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Fentanyl, carfentanil and the opioid crisis: where do we stand now?
3.5 out of 5 stars Controversies and carfentanil: We have much to learn about the present state of opioid poisoning. Cole JB, Nelson LS. Am J Emerg Med 2017 Aug 24 [Epub ahead of print] Reference I have argued — both in a post on this blog and a column in Emergency Medicine News — that the idea of a “heroin overdose” is a completely outdated concept that is never coming back. The fact is, when a patient comes in today with a history of shooting or snorting heroin, none of us have any firm idea about exactly what drug or drugs were involved. The chance that such a patient was exposed only to heroin i...
Source: The Poison Review - September 19, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical carfentanil fentanyl opiates opioids Source Type: news

Great New Toxicology Podcast
In the first episode of “The Dantastic Mr. Tox & Howard Show,” Drs. Dan Rusyniak and Howard Greller — formerly of the Journal of Medical Toxicology Podcast — have a superb discussion about the current expanding opioid crisis with Dr. David Juurlink from Sunnybrook Health Sciences Centre in Toronto. Topics covered include opioid-induced hyperalgesia, the key difference between relieving pain and relieving suffering, and why tramadol is generally such a poor drug. The episode is smart, succinct, and highly recommended. I look forward to future podcasts. To listen, cli...
Source: The Poison Review - June 16, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical daniel rusyniak dantastic mr. tox & howard david juurlink howard greller podcast Source Type: news

Episode #15: How easy is it to get addicted to opioids?
TPR PODCAST EPISODE #15: HOW EASY IS IT TO GET ADDICTED TO OPIOIDS?     As has been well reported in medical papers, government studies and popular media, rates of overdose deaths from opioids have been increasing steadily over the last several decades. A recent article in the New York Times reported that there were likely more than 59,000 drug overdose deaths in 2016, an estimated 19% increase over the number in 2015. The total for 2017 is likely to be even higher.   Many deaths have been associated with prescription opioid analgesics, or have occurred among patients who became addicted to prescription opio...
Source: The Poison Review - June 11, 2017 Category: Toxicology Authors: Leon Gussow The Poison Review Tags: Podcast Source Type: news

Lipid rescue therapy for local anesthetic toxicity: is less more
DISCUSSION: Most of the “adverse events” associated with lipid rescue therapy have occurred after administration of relatively high doses. Although there have been no good studies demonstrating the maximum “safe” dose of intralipid for lipid rescue therapy, many authors recommended limiting the dose to that recommended by the FDA for nutritional support: 12.5 mL/kg (lean body mass) per day total. In specific cases it may be reasonable to consider extending the infusion beyond this, but such situations are likely rare. In this patient, who did not appear to have cardiovascular instability, it is...
Source: The Poison Review - May 25, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical adverse event intralipid lipid rescue therapy local anesthetic toxicity mepivacaine Source Type: news

Hemodialysis and the intubated salicylate-toxic patient
3.5 out of 5 stars The association of hemodialysis and survival in intubated salicylate-poisoned patients. McCabe DJ, Lu JJ. Am J Emerg Med 2017 Apr 10 [Epub ahead of print] Abstract [Disclosure: the co-authors of this paper are members of the Toxikon Consortium in Chicago, as am I.] This retrospective observational study looked at cases from the Illinois Poison Center over 12 years (2003 thru 2015) to identify intubated patients with recorded serum salicylate levels> 50 mg/dL. The goal was “to describe the impact of hemodialysis on survival rates of salicylate-intoxicated patients . . .”...
Source: The Poison Review - May 20, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical aspirin poisoning enhanced elimination hemodialysis salicylate toxicity Source Type: news

Hemp seed oil may possibly (but not probably) cause cannabinoid poisoning
2.5 out of 5 stars Cannabinoid Poisoning by Hemp Seed Oil in a Child. Chinello M et al. Pediatr Emerg Care 2017;33:344-345. Abstract This interesting but non-dispositive short case report from Italy suggests that, in rare instances, commercially marketed hemp seed oil can cause mild cannabinoid toxicity. A 2-year-7-month old male was brought to hospital with altered mental status and several hours of “decreased alertness, refusal to walk, and no verbal response.” Additional findings included: “paleness, stupor, [and] low reactivity to stimulation.” Pulse rate was 129 bpm. There was no ataxia. The p...
Source: The Poison Review - May 10, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical cannabinoid cannabis hemp seed oil pediatric subacute poisoning Source Type: news

Tox Tunes #110: Nutmeg (John Legend & Stephen Colbert)
Started thinking about this song again earlier in the week as I prepared to take part in an hour-long discussion of the spice on Connecticut Public Radio’s Colin McEnroe Show. The discussion touched on many aspects the spice: historical, economic, culinary, medicinal, and toxicological. To listen to the show, click here. To read my 2011 Emergency Medicine News column about nutmeg, click here. (Source: The Poison Review)
Source: The Poison Review - May 7, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical john legend nutmeg stephen colbert tox tunes Source Type: news

