The Poison Lab

In this episode of The Poison Lab, host Ryan Feldman is joined by Dr. Amy Zosel, a medical toxicologist, emergency physician, and educator. Together, they use real poisoning cases to practice identifying toxins and flexing their toxic differential The conversation dives into intriguing and challenging toxicology cases, with a focus on educating listeners about real-world poisoning scenarios, myth-busting internet misinformation, and providing practical clinical insights. Mini episode with Dr. Robert Bassett on Remembering Poisonous Mushrooms Dr. Zosel and Ryan discuss:14:15 Case 1 33:04 Case 2News story37:00 Case 3 New story48:00 Case 4 News storyUS outbreak "Robocough"Study about Naloxone in Clonidine overdose++Spoiler++: Below this will be key takeaways regarding managing the poisonings discussed, it may ruin your experience if you are guessing the poisons Key Takeaways:Amatoxin Mushroom Poisoning: The classic delayed onset of severe GI symptoms, followed by a latent phase, can mask progressive liver damage. Early recognition and treatment with hydration, silibinin, and possible liver transplant are critical.Tetramine Toxicity: Known for causing refractory seizures, tetramine is a rare but serious poisoning often requiring aggressive supportive care and anticonvulsants.A Lethal mushroom hiding in edible mushrooms Mushroom foraging dangerResources Mentioned:National Poison Control Hotline: 1-800-222-1222National Suicide Prevention Lifeline: 1-800-273-8255SAMHSA Free Helpline: 1-800-662-HELP (4357)Follow The Poison Lab:Twitter: @LabPoisonInstagram: @tox_talkWebsite: www.ThePoisonLab.comSubscribe and Review:Love what you're hearing? Help us reach more toxicology enthusiasts by leaving a review on Apple Podcasts, Spotify, or wherever you listen. Don't forget to share this episode with...

Support the showReview the show where ever your listeningJoin as a donating memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game Landing Page!Tox trinkets (Rep the show at home!)Reach the showEmail: Toxtalk1@gmail.comMore Show ResourcesGet Messages from Toxo (Newsletter)Ryan's Medical Games and ResourcesShow Website If you are looking for links to Dr. Basset's initiatives check back later, they are not fully launched yet!Check it out on Dr. Hamilton's website as well Poison Mushrooms! Got'a Pic'em (GOTAAPPICEM) A mnemonic device to sort through mushroom ingestions – The Hot Stove League of EM/ToxThe GOTAA PPICCEM MnemonicLate-Onset (Severe) Toxic Mushrooms ("GOTA")These mushrooms have delayed symptoms (>6 hours) and are associated with significant toxicity:G – Gyromitrin (Gyromitra esculenta) – False morels; inhibits GABA, leading to seizures.O – Orellanine (Cortinarius spp.) – Causes renal failure; famously poisoned The Horse Whisperer author.T – Tricholoma equestre (Man on Horseback) – Leads to rhabdomyolysis.A – Amatoxin (Amanita phalloides, Galerina spp.) – Causes liver failure; the most lethal mushroom toxicity. Early Onset Nausea, Late Toxicity Mushrooms ("A²P²")A² – Allenic norleucine (Amanita smithiana) – Found in the Pacific Northwest; early GI symptoms followed by renal failure.These may present early but still cause significant toxicity.P² – Paxillus spp. – Can cause hemolytic anemia and multi-organ injury. Early-Onset Nausea Mushrooms ("PICCEM")P– Psilocybin (Psilocybe spp.) – Hallucinogenic, similar to LSD, typically low toxicity but may cause hyperthermia or seizures.Symptoms appear within 6 hours and are usually self-limited.I – Ibotenic Acid & Muscimol (Amanita muscaria, Amanita pantherina) – Acts like a “mushroom speedball”, causing both stimulant and sedative effects.C – Coprine (Coprinus spp., Inky Caps) – Induces disulfiram-like reaction with alcohol.E – Emetic Mushrooms (LBMs: Little Brown Mushrooms) – Various species that cause self-limited vomiting and diarrhea.M – Muscarine...

In this special collaboration with NephMadness, we're diving into the world of nephrotoxins with an expert panel from Virginia Commonwealth University. NephMadness is an educational competition modeled after March Madness, and this year, one of the featured regions focuses on plant-based nephrotoxins. Together, with our expert panel we break down the competing nephrotoxin teams: Tubular Toxins vs. Oxalate Offenders. Joining us are Dr. Anna Vinnokova (Nephrologist), Dr. Rachel Khan PharmD (Neph pharmacist), Dr. Ethan Downes (Nephrology fellow), and the legendary nephrotoxicologist, Dr. Josh King (Board certified Nephrologist and Toxicologist). We ALMOST named this episode "Getting Downe with the Mad Neph King and the Bean Queens"... but we didn't, your welcome. After the show, go to the blog and vote for your favorite!Expect irreverent musings, deep dives into toxic plant exposures, and a mystery case reveal that will leave you questioning your diet.Topics and Timeline of Episode:IntroListener Guesses With Josh and Ryan– 8:30Listener Winner – 25:42NephMadness and Guest Introductions – 28:07Toxin Reveal – 33:41NEJM Case reportTubular Toxins – 35:46Aristolochic Acid & the Belgian Weight-Loss Clinic Outbreak – 40:30Black Licorice & Its Surprising Toxic Effects – 47:16The Oxalate Offenders Team: How Dietary Oxalates Harm the Kidneys – 52:00Historical Context: First recognized through sheep die-offs when herds grazed on Halogeton glomeratus, a high-oxalate plant, leading to fatal poisoning.Oxalate in Plants: Functions to bind excess calcium in the soil.Impact on the Body: Plants high in oxalate but low in calcium can contribute to oxalate accumulation, this leads to binding calcium in the blood, creating calcium oxalate crystals and acute renal calculi. Chronic inflammation from excess oxalate deposition leads to CKD progression.High-Oxalate Foods: Spinach, Swiss chard, rhubarb, cashews. Everything in moderation!Practical Advice for Clinicians & Patients on Herbal Medicine Use – 1:00:00Resources for identifying nephrotoxic herbal productsTalk to your patients non judgmentally, open conversations, discuss efficacy (or lack there of, see resources below) and safetyHerbal medicines are not FDA approved and may not contain what they claim toHerbals may not all be safe: Josh King Discovering Contaminants– 1:01:11Wrap up– 1:08Key Takeaways:Aristolochic acid is a direct nephrotoxin, associated with progressive kidney damage and urothelial cancers.Black licorice toxicity results from...

