewed articles about these substances are scarce, using unconfirmed anecdotal reports on sites like Bluelight and Drugs-Forum is justified. I don’t buy it. However, the authors do reference several medical papers about N-bomb. for example,  a recent article by Grautoff and Kahler described a 19-year-old man who suppose...
Source: The Poison Review - August 18, 2014 Category: Toxicology Authors: Leon Tags: Medical 25C-NBOME n-bomb Source Type: news

Tox Tunes #85: Goodnight, Irene (Jerry Lee Lewis and Van Morrison)
http://www.youtube.com/watch?v=wmvCAzLseu8 “Goodnight, Irene” was introduced by the folksinger and blues musician Lead Belly (Huddie Ledbetter, 1888-1949) and became a big hit for The Weavers in 1950. This fascinating song tells a somewhat murky story about unrequited passion and suicidal fantasies. The Weavers, however, left out the reference to opiates in Lead Belly’s original lyrics: I love Irene I swear I do I love her ’til the sea runs dry If Irene turns her back on me I’m gonna take morphine and die. Jerry Lee Lewis and Van Morrison keep this verse in their version. Lead Belly’s ...
Source: The Poison Review - August 18, 2014 Category: Toxicology Authors: Leon Tags: Medical drug references goodnight irene jerry lee lewis lead belly leadbelly morphine popular song the weavers tox tunes van morrison Source Type: news

Iron poisoning: Tox on the Web
Academic Life in Emergency Medicine has a very nice review of iron toxicity by Mary A. Wittler and David Manthey from Wake Forest University Baptist Medical Center. Also, in a recent post at Life in the Fast Lane, Chris Nickson discusses “The Toddler with the Iron Gut” in a Q&A format. (Source: The Poison Review)
Source: The Poison Review - August 12, 2014 Category: Toxicology Authors: Leon Tags: Medical deferoxamine iron toxicity pediatric poisoning Source Type: news

Review of scorpion envenomation
Asian forest scorpion 3 out of 5 stars Scorpion Envenomation. Isbister GK, Bawaskar HS. N Engl J Med 2014 Jul 31;371:457-463. Reference With over 1700 species of scorpions found all over the world, this brief review article is much too short and unfocused to provide more than a superficial overview of its topic. The authors point out that most scorpion stings cause, at most, minor toxicity with pain and other local effects only. Most serious envenomations are associated with the Buthidae family, which include the genus Centruroides, several of which are found in North America and commonly cause neuromuscular excitation...
Source: The Poison Review - August 12, 2014 Category: Toxicology Authors: Leon Tags: Medical antivenom centruroides Review scorpion envenomaton Source Type: news

MIcrocystin: the hepatotoxin that shut down Toledo’s water supply
  Microcystin-LR 3.5 out of 5 stars The Toxicology of Microcystins. Dawson RM. Toxicon 1998;36:953-962. Abstract Just when you thought it was safe to go back to the faucet . . . While I was on vacation, the big toxicology story involved contamination of the water supply to Toledo Ohio. As a result almost half a million people in the area were warned not to drink — or even shower with — water from Lake Erie. The cause was a bloom of freshwater cyanobacteria, resulting from increased levels of phosphates and fertilizer. These cyanobacteria product microcystin, a heat-stable hepatotoxin. Microcystin can cause 3 clin...
Source: The Poison Review - August 8, 2014 Category: Toxicology Authors: Leon Tags: Medical acute liver failure algae cyanobacteria hepatoxicity microcystin toledo ohio Source Type: news

Nicotine liquid fatality — but was it from intravenous injection?
2.5 out of 5 stars Fatal Intravenous Injection of Electronic Nicotine Delivery System Refilling Solution. Thornton SL et al. J Med Toxicol 2014;10:202-204. Reference Well, any case report of a fatality following exposure to e-cigarette nicotine  refill liquid is interesting, but this one has problems. Lately, TPR has been whinging about the BuzzFeed-ificiation of the medical literature, especially with regard to titles of published papers. In this process, nuanced topics and cases are simplified to produce a misleading title that serves better as clickbait. This case report describes  29-year-old male who was found at ...
Source: The Poison Review - July 31, 2014 Category: Toxicology Authors: Leon Tags: Medical e-cigarette fatality nicotine liquid Source Type: news

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