TPR Podcast Episode #14: VX and the Assassination of Kim Jong-Nam
  On February 13, 2017 Kim Jong Nam — half-brother to North Korean leader Kim Jong Un — was attacked by two women in Malaysia’s Kuala Lumpur International airport. The attacks smeared some substance on his face. Within 10 or 15 minutes Mr. Kim collapsed in the airport medical clinic and died apparently in the ambulance on way to hospital.   Days later, Malaysian authorities announced that the nerve agent VX was detected in samples taken from Mr. Kim’s face.   Security camera footage from the airport showing the attack on Mr. Kim and its aftermath can be viewed here. In the video, the ...
Source: The Poison Review - March 30, 2017 Category: Toxicology Authors: Leon Gussow The Poison Review Tags: Podcast Source Type: news

Tox Tunes #109: I Killed Robert Johnson (The Stone Foxes)
More myths and legends are attached to the life of Robert Johnson (1911 – 1938) than surround any other American blues artist. It’s said that he sold his soul to the devil down at a Mississippi crossroads in return for the ability to play guitar with a technique that musicians like Eric Clapton are still trying to replicate. It’s said that his death at age 27 established a precedent for other great American musicians who also died at that same age, including Jimi Hendrix, Janis Joplin, Jim Morrison, and Al “Blind Owl” Wilson. And it is said that Johnson was poisoned with strychnine in Greenwoo...
Source: The Poison Review - March 6, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical american delta blues i killed robert johnson nux vomica sonte foxes strychnine tox tunes Source Type: news

Labetalol in acute cocaine toxicity: is it safe?
3 out of 5 stars Acute Toxicity from Topical Cocaine for Epistaxis: Treatment with Labetalol. Richards JR et al. J Emerg Med 2017 Mar;52:311-313. Abstract There has long been a debate among toxicologists — still unresolved — as to whether it is safe to use a beta-blocker to treat cocaine-related hypertension and tachycardia. The (theoretical) concern is that since cocaine is both an α- and a β-agonist, blocking the β-receptors could lead to unopposed α stimulation with increased severe hypertension. Some authors contend that in this setting, labetalol would be safe since it blocks bot...
Source: The Poison Review - March 1, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical beta blocker cocaine epistaxis labetalol safety toxicity Source Type: news

Tox Tunes #108: Commit a Crime (Howlin ’ Wolf)
You put poison in my coffee, instead of milk or cream You put poison in my coffee, instead of milk or cream You bout the evilest woman, that I ever seen You mixed my drinks with a can of Red Devil lye You mixed my drinks with a can of Red Devil lye Then you sit down, watch me, hopin’ that I might die This is one of the great dysfunctional relationship songs in all of the blues. Howling’ Wolf (Chester Burnett 1910 – 1976) also recorded a great version of the song — under the title “What a Woman” and with Eric Clapton playing lead guitar — on the 1970 London Sessi...
Source: The Poison Review - February 26, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical commit a crime eric clapton howling' wolf london sessions rolling stones tox tunes Source Type: news

Did the nerve agent VX kill Kim Jong Nam?
Last night Malaysian authorities announced that they identified the nerve agent VX taken off the face of Kim Jong Nam, who was murdered on February 13 at Kuala Lumpur International Airport. As the History Channel video above indicates, nerve agents are potent acetylcholinesterase inhibitors that utilize the same mechanism as organophosphate insecticides such as parathion. Conceptually, the effect of VX exposure is simple: wherever in the body acetylcholine acts as a neurotransmitter, nerve agents cause unregulated, chaotic activity. There are generally 3 such sites: muscarinic sites: connections between ner...
Source: The Poison Review - February 24, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical assassination Kim Jong Nam Kuala Lumpur International Airport malaysia murder nerve agent North Korea VX Source Type: news

Must-watch: video showing murder of Kim Jong Nam
Discussion on toxicology discussion boards have brought up the following possibilities: Tetramine: Tetramethylenedisulfotetramine (TETS) is a rat poison that has been banned since 1984 but which — according to Wikipedia — is still used in China. It is a white powder that is slightly soluble both in water and DMSO, a solvent that could accelerate dermal absorption. TETS is a neurotoxin that acts as a GABA antagonist causing refractory status epileptics, coma, and death. There is no specific antidote. Aconite: This plant poison is used in several Chinese herbal medicines.Aconite is a sodium channel opener, ...
Source: The Poison Review - February 22, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical assassination Kim Jong Nam Kuala Lumpur International Airport malaysia murder North Korea Source Type: news