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Finally, the journal club to rule ALL journal clubs. In this episode of The Poison Lab, we tackle one of the biggest topics in emergency medicine and toxicology: Should naloxone be given during opioid-associated cardiac arrest? With three fantastic studies published in 2024, we're diving into the data and hearing directly from the authors themselves.Join host Ryan Feldman as he interviews Dr. Eric Quinn, Dr. Joshua Lupton, and Dr. David Dillon, some of the minds behind the latest research exploring the role of naloxone in out-of-hospital cardiac arrest (OHCA). With perspectives ranging from clinical outcomes to practical implementation, this episode offers a deep dive into what these studies tell us—and what remains unanswered.But that's not all! Featuring special guests Spencer Oliver and Chris Pfingston from EMS 2020, this roundtable discussion incorporates the real-world insights of prehospital EMS professionals who face these decisions every day. Together, the panel unpacks:Conflicting evidence on naloxone's impact on ROSC and survival.The challenges of interpreting retrospective studies in a high-stakes setting.Ethical dilemmas surrounding randomized trials for naloxone.Practical considerations for paramedics and emergency physicians in the field.Whether you're a toxicologist, EMS professional, or just curious about the intersection of drugs, overdose, and resuscitation, this episode is packed with actionable insights, expert opinions, and engaging discussions.Tune in now to explore the science, controversy, and future directions for naloxone in cardiac arrest care!Studies discussed in the showOutcomes of Out-of-Hospital Cardiac Arrest Patients Who Receive Naloxone in an EMS System with a High Prevalence of Opioid Overdose – Dr. Eric Quinn.Association of Early Naloxone Use with Outcomes in Nonshockable Out-of-Hospital Cardiac Arrest – Dr. Joshua Lupton.Naloxone and Patient Outcomes in Out-of-Hospital Cardiac Arrest in Northern California – Dr. David Dillon.Studies and guidelines mentioned Editorial by Dr. Lavonas on Dr. Lupton's study AHA 2023 Guidelines for poisoning cardiac arrestAHA 2021 Position statement on opioid overdose out of hospital cardiac arrest Study of opioid overdose death after bystander naloxone training mentioned by ToxoShows mentionedChris and Spencer's excellent EMS showRyan's Interview on Poisoning Cardiac Arrest Guidelines with Dr. Eric LavonasJournal club with Ryan and Dr. Dillon Timestamps and chaptersIntroduction (0:00–12:25)Podcast

In this special holiday bonus episode, Ryan takes a look back at some of the most captivating episodes of The Poison Lab from 2022. Get ready for an ultimate test of your toxicology differential diagnosis skills as we compile all the "Stump the Toxicologist" segments into one streamlined, binge-worthy episode. Explore eight unique poisoning cases, be sure to check the show notes for a description of each case. time stamp of where it begins, and links to the original episodes, where you can dive deeper into the discussions and unravel the mysteries behind these intriguing cases! Case Teasers and Time StampsEpisode 13, March 2nd, 2022: Dr. Howard Greller0:06:19 Case 1: A 19-year-old male collapses at home and presents to the ED unresponsive, tachycardic, and hypotensive, with a wide QRS complex on EKG and a serum lactate of 20. 0:22:58 Case 2: A 16-year-old female presents to the ED 9 hours after ingesting 100 tablets of an unknown medication in a suicide attempt. She presents with vomiting, lethargy, bloody diarrhea, and a metabolic acidosis. An abdominal x-ray shows numerous radiopaque tablets in her GI tract. She is treated with a redacted antidote and whole bowel irrigation, but her condition worsens and she develops liver failure. She is transferred to a tertiary care center for a liver transplant, but recovers. On day 12, she develops a lower GI bleed and bowel perforation and dies. 0:34:42 Case 3: A seven-month-old child presents with crying, cough, vomiting, and respiratory distress. 0:37:42 Case 4: A 32-year-old male with a history of alcohol use and depression presents to the ED seven hours after ingesting two handfuls of an unknown medication and alcohol in a suicide attempt. He is initially anxious and tremulous, but has normal vital signs and labs, aside from an elevated ethanol level. He has a seizure nine hours after ingestion. His EKG shows a widened QRS, and he becomes hypotensive. He is intubated, placed on vasopressors, and undergoes extracorporeal membrane oxygenation (ECMO) and targeted temperature management (TTM), but dies three days later. Episode 15, July 6th, 2022: Dr. Josh Trebach0:46:11 Case 1: Two British medical students present to the ED after developing nausea, vomiting, paresthesias, myalgias, pruritus, and cold allodynia 12 hours after sharing a meal. Their neurological symptoms persisted for 4 weeks and the cold allodynia for 10 weeks.0:54:18 - 1:05:23 Case 2: A 16-year-old female presents to the ED unresponsive and cyanotic after intentionally ingesting a substance purchased online. Her oxygen saturation is in the 70s and a methemoglobin level is greater than 30%. 1:05:25 - 1:10:18 Case 3: A 48-year-old female, and co-author of the published case report, presents to the ED 10 minutes after eating a “peppery” tuna steak. She is tachycardic, hypotensive, flushed, and has conjunctival erythema. She also experiences abdominal pain, nausea, vomiting, diarrhea, headache, and chest pain. Her EKG shows tachycardia with ST depression. She requires phenylephrine to maintain her blood pressure. She is treated with famotidine and discharged from the hospital 43 hours later. 1:10:20 – 1:13:16 Case 4: A 63-year-old female presents to the ED 12 hours after ingesting five capsules of a weight loss product. She is bradycardic and has nausea, vomiting, and hyperkalemia.Episode 17, November 9th, 2022: Dr. Emily Kieran1:16:35 Case 1: A 34-year-old female presents to a clinic in West Bengal, India, with a three-year history of skin changes. She has hypo-pigmented macules on a background of hyperpigmentation, creating a “raindrop” like appearance on her...