Do not get a serum acetaminophen level less than 4 hours after an acute ingestion
4 out of 5 stars Can a serum acetaminophen concentration obtained less than 4 hours post-ingestion determine which patients do not require treatment with acetylcysteine? Yarema MC et al. Clin Toxicol 2017 Feb;55:102-108. Abstract For decades the decision whether or not to treat acute acetaminophen [APAP] toxicity with N-acetylcysteine (NAC) has been guided by a serum APAP level drawn 4 or more hours after ingestion. The thought was that before 4 hours the level might be misleading because absorption of the drug might not be complete. This paper addresses the question of whether an earlier level can be suffic...
Source: The Poison Review - February 9, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical acetaminophen antidote APAP N-acetylcysteine rumack-matthew nomogram treatment Source Type: news

Amnesia and hippocampal ischemia in 4 opiate abusers: a case series
Hippocampus (wikipedia.org) 3.5 out of 5 stars Complete, bilateral hippocampal ischemia: a case series. Small JE et al. Neruocase 2016 Oct;22:411-415. Abstract Last week, we reviewed an MMWR investigation into a cluster of 14 cases of acute anterograde amnesia with MRI evidence of bilateral hippocampal ischemia identified in Massachusetts during the years 2012-2016. This constellation of features is distinctly unusual — especially when symmetric and accompanied by scant pathology outside the hippocampus —  but has in the past been associated with cocaine abuse and carbon monoxide p...
Source: The Poison Review - February 1, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical amnesia hippocampus ischemia memory opiate abuse Source Type: news

Amnesia and hippocmpal ischemia in 4 opiate abusers: a case series
Hippocampus (wikipedia.org) 3.5 out of 5 stars Complete, bilateral hippocampal ischemia: a case series. Small JE et al. Neruocase 2016 Oct;22:411-415. Abstract Last week, we reviewed an MMWR investigation into a cluster of 14 cases of acute anterograde amnesia with MRI evidence of bilateral hippocampal ischemia identified in Massachusetts during the years 2012-2016. This constellation of features is distinctly unusual — especially when symmetric and accompanied by scant pathology outside the hippocampus —  but has in the past been associated with cocaine abuse and carbon monoxide p...
Source: The Poison Review - February 1, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical amnesia hippocampus ischemia memory opiate abuse Source Type: news

Anterograde amnesia and bilateral hippocampus ischemia: is it caused by substance abuse?
Diffusion weighted MRI findings in patient with unusual amnestic syndrome — Massachusetts, 2012 [Source: MMWR]3.5 out of 5 stars Cluster of an Unusual Amnestic Syndrome — Massachusetts, 2012-2016. Barash JA et al. MMWR Morb Mortal Wkly Rep 2017;66:76-79 Full Text Late in 2015 a Boston neurologist reported a cluster of 4 cases of anterograde amnesia associated with MRI evidence of bilateral hippocampal ischemia. After a public health alert was issued an additional 10 cases were identified in the years 2012-2016, using the case definition of: “1) new onset amnesia in the absence of evidence t...
Source: The Poison Review - January 27, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical amnestic syndrome e opioid overdose hippocampus ischemia opiat Source Type: news

Is commercial kratom being spiked with a naturally occurring potent opioid
  3.5 out of 5 stars Suspected Adulteration of Commercial Kratom Products with 7-Hydroxymitragynine. Lydecker AG et al. J Med Toxicol 2016;12:341-349. Abstract This well done paper provides — among other things — a helpful short review kratom, a psychoactive product  derived from the Mitragyna speciosa plant. M speciosa contains more than 40 distinct alkaloids. The primary alkaloid — mitragynine — is an opioid agonist at the mu and delta receptors. Mitragynine has about 33% the opioid potency of morphine. A minor component of M speciosa —  7-h...
Source: The Poison Review - January 24, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical 7-hydroxymitragynine kratom mitragyna speciosa Source Type: news

TPR Podcast Episode #13: Naloxone in the Age of Carfentanil
In this “Lucky 13” episode of the TPR podcast, Steven and Leon discuss naloxone, and address the following issues:   Does the concept of a “heroin overdose patient” have meaning anymore in this age of U-47700, fentanyl, and carfentanil? Given the adulteration of both heroin and counterfeit prescription medications with extremely potent synthetic opioids, do we have to reconsider our entire approach to opioid overdose patients? Can past medical literature guide us in our management of these patients?(Hint: the answer is no.) What medical toxicology paper do Steve and Leon — in an unusual ...
Source: The Poison Review - January 19, 2017 Category: Toxicology Authors: Leon Gussow The Poison Review Tags: Podcast Source Type: news

The 7th Annual Alexander Awards: The Best Tox Reading of 2016
Alexander Gettler When TPR began giving out the annual Alexander Awards for best long-form writing in the field of toxicology, the eligibility criteria included the requirement that “entries must be fully and freely accessible” on the web. After 2016 — a remarkably truth-impaired year scarred by fake news and unchallenged mendacity — supporting aggressive, unbiased, fearless journalism appears to us to be a civic duty. A number of our selections this year come from sources such as the New York Times and Los Angeles Times that have much of their content behind a paywall. Often the...
Source: The Poison Review - January 1, 2017 Category: Toxicology Authors: Leon Gussow Tags: Medical adder all Alexander awards ayahuasca cannabidiol carfentanil fentanyl Gettler opiates opioids oxycontin Source Type: news

Severe respiratory depression after snorting U-47700
3.5 out of 5 stars Two cases of intoxication with new synthetic opioid, U-47700. Domanski K et al. Clin Toxicol 2017 Jan;55:46-50. Abstract U-47700 was first synthesized by Upjohn in the 1970s — hence the “U”. The company was seeking to develop an analgesic as effective as morphine but not addictive. Work on this compound was abandoned when the addictive properties of the drug became apparent. U-47700 is a μ-receptor agonist that is approximately 7.5 times as potent as morphine. This paper reports two patients who presented to hospital after insufflating U-47700 (confirmed on laboratory ...
Source: The Poison Review - December 30, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical synthetic opioid U-47700 Source Type: news

Lipid therapy in oral poisoning: a not-so-systematic review
2 out of 5 stars No support for lipid rescue in oral poisoning: A systematic review and analysis of 160 published cases. Forsberg M et al. Hum Exp Toxicol 2016 Nov 24 [Epub ahead of print] Abstract The authors’ goal was “to present a systematic review and case analysis of practically all published reports on humans treated with lipid rescue for LAST [local anesthetic systemic toxicity] or oral poisoning.” The focus of the paper is on oral poisonings. The authors report that they identified 94 reported cases of oral poisoning with “alleged” positive response to lipid rescue therapy (LRT.) Two a...
Source: The Poison Review - December 27, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical intralipid intravenous lipid emulsion lipid rescue therapy systematic review Source Type: news

Synthetic cannabinoid AMB-FUBINACA responsible for July 2016 “zombie” episode
4 out of 5 stars “Zombie” Outbreak Caused by the Synthetic Cannabinoid AMB-FUBINACA in New York, Adams AJ et al. N Engl J Med 2016 Dec 14 [Epub ahead of print] Abstract  On July 12, 2016, the New York Times reported that in the course of one day, in the Bushwick and Bedford-Stuyvesant areas of Brooklyn, 33 people had been transported to hospitals after apparently overdosing on a synthetic cannabinoid. The major manifestations shown by the victims were altered mental status and lethargy. One observer described what he say at the scene: “’It’s like a scene out of a zombie movie, a...
Source: The Poison Review - December 18, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical AMB-FUBINACA Brooklyn synthetic cannabinoid zombie Source Type: news

Tox Tunes #107: Lullaby (The Cure)
There is, to be sure, whether the subtext of this song involves child abuse or drug addiction. The director of this video, Tim Pope, has stated that Lullaby is “an allegory of [The Cure frontman] Robert Smith’s druggy past.” Certainly, the lyrics would back back this up: On candy stripe legs the Spiderman comes Softly through the shadow of the evening sun Stealing past the windows of the blissfully dead Looking for the victim shivering in bed Searching out fear in the gathering gloom and Suddenly A movement in the corner of the room And there is nothing I can do When I realize with fright That the Sp...
Source: The Poison Review - December 12, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical lullaby the cure tox tunes Source Type: news

Great video: tongue fasciculations in organophosphate poisoning
3.5 out of 5 stars Tongue Fasciculations in Organophosphate Poisoning. Chhabria BA, Bhalla A. . N Engl J Med 2016 Dec 8;375:e47 Full text with video The New England Journal of Medicine just posted a brief case of dichlorvos poisoning with a great video demonstrating organophosphate-induced tongue fasciculations. The case and video can be seen here. The NEJM also has video of tongue fasciculations caused by amyotrophic lateral sclerosis (Lou Gehrig’s Disease) that can be seen here. Here is another video of tongue fasciculations associated with amyotrophic lateral sclerosis: Other causes ...
Source: The Poison Review - December 8, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical amyotrophic lateral sclerosis lou gehrig's disease organophosphate poisoning tongue fasciculations Source Type: news