Join host Ryan Feldman in an insightful episode of "The Poison Lab" as he sits down with Dr. John Downs, Director of the Virginia Poison Center, and one of the leading experts on per- and polyfluoroalkyl substances (PFAS), commonly known as "forever chemicals." Known for their persistence in the environment and human body, PFAS have raised significant public health concerns over the past few decades. Dr. Downs shares his journey through occupational medicine, toxicology, and public health, which uniquely positioned him to provide expertise on PFAS exposure, health risks, and ongoing regulatory efforts. Together, they delve into the origins, uses, and potential health effects of these ubiquitous compounds, while examining government policies, environmental impact, and strategies to reduce exposure. A must-listen for anyone interested in the intersection of environmental health and toxicology! Episode Breakdown:2:42 – What Are Forever Chemicals?8:01 – History of PFAS and Associated Health Concerns15:41 – Government Regulation of PFAS20:42 – Shortcomings in PFAS Regulation25:20 – How Individuals Can Mitigate Risk31:15 – Testing for PFAS Levels and Exploring Treatment Options41:14 – Future Directions and Research Needs for PFAS45:29 – Conclusion and OutroKey Topics Discussed2:42 – What Are Forever Chemicals?PFAS are a large group of man-made chemicals that are persistent in the environment and human body.The podcast focuses primarily on PFOA (perfluorooctanoic acid) and PFOS (perfluorooctanoic sulfonic acid), as these were the first compounds identified as having very long elimination half-lives, measured in years, and not undergoing significant human metabolismThe podcast mentions that there are potentially thousands of different PFAS compounds and that more research is needed to determine if they all induce the same health effects as PFOA and PFOSCommonly used for their water- and oil-resistant properties in nonstick cookware, fast food wrappers, firefighting foams, and more.8:01 – History of PFAS and Associated Health ConcernsFirst created by Dupont chemical, used widely in 1940's in TeflonLarge contamination of water by PFAS identified in West Virginia townLed to landmark study in West Virginia (the C8 study) on epidemiological data of PFAS-related health risks.Effects noted: High cholesterol, thyroid dysfunction, ulcerative colitis, hypertension in pregnancy, decreased immune response to vaccine, and certain cancers (testicular and kidney cancer).PFAS in the EnvironmentPFAS are not easily degraded, leading to bioaccumulation in humans and animals.Non-stick cookware: Teflon, the trade name for non-stick cookware, was one of the earliest applications of PFAS, utilizing PFOA.Firefighting foam: PFAS was used in firefighting foams, particularly for aviation fuel fires. This has led to contamination of groundwater around military installations and airports.Fast food wrappers and other consumer products: PFAS are used to make products water and oil resistant, including fast food wrappers, clothing, upholstery, and popcorn bags.Biosolids: The nitrogenous waste produced after wastewater treatment, have been found to contain concentrated PFAS. These biosolids are sometimes sold to farms as fertilizer, potentially contaminating water and crops.Ski wax: Ski waxers have been found to have a high degree of PFAS...

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In this exciting live episode from the 2024 North American Congress of Clinical Toxicology (NACCT) in Denver, Ryan dives into 12 of the most impactful research abstracts presented at the conference directly with the authors themselves. Covering a wide range of toxicology topics—from the NACSTOP2 trial on acetaminophen overdose, ECG intervals, cannabis toxicity in young children, and more—each guest breaks down their study's findings and clinical relevance. If you missed the conference or want a deeper understanding of the year's most important toxicology research, this episode is for you. Check the show notes for links to the published abstracts, the full list of studies discussed, and time stamps for where you can find those studies.   This description highlights the live format, the inclusion of the authors, and the variety of topics discussed. Let me know if you need any tweaks!Link to published abstract manuscriptAbstracts07:48-Abstract #1. The NACSTOP2 trial: a multi-center randomized controlled trial investigating the early cessation of n-acetylcysteine in acetaminophen overdoseGuest- Dr. Anslem Wong, MD, PhD21:33- Abstract  #36. ECG intervals: does one size really fit all?Guest- Dr. Caitlin Roake, MD, PhD25:41- Abstract #85. Do abnormal electrocardiographic intervals predict death in poisoned patients older than 65 years?Guest- Dr. Michael Chary, MD30:06- Abstract #61. Minimum tetrahydrocannabinol dose that produces severe symptoms in children

In this episode the poison lab hosts scientific discourse . Three listeners (Dr. Michael Mullins, Dr. Donna Seger, and Dr. Leon Gussow) write in their critiques surrounding specific recommendations and language used with the AHA 2023 Management of Poisoning Cardiac Arrest or Life-Threatening Toxicity guidelines. Lead author of the guidelines Dr. Eric Lavonas then responds to and addresses their points with counterpoints or appraisals. Tune in and draw your own conclusions!Link to guidelinesLink to high yield review 

Have a burning question you have always wanted to ask a toxicologist? What are tips for managing an anticholinergic overdose? What is the deadliest poison? Why are they called lead pencils if there is no lead?! Send your questions in to toxtalk1@gmail.com to take part in a future episode! (If you would like to be anonymous simply state it in the email)

In this episode Ryan is joined by two expert guests to help read listener guesses for the cause of this poisoning murder and shed light on the toxin involved in the case, which puzzled medicolegal investigators. Ryan is joined by Dr. Dan McCabe, MD (emergency medicine physician, medical toxicologist, medical director of Iowa poison center) and Dr. Crissy Lawson PharmD (emergency medicine pharmacist). SPOLIER ALERT Mystery case from the showReview Paper from Dr's  Lawson, McCabe, and Feldman (PMID: 38613376)Toxo's show note references TV special about Mary Yoder colchicine murderColchicine potential arrhythmic effectsGo fund me for Dr. Betty Bowman 

In this bonus episode Ryan highlights some of the great episodes done in 2023 and compiles ALL of the stump the toxicologist segments from 2023 into one easy to consume episode. Test your toxicology differential skills with more than six poisoning cases. Check out the actual episodes for more information in the show notes on each of the poisonings. 

Do you think you know the cause of these symptoms? Send your guesses to toxtalk1@gmail.com to take part in the next episode 

A quick update to share some other shows Ryan has been on in the last few weeks! Check the show notes for links to each episode!Ryan on "The Larry Meiller Show" discussing delta cannabanoidsLink to streamLink to downloadRyan on EMS2020 talking prehospital overdoseLink to episode Show homepage

In this episode Ryan interviews Dr. Alex Krotulski PhD from the Center for Forensic Science Research and Education. Together take a look at trends in novel opioids, benzodiazepines, stimulants, hallucinogens, synthetic cannabinoids, and "hemp products" that are showing up in your patients, drug products, and fatal overdoses. The conversation takes places around the Center for Forensic Science Research and Education quarterly report on Novel Psychoactive Substances found in patients and drug products. The episode starts with a discussion of the novel benzodiazepines market, highlighting bromazolam and how long it may remain in the market. Then they discuss the opioids highlighting where we are seeing carfentanil, what is happening with Para Fluorofentanyl, and other super potent opioids emergening (such as  N -pyrrolidino etonitazene). After a quick discussion of synthetic cathinone's and PCP/ketamine derivatives they jump to synthetic cannabinoids, examining the history of brodifacoum contamination and how regulation has led to market changes.  Resourceshttps://www.cfsre.org/Quarterly report  discussed on this episodeMore on Dr. KrotulskiPoster from Dr. Kortulksi on naming conventions for NPS Time stamps to jump to any portion of the episode you want to revisitIntroduction-5:00-32:5006:30-25:16- Discussion CSFRE mission, history of NPS reports, and other available reports25:14- "Miscellaneous drugs: Furanyl UF17, medetomidine"28:15- Difference between GC/MS and LCqTOFNovel Benzodiazepines- 32:50Novel Opioids-43:00Stimulants and hallucinogens- 1:01:43Synthetic cannabinoids- 1:07:40Novel psychedelics markets, hemp products, phenibut, tianeptine, and kratom-1:25:12

Case report for mystery caseReview paper cited by Dr. ArensCase 1 Some also contain CALCIUM NITRATE and can cause methemoglobinemiaCase 2Case 3

Do you think you know the cause of these symptoms? Send your guesses to toxtalk1@gmail.com to take part in episode 18 

In this episode Ryan is joined by a guest panel (Dr. Grant Comstock MD, Dr. Joshua Trebach MD, Dr. Emily Kiernan DO, and Dr Frank Paloucek PharmD, DABAT) to review nine of the most interesting or clinically impactful research abstracts that were presented at the 2023 North American Congress of Clinical Toxicology (NACCT) in Montreal Canada. If you didn't get a chance to read all 363 research abstracts from some of Toxicology's best and brightest this year, tune in for a high yield review as well as clinical a break down of the studies and their relevance from the expert panel.  Check the show notes for a link to the published abstracts and the list of all studies discussed in the showAbstracts available here10:40- Abstract 1 (PDF #225) Methotrexate toxicity in the setting of therapeutic error, a multicenter retrospective reviewLead author: Andrew Chambers24:12- Abstract #2 (PDF #251) Oleander seeds in candlenut weight loss product strike againLead author: Masha Yemets31:16- Abstract #3 (PDF #2) Efficacy of sodium tetrathionate when administered intramuscularly for the treatment of acute oral cyanide toxicity in a swine model (Sus scrofa)Lead author: Brooke Lajeunesse39:45- Abstract #4 (PDF #10) Is HOUR enough after out-of hospital naloxone for opioid overdose? Prospective preliminary data from real-world implementation of the modified St. Paul's early discharge ruleLead author: Stephen Douglas49:05- Abstract #5- Poster titles at NACCT 2013–2022: is NACCT experiencing a pun-demic?Lead author: Dayne Laskey52:40- Rivastigmine discussionLead author: none58:40- Abstract #6 (PDF #5)  Randomized controlled trial of ANEB-001 as an antidote for acute cannabinoid intoxication in healthy adultsLead author: Andrew Monte1:08:00- Abstract #7 (PDF#216) Successful use of expired physostigmine to treat anticholinergic delirium in a pediatric patientLead author: Bryan Hayes01:20:00- Abstract #8 (PDF #202) Enough negativity? Clinically significant salicylism with first detectable concentration twelve hours )post-ingestionLead author: Stacey Bangh01:25:24 - Abstract #9 (PDF #267) High sensitivity troponin is frequently elevated after carbon monoxide exposureLead author: Abdullatif Aloumi