Loperamide abuse and cardiac dysrhythmia
3.5 out of 5 stars Cardiac Dysrhythmias After Loperamide Abuse — New York, 2008-2016. Eggleston W et al. MMWR 2016 Nov 18;65:1276-1277. Full Text Last week we reviewed a new paper showing that the number of cases of loperamide abuse reported to the National Poison Data System increased by 91% from the years 2000 to 2015. For reasons detailed in that review and in my recent Emergency Medicine News article on the topic, massive doses of loperamide can alleviate opioid withdrawal symptoms and also produce opioid-like effects. This very brief report has some interesting clinical and epidemiological nu...
Source: The Poison Review - November 25, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical cardiotoxicity ecg ekg electrocardiogram imodium loperamide Source Type: news

Treating “heroin” overdose: the past is no guide
1.5 out of 5 stars Do heroin overdose patients require observation after receiving naloxone? Tillman MW et al. Clin Toxicol 2016 Nov 16:1-7 [Epub ahead of print] Abstract The stated goal of this study was to search the medical literature in an attempt to answer 3 main questions: “What are the medical risks to a heroin user who refuses ambulance transfer after naloxone? “If the heroin user is treated in the emergency department after naloxone, how long must the be observed prior to discharge? “How effective in heroin users is naloxone administered by first responders and bystanders?” ...
Source: The Poison Review - November 22, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical antidote emergency department heroin naloxone narcan opiate opioid overdose pre-hospital treat-and-release Source Type: news

How to interpret urine drug tests for marijuana: a review
Linda Parton/shutterstock.com 4 out of 5 stars Interpretation of Workplace Tests for Cannabinoids. Kulig K. J Med Toxicol 2016 Sep 29 [Epub ahead of print] Abstract The interpretation of workplace urine drug tests for marijuana often becomes a point of contention in workman’s compensation cases or proceedings moving towards firing an employee. In may experience, the court or arbitrator not infrequently gets the science of these tests wrong. Such misinterpretation can be devastating for the employee who is at risk of losing his or her job and benefits. This concise review of the subject by Ken Kulig gets the science r...
Source: The Poison Review - November 19, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical marijuana occupational medicine THC THC acid THC-COOH THCa urine drug screen workman's compensation Source Type: news

Missing loperamide (Imodium) abuse can be a fatal mistake
3 out of 5 stars Epidemiologic Trends in Loperamide Abuse and Misuse. Vakkalanka JP et al. Ann Emerg Med 2016 Nov 4 [Epub ahead of print] Abstract This paper reviews loperamide exposures reported to the National Poison Data System  over the 6-year period from 2010 through 2015. Because of the well-recognized limitations involved in retrospective analysis of poison center data, there is not much clinically useful information revealed by their study. The authors did find — unsurprisingly — that reported exposures to loperamide went up from 2010 to 2015, increasing by 91%. As we’ve discus...
Source: The Poison Review - November 15, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical cardiotoxicity fatality imodium loperamide overdose prolonged QT syndrome Source Type: news

Does exposure to marijuana cause myocardial infarction?
2 out of 5 stars Prolonged cardiac arrest complicating a massive ST-segment elevation myocardial infarction associated with marijuana consumption. Orsini J et al. J Community Hosp Intern Med Perspect 2016 Sept 7;6(4):31695 Full Text The medical literature contains scattered, rare case reports and series describing myocardial infarction, acute coronary syndrome, and cardiac arrest associated with exposure to cannabis. (Extreme emphasis on the word “associated.”) This literature is limited by a number of crippling problems, including failure to screen completely for presence of other drugs, failure to collect com...
Source: The Poison Review - November 12, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical cannabis cardiotoxicity heart attack cardiac arrest marijuana myocardial infarction Source Type: news

Exposure to edible marijuana products causes lethargy, especially in children
Li’l Ratskull Designs/shutterstock.com 3 out of 5 stars Characterization of edible marijuana product exposures reported to United States poison centers. Cao D et al. Clin Toxic 2016 Nov;54:840-846. Abstract As mentioned here a number of times in the past, I find papers that abstract and collate data from computerized poison center registries frustrating and infuriating. They are invariably beset by multiple intractable limitations: incomplete and unreliable data, poor follow-up, unconfirmed assertions, reporting bias, mis-coding, etc etc.  Typically, extensive statistical analysis manipulations ar...
Source: The Poison Review - November 4, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical brownies cannabis edibles marijuana Source Type: news

Alcoholic ketoacidosis: case report and review
3.5 out of 5 stars A Patient with Alcoholic Ketoacidosis and Profound Lactemia. Gerrity RS et al. J Emerg Med 2016 Oct;51:447-449. Abstract This is a very good short case-based review of alcoholic ketoacidosis (AKA), and well-worth the 5 – 10 minutes reading time. Some key points: Development of AKA requires increased (binge) alcohol intake along with starvation (decreased food and water intake.) The characteristic high anion gap metabolic acidosis with elevated lactate and β-hydroxybutyrate levels are the result of dehydration, decreased glycogen stores, increased reducing potential (increased NADH) ...
Source: The Poison Review - October 12, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical alcoholic ketoacidosis fluid repletion Review thiamine TUSH ultrasound Source Type: news