In this episode, Ryan dives into cutting-edge research on the treatment of acetaminophen (APAP) overdose, featuring interviews with authors of several key abstracts from the North American Congress of Clinical Toxicology (NACCT) in Montreal Canada (Abstracts and posters available in the show notes). We get first looks insights into research evaluating the impact of fomepizole high risk acetaminophen overdose, as well as who gets fomepizole for acetaminophen overdose and dies. Then we evaluate the effectiveness of standard N-acetylcysteine (NAC) treatment in high risk patients and high dose NAC in high risk patients. Join us for an insightful discussion on these advancements that are reshaping the management of APAP toxicity. Guests include Dr. Masha Yemets PharmD, Dr. Molly Stott PharmD, Dr. Alexandru Ulici PharmD, and Dr. Michael Moss MD.   Link to published abstracts(First guest) Abstract #126 Characterizing fomepizole use in acetaminophen deaths reported to US poison centers- Dr. Yemets(Second guest) Abstract #125 Clinical impact of fomepizole as an adjunct therapy in massive acetaminophen overdose- Dr. Stott(Third guest) Abstract #131 Comparison of low-risk and high risk acetaminophen ingestions using the standard prescott protocol of intravenous N-acetylcysteine- Dr. Ulici(Fourth guest) Abstract #130 High-risk acetaminophen overdose outcomes after treatment with standard dose vs. increased dose N-acetylcysteine- Dr. MossOther studies discussed regarding NAC dosingATOM 2 Angela ChiewOutcomes of massive APAP treated with regular NAC (Virginia group, lead author Dr. Downes)

In this episode, Ryan sits down with Dr. Eric Lavonas MD, a seasoned EM resuscitation guideline writer, emergency medicine physician, medical toxicologist, and lead author of the latest update to the American Heart Association's guidelines for the management of cardiac arrest and life-threatening toxicity due to poisoning. They have an in-depth discussion as they explore the key aspects of the 2023 AHA treatment recommendations and the rationale behind each decision point. A great review to discover how to effectively apply these guidelines in real-world scenarios and find out what knowledge gaps exist in the realm of toxin resuscitation. Be sure to also check out the accompanying mini-episode for a high-yield review of the major treatment recommendations. Link to guidelinesLink to high yield review Cyanide paper mentioned in the showAdult calcium channel blocker toxicity guidelines

In this episode Ryan does a high yield "just the facts" break down of the recently released "2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Tune in to learn about the most recent treatment recommendations made by AHA via a panel of toxicology experts. This was released alongside a full interview with the lead author Dr. Eric Lavonas MD. Be sure to check out the full interview to hear it straight from the source! (link in show notes).Link to guidelinesLink to full in depth interview

In this enlightening episode, Ryan engages in a deep conversation with Dr. Paul Hutson, PharmD, a renowned researcher in the field of psilocybin and director of the Transdisciplinary Center for Research in Psychoactive Substances at the University of Wisconsin Madison. Dr. Hutson shares his extensive knowledge and insights into the promising role of psilocybin in the treatment of depression and substance use disorder.  Throughout the discussion, they delve into the research that supports the use of psilocybin in medical therapy, shedding light on the rigorous processes involved in conducting such studies. Dr. Hutson elucidates the efficacy and safety findings that have emerged from his and others research, offering listeners a glimpse into the potential future of psilocybin in mainstream medical practices. Listeners will gain a deeper understanding of the meticulous approach to research that ensures both safety and effectiveness. Dr. Hutson shares firsthand experiences and observations, providing a rich and detailed perspective on the current state of psilocybin research. Moreover, the conversation ventures into the practical aspects of integrating psilocybin into contemporary medical practices, discussing the potential frameworks and guidelines that would govern its use. They explore what the future might hold for patients and practitioners alike as they stand on the cusp of a revolutionary shift in mental health treatment.Whether you're a healthcare professional keen on the latest developments in medical research or someone interested in the evolving landscape of mental health treatment, this episode promises to be a rich source of information and insight. Tune in to be informed and to foster a deeper understanding of the promising horizon that psilocybin research is unveiling in the medical community.Biography for Dr. Paul Hutson PharmDTransdisciplinary Center for Research in Psychoactive SubstancesDr Hutson's PublicationsSingle Dose Psilocybin for Major Depression- JAMA 2023Psilocybin and QTc in healthy volunteersMeta-Analysis of research supporting Psilocybin use in anxiety and depressionPharmacokinetics of PsilocybinSubjective effects of high dose PsilocybinOther referenced studiesSingle dose psilocybin for treatment resistant depression Psilocybin for alcohol use disorderPsilocybin for For tobacco cessation

New Art and New Tox Trinkets. If you want to share your tox joy in the real world, find some trinkets here: https://www.etsy.com/shop/thepoisonlab

This episode is a a high yield "just the facts" break down of the recently released "Management of Acetaminophen Poisoning in the US and Canada Consensus Statement" from the American Academy of Clinical Toxicology, American College of Medical Toxicology, Americans Poisons Centers, and the Canadian Association of Poison Centers. Listen to be informed on the most recent treatment recommendations. This was released alongside a full interview with the consensus statement corresponding author Dr. Richard Dart MD, PhD. Be sure to check out the full interview to hear it straight from the source! (link in show notes).Link to the guidelines:Full interview with consensus statement author Dr. Richard Darthttps://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808062Definitions made by the guidelineAcute ingestion>7.5 g in 24 h per Rummack Matthew initial studies10 g/d or 200 mg/kg/day in 48 hHigh risk ingestionReported dose >30 grams OR[APAP] 2 x Rummack-Matthew nomogram treatment lineNAC stopping criteriaAPAP4 g x >48 hours) AND signs of APAP toxicity (vomiting, RUQ abd pain, AMS)Treat if APAP >20 ug/ml OR AST/ALT elevatedAcuteNon-detectable [APAP] between 2 and 4 hours excludes ingestionGive SDAC w/in 4 hours (something I've been a proponent of since ATOM2)Start treatment with NAC if unable to plot on nomogram by 8 hoursNAC dose“Higher dose” NAC (undefined) for high risk ingestionMinimum NAC regimen should include 300 mg/kg orally or within 20-24 hoursCAP NAC dose at 100 kg (this was known with PO, but IV there was always some question since it delivers less overall)Unique scenariosLine crossersAPAP with anticholinergic or opioidIf 1st  concentration below treatment line repeat in 4-6 hoursAPAP Extended releaseIf 1st  concentration below treatment line @ 4-12 hours, repeat in 4-6 hoursDialysis-Dialyze If APAP >900 w/ AMS or acidosis.NAC IV rate during HD 12.5 mg/kg/hr minimum. No dose change for PO (not new but good reminders)Consult liver transplant for rapid AST/ALT inc w/ coagulopathy, AMS, or mulistytem organ failureThe addition of fomepizole to acetylcysteine in the treatment of serious acetaminophen ingestions has been proposed. The panel concluded that the data available did not support a standard recommendation. As for any complicated or serious acetaminophen poisoning, a PC or clinical toxicologist should be consulted.