TPR Podcast Episode #12: 25 years of weird and wacky toxicology papers
25th Anniversary The Poison Review Podcast: Wild, Wacky and Weird Toxicology Articles From The Last Quarter-Century “It is universally well known, that in ingesting our common food, there is created or produced in the bowels of human creatures, a great quantity of wind.”  Benjamin Franklin Does Beano prevent gas? A double-blind crossover study of oral alpha-galactosidase to treat dietary oligosaccharide intolerance. Ganiats TG et al. J Fam Pract 1994 Nov;39:441-5. An air stewardess with puzzling diarrhoea. Greaves RR et al. Lancet 1996 Nov 30;348:1488 Lithium intoxication of unusual origin. Pristach CA. P...
Source: The Poison Review - September 26, 2016 Category: Toxicology Authors: Leon Gussow The Poison Review Tags: Medical Podcast Source Type: news

Must-read post: Why dialyze patients with chronic, asymptomatic hyperlithemia?
About a month ago I discussed a new state-of-the-art review of lithium poisoning, which I rated “four skulls” and called a near must-read. Now comes a superb post entitled “Why dialyze patients with chronic, asymptomatic hyperlithemia” from Josh Farkas from PulmCrit.org and emcrit.org. It is essential reading for all clinicians who deal with lithium poisoned patients. Dr. Farkas makes the following important points: A single lithium level, not correlated with the patient’s clinical condition or history, does not provide much useful information. The serum lithium level does not corre...
Source: The Poison Review - September 20, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical chronic extrip hemodialysis lithium poisoning Source Type: news

Must-read: ayahuasca in America
Ecuadorian ayahuasca shaman (Ammit Jack/shutterstock.com) In the current (Sept 12) issue of The New Yorker. Ariel Levy writes about the drug-fueled South American shamanistic ritual ayahuasca (or yagé,) and how its plants and practices are being imported to “hip” American areas such as Brooklyn and Silicon Valley. As TPR has explained before: Pharmacologically, ayahuasca is quite interesting. It is commonly made by macerating and boiling together parts of the plants Banisteriopsis caapi and Psychotria viridis. Neither of these plants, taken alone, has psychedelic properties. P. viridis doe...
Source: The Poison Review - September 9, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical ariel levy ayahuasca Banisteriopsis caapi dmt New Yorker psychotria viridis Source Type: news

Case series: 8 patients exposed to phony alprazolam (Xanax) containing fentanyl and/or etizolam
3 out of 5 stars Adverse Effects From Counterfeit Alprazolam Tablets. Arens AM et al. Ann Emerg Med 2016 Aug 8 [Epub ahead of print] Reference In March of this year,there were 9 deaths reported in Pinellas County, Florida (the Tampa/St. Petersburg area) associated with fake alprazolam (Xanax) tablets containing fentanyl. Earlier, similar counterfeit pills had been seen around San Francisco and in Monroe County Southern Illinois. This letter, from the University of California-San Francisco and the California Poison Control System describes 8 cases — including 1 cardiac arrest — from that region. A...
Source: The Poison Review - August 25, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical alprazolam counterfeit etizolam fake phony xanax Source Type: news

State-of-the-art review of lithium poisoning: almost a must-read
4 out of 5 stars Lithium Poisoning: State of the Art.  Baird-Gunning J et al. J Intensive Care Med 2016 Aug 11 [Epub ahead of print] Abstract This is a very good paper, the best comprehensive review I can remember reading on lithium. It is up to date, with 78 references as recent as 2015. A major reason I liked it so much is that the authors are quire frank about how much we don’t know, and resist giving, for instance, mandates about when to start hemodialysis based on lithium levels. This is a temptation that the authors of the recent ExTRIP review  succumbed to. Interestingly, the two papers sha...
Source: The Poison Review - August 20, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical lithium poisoning Review TUSH ultrasound Source Type: news

Elephant-tranquilizer (carfentanil)-tainted heroin showing up in Ohio
4 out of 5 stars Human Health Hazards of Veterinary Medications: Information for Emergency Departments. Lust EB et al. J Emerg Med 2011 Feb;40:198-207 Abstract Yesterday, Canadian police announced that, earlier in the summer, they had seized one kilogram of carfentanil contained in a package labelled “Printer Parts” shipped from China and addressed to a man in Calgary. Carfentanil is frequently, and accurately, referred to as an “elephant tranquilizer.” It is a fentanyl analog with a potency 10,000 times that of morphine (or 100 times that of fentanyl.) It is not approved for any medical i...
Source: The Poison Review - August 10, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical animal tranquilizer carfentanil opiate opioid tainted heroin Source Type: news