Mini episode- High-yield over view of Management of Acetaminophen Poisoning in the US and Canada Consensus Statement In this Ryan sits down with Dr. Richard Dart MD, PhD. He is the lead author of the recently released "Management of Acetaminophen Poisoning in the US and Canada Consensus Statement" from the American Academy of Clinical Toxicology, American College of Medical Toxicology, Americans Poisons Centers, and the Canadian Association of Poison Centers. Listen to be informed on the most recent treatment recommendations.  They dive in to the definitions established by the guideline and notable treatment recommendations, dissecting the ratinonale for each desiscion point and how to apply the guidelines. A mini episode was released along side this episode that is a high yield review of major treatment recommendations and definitions estabilished by the consensus statement.  Links :Mini episode- High-yield over view of Management of Acetaminophen Poisoning in the US and Canada Consensus Statement Guidelines https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808062Definitions made by the guidelineAcute ingestionAny overdose taken with 24 hours periodOverdose "dose" not defined>7.5 g in 24 h was criteria for Rumack Matthew nomogramConsensus statementAdult overdose at 10g/d or 200 mg/kg/d in 48 hours) AND signs of APAP toxicity (vomiting, RUQ abd pain, AMS)Treat if APAP >20 ug/ml OR AST/ALT elevatedAcuteNon-detectable [APAP] between 2 and 4 hours excludes ingestionGive SDAC w/in 4 hours (something I've been a proponent of since ATOM2)TreatStart treatment with NAC if unable to plot on nomogram by 8 hoursNAC dose“Higher dose” NAC (undefined) for high risk ingestionMinimum NAC regimen should include 300 mg/kg orally or within 20-24 hoursCAP NAC dose at 100 kg (this was known with PO, but IV there was always some question since it delivers less overall)Unique scenariosLine crossersAPAP with anticholinergic or opioidIf 1st  concentration below treatment line repeat in 4-6 hoursAPAP Extended releaseIf 1st  concentration below treatment line @ 4-12 hours, repeat in 4-6 hoursDialysis-Dialyze If APAP >900 w/ AMS or acidosis.NAC IV rate during HD 12.5 mg/kg/hr minimum. No dose change for PO (not new but good reminders)Consult liver transplant for rapid AST/ALT inc w/ coagulopathy, AMS, or mulistytem organ failureThe addition of fomepizole to acetylcysteine in the treatment of serious acetaminophen ingestions has been proposed. The panel concluded that the data available did not support a standard recommendation. As for any complicated or serious acetaminophen poisoning, a PC or clinical toxicologist should be consulted.

IntroductionChisolm lead papersTylenol murders suspect diesFranks bookToxikon fellowshipStump the toxicologistCase 1CDC articleNEJM ArticleCase 2A review paper written by the Frank Paloucek himself on toxin #2Case 3Case reportCase where toxin was found in stomach on autopsy published by colleagues  Dr. Amy Zosel and Dr. Matt Stanton Case 4A very SIMILAR case to case 4

00:00-19:00 Introduction to brain death guidelines19:00-28:00 Introduction to limitations in guidelines regarding overdose28:30-38:00 Interview with ACMT Position statement author39:00- End- Interview with Bupropion brain death mimic authors and summaryLinks references in showAmerican Academy of Neurology Bran death guidanceACMT Position statement on brain death in overdoseBrain death mimics with cerebral edemaCase report of “hypoxic patient with diffuses cerebral edema” who recovered in 48 hourCarbamazepine with diffuse cerebral edema who recoveredCases taking >2 months to recover brain stem reflexeshttps://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)07577-3/fulltexthttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4543058/Attempts to withdraw care in as little as 48 hours Dr. Stranges case reportDr. Reyes case reportNarrative review of brain death mimicsIntroductory casesCaroline Burns- Patient who woke up on operating tablePaul Maturo- Patient woke up in a morgue

Dr. Blumenberg' s projectswww.ToxicHistory.comwww.medsimstudio.com (medical vital/imaging simulator)www.toxrunner.net (toxicology question bank)Things discussed in the introMithradata Ohio vinyl chloride disasterArizona nitric acid spillOhio metal factory explosionCasesCase 1Case 1 triage guidelinesCase 1 video demonstrationCase 2Full textCase 3Review article MechanismCase 4Full textCase 5Not the actual case from the show but close enough QuestionsBHO explosions

 Bupropion is the #1 antidepressant cause of major (life threatening) reported to U.S. Poison Centers It is difficult to manage due to Potential for delays seizuresUnique cardiogenic shock in overdosePotential wide complex arrhythmia refractory to Sodium Bicarbonate Potential interference with brain death testingTreatmentDecontaminationAggressive whole bowel irrigation or charcoal may be indicated if large ingestion Supportive careIntubation if airway compromisedBenzodiazepine for agitationBenzodiazepines and GABA-ergic AED's for status epilepticsTachycardia, tremor, and agitation are risk factor for seizuresTachycardia may be masked by alpha 2 agonist co ingestionsSeizures may occur 24 hour outSodium bicarbonate for wide QRS (it may be refractory)Inodilators and vasopressors for cardiogenic shockECMO for refractory shock or arrhythmiaAwareness that severe bupropion toxicity can mimic brain deathsend analytical confirmation of bupropion if possible to rule out confoundingEnhanced eliminationlimited options due to protein binding, not routineFocused antidoteConsider IV fat emulsion if the patient is peri arrestObservation timesTalk to a toxicolleague about observation times, decontamination, and use of invasive therapies to avoid falling into a trap 

 This antidepressant is the #1 cause of major (life threatening) effects in overdose reported to U.S. Poison CentersIt is difficult to manage due toPotential for delays seizuresUnique cardiogenic shock in overdosePotential wide complex arrhythmia refractory to Sodium Bicarbonate Potential interference with brain death testingToxicityIt increases dopamine and norepinephrine, it also blocks the gap junction in the cardiac myocyteRohr 2004- Gap junction blockade can cause a wide QRVink 2004 Connexin 43 is the most important protein for connexon formation and cardiac signal transmissionCallier 2012- Bupropion does not block sodium channels, and does exhibit similar effects on the cardiac action potential as known gap junctionBurnham 2014 Bupropion has an IC50 for connexin 43 >50 uMol, larger than other drugs such as fluoextine and lamotrigineShaikh Quereshi 2014 Bupropion interferes with connexin43 production and localization in chicken cardiac myoctes at concentration >50 uMolEffectsSympathetic toxidromeSeizuresTL;DRYour patient can seize 8-24 hours in, usually they have neurologic symptoms and tachycardia before handTachycardia may be masked by coingestions and symptoms may be very delayedDo not discharge a patient without discussing observation time with a toxicologist or poison centerDo not dismiss tachycardia and anxiety as situational in a bupropion overdoseShepherd 2004- Seizures in primarily sustained release productsMost seizures had prodromal neuropsychiatric symptomsStarr 2009- Seizure in XL products. Tachycardia, tremor, agitation most associated with seizuresSeizure occured as late as 24 hours and 25% occurred after 8 hoursOfferman 2020- Primarily sustained/extended release productsTachycardia duration, and extent (>120) predicted seizure. (Hypotnesion and neuropsych symptoms also predict)Late seizure occurred only in those with symptoms on presentationThose who had cardiac arrest had prehospital seizure= bad signRianprakaisang 2021- ToxIC review of risk factors for seizuresQTc and HR>140 predict seizuresUnique cardiogenic shock in overdosePotential wide complex arrhythmia refractory to Sodium Bicarbonate Potential interference with brain death testingTreatment DecontaminationAggressive whole bowel irrigation or charcoal may be indicated if large ingestionSupportive careIntubation if airway compromisedBenzodiazepine for agitationBenzodiazepines and GABA-ergic AED's for status epilepticsTachycardia, tremor, and agitation are risk factor for seizuresTachycardia may be masked by alpha 2 agonist co ingestionsSeizures may occur 24 hour outSodium bicarbonate for wide QRS (it may be refractory)Inodilators and vasopressors for cardiogenic shockECMO for refractory shock or arrhythmiaAwareness that severe bupropion toxicity can mimic brain deathsend analytical confirmation of bupropion if possible to rule out confoundingEnhanced eliminationlimited options due to protein binding, not routineFocused antidoteConsider IV fat emulsion if the patient is peri arrestObservation timesTalk to a toxicolleague about observation times, decontamination, and use of invasive therapies to avoid falling into a trapNot all ingestions are made the same   

Rohr 2004- Gap junction blockade can cause a wide QRS Vink 2004 Connexin 43 is the most important protein for connexon formation and cardiac signal transmissionCallier 2012- Bupropion does not block sodium channels, and does exhibit similar effects on the cardiac action potential as known gap junction  Burnham 2014 Bupropion has an IC50 for connexin 43 >50 uMol, larger than other drugs such as fluoextine and lamotrigineShaikh Quereshi 2014 Bupropion interferes with connexin43 production and localization in chicken cardiac myoctes at concentration >50 uMol

TL;DRYour patient can seize 8-24 hours in, usually they have neurologic symptoms and tachycardia before handTachycardia may be masked by coingestions and symptoms may be very delayedDo not discharge a patient without discussing observation time with a toxicologist or poison centerDo not dismiss tachycardia and anxiety as situational in a bupropion overdoseSpiller 1994- Review of instant release product overdoses Shepherd 2004- Seizures in primarily sustained release productsMost seizures had prodromal neuropsychiatric symptomsStarr 2009- Seizure in XL products. Tachycardia, tremor, agitation most associated with seizuresSeizure occured as late as 24 hours and 25% occurred after 8 hours Offerman 2020- Primarily sustained/extended release productsTachycardia duration, and extent (>120) predicted seizure. (Hypotnesion and neuropsych symptoms also predict)Late seizure occurred only in those with symptoms on presentationThose who had cardiac arrest had prehospital seizure= bad signRianprakaisang 2021- ToxIC review of risk factors for seizuresQTc and HR>140 predict seizures 

All published abstracts can be found here AbstractsCategory 1: Amlodipine VasoplegiaAbstract 1: Vasodilation in patients with calcium channel blocker poisoning treated with high dose insulin: a comparison of amlodipine versus non-dihydropyridinesStudy of HDI on propranolol poisoned pigsStudy of Minnesota HDI protocolAbstract 2: Amlodipine anxiety: a 10-year review of amlodipine associated fatalitiesAbstract 3: Extracorporeal membrane oxygenation utilization for vasoplegic shock due to pediatric toxic ingestionsData of ECMO in poisoningCategory 2: XylazineAbstract 4: “Tranq dope” opioid overdose: clinical outcomes for emergency department patients with illicit opioid overdose adulterated with xylazineCategory 3: Case Reports with Terrifying Clinical ImplicationsAbstract 5: Recovery after poly-drug overdose despite blood flow imaging demonstrating no brain perfusionAbstract 6: Challenges in diagnosing an environmental cause of recurrent methemoglobinemiaAbstract 7: Acute thiamine deficiency as a complication of insulin euglycemic therapy for an amlodipine overdoseCategory 4: Comparative evidence, Prognostication, and TriageAbstract 8: Utility of pre four-hour iron concentration in predicting toxicologyAbstract 9: Andexanet alfa vs 4-factor prothrombin complex concentrate for intracranial hemorrhage at a level I trauma hospitalCategory 5: Rapid ReviewAbstract 10: Fentanyl and fentanyl analogue exposure among emergency personnel and first responders: a systematic reviewAbstract 11: Significance of falsely low creatinine values in diagnosing massive acetaminophen ingestionAbstract 12: Large dose intentional ciprofloxacin ingestion associated with false-positive urine immunoassay for oxycodone and fentanylAbstract 13: Don't make it a double?: a 20- year review of supratherapeutic amlodipine ingestions while on chronic therapyAbstract 14: Evaluation of pediatric lisdexamfetamine exposures reported to a statewide poison control systemAbstract 15: An assessment of the reliability of stated quantity in acute acetaminophen overdoses reported to a regional poison center