Seven cases of laboratory-confirmed exposures to the synthetic cannabinoid MDMB-CHMICA
3 out of 5 stars Clinical toxicity following analytically confirmed use of the synthetic cannabinoid receptor agonist MDMB-CHMICA. A report from the Identification Of Novel psychoActive substances (IONA) study. Hill SL et al. Clin Toxicol 2016 Sep;54:638-643. Abstract MDMB-CHMICA is a synthetic cannabinoid receptor agonist (SCRA) with strong affinity for the CB1 receptor. It has to date not been banned in may localities, and is available on the street under labels such as “AK47 Loaded,” “Manga Hot,” “Black Diamond,” and “Sweet Leaf Obliteration.” It use has been associated w...
Source: The Poison Review - August 8, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical MDMB-CHMICA sweet leaf synthetic cannabinoid Source Type: news

Seven cases of laboratory-confirmed exposed to the synthetic cannabinoid MDMB-CHMICA
3 out of 5 stars Clinical toxicity following analytically confirmed use of the synthetic cannabinoid receptor agonist MDMB-CHMICA. A report from the Identification Of Novel psychoActive substances (IONA) study. Hill SL et al. Clin Toxicol 2016 Sep;54:638-643. Abstract MDMB-CHMICA is a synthetic cannabinoid receptor agonist (SCRA) with strong affinity for the CB1 receptor. It has to date not been banned in may localities, and is available on the street under labels such as “AK47 Loaded,” “Manga Hot,” “Black Diamond,” and “Sweet Leaf Obliteration.” It use has been associated w...
Source: The Poison Review - August 8, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical MDMB-CHMICA sweet leaf synthetic cannabinoid Source Type: news

Counterfeit Norco containing fentanyl and the synthetic opioid U-47700
3 out of 5 stars Fentanyl and a Novel Synthetic Opioid U-47700 Masquerading as Street “Norco” in Central California: A Case Report. Armenian P et al. Ann Emerg Med 2016 [Epub ahead of print] Full Text In a recent “Toxicology Rounds” column for Emergency Medicine News, I pointed out that designer opioids such as U-47700 are being identified in street drug specimens and overdose cases with increasing frequency. Knowing this, I was not really surprised when it was announced last week that the autopsy on music superstar Prince confirmed the presence of U-47700, as well as fentanyl. U...
Source: The Poison Review - July 28, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical counterfeit Norco synthetic opioid U-47700 Source Type: news

All bleeding stops — but does idarucizumab (Praxbind) make it stop faster?
3.5 out of 5 stars Persistent life-threatening hemorrhage after administration of idarucizumab. Alhashem HM et al. Am J Emerg Med 2016 June 30 [Epub ahead of print] Reference Dabigatran (Pradaxa) is a direct thrombin inhibitor approved for stroke and embolism prophylaxis in patients with non-valve-related atrial fibrillation. When it was first released in 2008, a major disincentive to widespread use was the lack of a reliable reversal agent to treat major bleeds, or to administer before necessary invasive procedures. In October 2015, the U.S. Food and Drug Administration approved idarucizumab (Praxbind), a monocl...
Source: The Poison Review - July 27, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical anticoagulant hemorrhage idarucizumab pradaxa praxbind reversal agent Source Type: news

A normal (or negative) anion gap does NOT rule out salicylate toxicity
3 out of 5 stars Salicylate toxicity in the absence of anion gap metabolic acidosis. Bauer S, Darracq MA. Am J Emerg Med  2016 Jul;34(7):1328.e1-3 Reference Moderate-to-severe salicylate toxicity typically presents with a combined metabolic acidosis and respiratory alkalosis. Often, the arterial blood gas shows a pH quite near the normal 7.4, but with decreased pCO2 and decreased bicarbonate. However, occasional case reports have shown that in these cases the anion cap may, rarely, but normal or even negative. This seems to be related to specific electrodes that measure chloride level loosing selectivity as ...
Source: The Poison Review - July 23, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical anion gap aspirin poisoning laboratory error salicylate toxicity Source Type: news

Fentanyl can cause serotonin syndrome
3.5 out of 5 stars Serotonin Syndrome Induced by Fentanyl in a Child: Case Report. Robles LA. Clin Neuropharmacol 2015 Sept-Oct;38:206-8. Abstract When many clinicians think of serotonin syndrome (SS), they consider the usual suspects: Selective Serotonin Uptake Inhibitors (SSRIs) Citalopram Fluoxetine Sertraline Escitalopram Paroxetine Serotonin-Norepinephrine Reuptake Inhibitors Venlafaxine Duloxetine Antidepressants Trazodone Buspirone Clomipramine Aside from these common culprits, there are other commonly used drugs whose clear association with serotonin syndrome is less-often realized: Fentanyl ...
Source: The Poison Review - July 8, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical fentanyl opioid serotonin syndrome Source Type: news