Do you think you know the cause of these symptoms? Send your guesses to toxtalk1@gmail.com to take part in episode 18

Recent Healthcare poisoning in the newsNurse reportedly feeding children insulin (all information is uncomfirmed) and killing 7 neonates (not all insulin related)Anesthesiologist charged with murder for 2000 mcg fentanyl doses given during care in ICUDiethylene glycol and Ethylene glycol outbreak in GambiaNot talked about in the show but physician spiking liter bags with bupivicaine to try to kill a colleague in 2022CasesCase 1Case 2 toxinsThe burden of empty Gatorade bottles on societyCase 3 toxins Case 4 toxins

More on St Anthony's fire All published cases of phenibut withdrawal, reported baclofen regimens, clinical outcomes, multimodal therapiesTHEORETICAL UNTESTED Phenibut withdrawal treatment schema (Not tested, not intended as treatment, intended to stimulate discussion and highlight key considerations in managing withdrawal)

Do you think you know the cause of these symptoms? Send your guesses to toxtalk1@gmail.com to take part in episode 16

Case report Ryan Feldman wrote about himselfStump the Tox casesCase #1Case #2case series from Dr Jillian TheobaldCase #3Case #4Ask drugsFanconi syndrome in expired tetracycline

Digoxin kineticsAmiodarone overdosePost market safety reviewReview of published exposures and severe outcomes from US poison centerCase from the show

Send in your guesses to toxtalk1@gmail.com

Music from PixabayAdditional information on toxins from fatal poisoning cases Toxin 1Toxin 2Toxin 3Toxin 4Popper article referenced by Dr. Greller

No episode today. Head here for the live radio show! Join us next show for Dr. Howard Greller of  Sirius XM Doctor Radio, Dantastic Mr Tox & Howard,  and Tox & HoundFind the article about the poison lab here  

Music in this episode from pixabay.com IntroCase report of hemolysis after sodium deoxycholate injection HistoryEpidemiologyASPS statsFlorida Unlicensed Activity Unit Cost of surgeon fee for buttock implant 2018Recent new storiesBotox and Bubbles grifterQuick bio on cases mentioned in showCommon injection practicesFeminizing body contouring (pumping parties)Synthol musclesCapsule face cosmeticsToxicityInfectionSelf explanatoryFiller embolismReview 1, Review 2, Review 3Filler lodges in pulmonary vasculature->clotting, bleeding, inflammation95% occur within 72 hoursPrimarily respiratory symptoms (cough/hypoxemia)Chest x ray ground glass opacityTreat with supportive care (oxygen all the way through ECMO) +/- steroidsFiller BlindnessCRAO from body fillerNo effective treatment (exception, can use hyaluronidase if filler is hyaluronic acid)GranulomaInflammatory nodules from prolonged filler exposureMay occur months to year after injectionIllegal cosmetic= frequently lipogranuloma due to oil being present in many illegal cosmeticGranulomatous hypercalcemiaExcess calcitriol production from ganuloma causes hyperCACan be extremely delayed (up to 28 years)Recurrence up to 45%Treat with standard therapies (fluid, bisphosphonate) + steroids and/or ketoconazole to turn down granuloma CYP27B1 calcitriol productionCase from the showSome details changed for educational purposes 

Send in your guesses to toxtalk1@gmail.com

Research from Dr FarkasAdditional information on toxins from Fatal poisoning cases Toxin 1Toxin 2Toxin 3Toxin 4"Toxicologist vs the internet" segmentCocaethylene reviewBenzodiazepine urine drug screening - Blog post

HistoryDiscovery of KetamineClinical EffectsIndex casesSurvey of Ketamine use prior to symptomsMechanism/TreatmentMechanism/Treatment systematic reviewRat models

What substance could cause these symptoms? Send your guesses to Toxtalk1@gmail.com to participate in episode 10!

"Toxicologist vs the internet" segmentEverythingisosm.com (Blog post)Biased Mu Receptor ligandsOliceridine mouse studiesOpioid hearing loss (Blog post)Opioid hearing loss reviewTox pupils  (Blog post)Why tramadol is awful (Blog post)Additional information on toxins from Fatal poisoning cases Toxin 1Toxin 2Toxin 3Toxin 4 

New york times article on delta 8 THChttps://www.nytimes.com/2021/02/27/health/marijuana-hemp-delta-8-thc.htmlStudies of delta 8 THC in manSystematic review that summarizes single studyhttps://pubmed.ncbi.nlm.nih.gov/29385080/Actual study(may not be accessible) https://www.karger.com/Article/Abstract/136375HPLCS-MS-MS delta 8 testing strategieshttps://academic.oup.com/jat/advance-article-abstract/doi/10.1093/jat/bkaa184/6018445?redirectedFrom=fulltext testingCannabanoid receptor bindinghttps://pubmed.ncbi.nlm.nih.gov/27398024/

Case from the showhttps://pubmed.ncbi.nlm.nih.gov/22163140/Mithradateshttps://www.wemjournal.org/article/S1080-6032(11)00043-3/pdfCase series on mad honey effectshttps://pubmed.ncbi.nlm.nih.gov/20575670/Blog post on sodium channel openershttps://emcrit.org/toxhound/ff-plant-sodium-channel-openers/