Loperamide (Imodium) overdose can cause fatal cardiac toxicity
A recent paper described two fatalities associated with overdose of the anti-diarrhea drug loperamide (Imodium.) This drug, once available by prescription only, had been thought so safe that in 1988 it was approved for purchase over-the-counter. Here are some important questions regarding this medication: Why is it sometimes called the “poor man’s methadone”? Why, despite having typical opiate μ-receptor activity, does it generally not cause respiratory or mental status depression? Why is P-glycoprotein (P-gp) important for understanding the pharmacokinetics of loperamide, and what does that have to d...
Source: The Poison Review - July 4, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical cardiotoxicity imodium loperamide opiate P-glycoprotein Source Type: news

Acetaminophen and N-acetylcysteine are removed by hemodialysis
3.5 out of 5 stars Massive acetaminophen overdose: effect of hemodialysis on acetaminophen and acetylcysteine kinetics. Ghannoum M et al. Clin Toxicol 2016 Jul;54:519-22. Abstract As we’ve discussed before, massive acetaminophen [APAP] overdose may be a somewhat different beast from the usual, run-of-the-mill case that reliably responds to N-acetylcysteine [NAC] (if administered at an early stage.)There is evidence that a very large intake of APAP (some say>500 mg/kg) can poison mitochondria, causing severe effects that manifest even before onset of hepatotoxicity. “Massive overdose” is ...
Source: The Poison Review - June 30, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical acetaminophen acetylcysteine hemodialysis massive overdose Source Type: news

A can ’t miss item in the differential diagnosis of neuroleptic malignant syndrome
2 out of 5 stars Psychiatric Emergencies for Clinicians: Emergency Department Management of Neuroleptic Malignant Syndrome. Wilson MP et al. J Emerg Med 2016;51:66-69. Reference This review article about neuroleptic malignant syndrome (NMS) is brief but disappointing and misleading on some points. For example, the authors state that: The majority of cases of NMS develop symptoms within the first week [after starting the offending medication], and virtually all develop symptoms within the first 30 days. The clinician who takes this statement to the bank could easily miss late-onset NMS occurring as a result of dose cha...
Source: The Poison Review - June 22, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical anti-NMDA receptor encephalitis dantrolene neuroleptic malignant syndrome Source Type: news

A can’t miss item in the differential diagnosis of neuroleptic malignant syndrome
2 out of 5 stars Psychiatric Emergencies for Clinicians: Emergency Department Management of Neuroleptic Malignant Syndrome. Wilson MP et al. J Emerg Med 2016;51:66-69. Reference This review article about neuroleptic malignant syndrome (NMS) is brief but disappointing and misleading on some points. For example, the authors state that: The majority of cases of NMS develop symptoms within the first week [after starting the offending medication], and virtually all develop symptoms within the first 30 days. The clinician who takes this statement to the bank could easily miss late-onset NMS occurring as a result of dose cha...
Source: The Poison Review - June 22, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical anti-NMDA receptor encephalitis dantrolene neuroleptic malignant syndrome Source Type: news

Rant: ultrasound visualization of pills in the stomach will never make sense
Konstantin Shevtsov/shutterstock.com 2 out of 5 stars Accuracy of Trans-Abdominal Ultrasound in a Simulated Massive Acute Overdose. Sullivan S et al.  Am J Emerg Med 2016 Apr 23 [Epub ahead of print] Abstract As soon as emergency portable bedside ultrasound became feasible approximately three decades ago, toxicologists wondered if it would be a useful modality for visualizing pills in the stomach of overdose patients. The answer, clearly, is no it would not. This misguided paper illustrates why. This randomized study had a study group (N=10) and a control group (N=10) ingest 50 enteric-coated placebo capsules plu...
Source: The Poison Review - May 25, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical activated charcoal acute ingestion gastric lavage sonography ultrasound whole bowel irrigation Source Type: news

5-MAPB: a novel psychoactive benzofuran
3.5 out of 5 stars Acute Toxicity Associated With the Recreational Use of the Novel Psychoactive Benzofuran N-methyl-5-(2 aminopropyl)benzofuran. Sofer KE et al. Ann Emerg Med 2016 Apr 26 [Epub ahead of print] Abstract 5-MAPB is a psychoactive benzofuran with a structure and effects similar to those of MDMA (Ecstasy.) Although there has been scant investigation of its pharmacologic and toxic effects, animal studies indicate that it inhibits re-uptake of monoamines, especially serotonin. This case report from Zurich Switzerland describes a patient with laboratory-confirmed exposure to 5-MAPB. He pre...
Source: The Poison Review - May 24, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical 5-MAPB 5_APB bensofuran benzo fury ecstasy mdma psychoactive Source Type: news