Podcasts about clin toxicol phila

Contributor: Aaron Lessen, MD Educational Pearls: Colchicine is most commonly used for the prevention and treatment of gout There is research investigating the anti-inflammatory and cardioprotective effects of colchicine  This drug has a narrow therapeutic index: a small margin between effective dose and toxic dose Colchicine overdoses can be unintentional or intentional and are associated with poor outcomes Phase 1: 10 - 24 hours after ingestion Patient looks well but may have mild symptoms mimicking gastroenteritis Phase 2: 24 hours - 7 days after ingestion Multiple organ dysfunction syndrome (MODS) Phase 3: recovery is usually within a few weeks of ingestion Treatment for colchicine overdose Treat early and aggressively Gastrointestinal decontamination with activated charcoal and orogastric lavage  Dialysis and ECMO for MODS treatment References Finkelstein Y, Aks SE, Hutson JR, Juurlink DN, Nguyen P, Dubnov-Raz G, Pollak U, Koren G, Bentur Y. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol (Phila). 2010 Jun;48(5):407-14. doi: 10.3109/15563650.2010.495348. PMID: 20586571. Gasparyan AY, Ayvazyan L, Yessirkepov M, Kitas GD. Colchicine as an anti-inflammatory and cardioprotective agent. Expert Opin Drug Metab Toxicol. 2015;11(11):1781-94. doi: 10.1517/17425255.2015.1076391. Epub 2015 Aug 4. PMID: 26239119. Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Contributor: Jorge Chalit-Hernandez, OMS3 Educational Pearls: Serotonin syndrome occurs most commonly due to the combination of monoamine oxidase inhibition with concomitant serotonergic medications like SSRIs Examples of unexpected monoamine oxidase inhibitors Linezolid - a last-line antibiotic reserved for patients with true anaphylaxis to penicillins and cephalosporins Methylene blue - not mentioned in the podcast due to its uncommon usage for methemoglobinemia Other medications that can interact with SSRIs to cause serotonin syndrome Dextromethorphan - primarily an anti-tussive at sigma opioid receptors that also has serotonin reuptake inhibition Clinical presentation of serotonin syndrome Altered mental status Autonomic dysregulation leading to hypertension (most common), hypotension, and tachycardia Hyperthermia Neuromuscular hyperactivity - tremors, myoclonus, and hyperreflexia Hunter Criteria (high sensitivity and specificity for serotonin syndrome): Spontaneous clonus Inducible clonus + agitation or diaphoresis Ocular clonus + agitation or diaphoresis Tremor + hyperreflexia Hypertonia, temperature > 38º C, and ocular or inducible clonus Management of serotonin syndrome Primarily supportive - benzodiazepines can help treat hypertension, agitation, and hyperthermia. Patients often require repeated and higher dosing of benzodiazepines Avoid antipyretics to treat hyperthermia since the elevated temperature is due to sustained muscle contraction and not central temperature dysregulation In refractory patients, cyproheptadine (a 5HT2 antagonist) may be used as a second-line treatment Patients with temperatures > 41.1º C or 106º F require medically induced paralysis and intubation to control their temperature References Boyer EW, Shannon M. The serotonin syndrome [published correction appears in N Engl J Med. 2007 Jun 7;356(23):2437] [published correction appears in N Engl J Med. 2009 Oct 22;361(17):1714]. N Engl J Med. 2005;352(11):1112-1120. doi:10.1056/NEJMra041867 Dunkley EJ, Isbister GK, Sibbritt D, Dawson AH, Whyte IM. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM. 2003;96(9):635-642. doi:10.1093/qjmed/hcg109 Ramsay RR, Dunford C, Gillman PK. Methylene blue and serotonin toxicity: inhibition of monoamine oxidase A (MAO A) confirms a theoretical prediction. Br J Pharmacol. 2007;152(6):946-951. doi:10.1038/sj.bjp.0707430 Schwartz AR, Pizon AF, Brooks DE. Dextromethorphan-induced serotonin syndrome. Clin Toxicol (Phila). 2008;46(8):771-773. doi:10.1080/15563650701668625 Thomas CR, Rosenberg M, Blythe V, Meyer WJ 3rd. Serotonin syndrome and linezolid. J Am Acad Child Adolesc Psychiatry. 2004;43(7):790. doi:10.1097/01.chi.0000128830.13997.aa Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/

This month we are joined by Sarah Branson (Coram Chambers) and Professor James Coulson (Professor in Clinical Pharmacology and Toxicology at Cardiff University).  We discuss the concern that over-reliance on the numbers generated in hair testing can lead to miscarriages of justice.  The issue is that the use of a standardised cut-off levels have a racial bias, because the dark melanin in the hair helps to incorporate the drugs in the hair so someone with black hair will have a much higher reading than someone with red or blond hair, even if they have used the same amount of drugs over the same period of time.  Sarah recommends that from now on when hair testing is commissioned that it has to be instructed like other expert evidence – with a letter of instruction, there is a full forensic history.  Sarah has drafted a template LOI and order which you can access on the Coram website: https://www.coramchambers.co.uk/resources/hair-strand-testing-resources/ James makes the point that in other Courts (like to civil, criminal or coroners courts) it is unusual to have an analytical chemist commenting on the wider interpretation of the result.  James agrees that it is very important that evidence is not seen in isolation.  James takes us through the information that he would to see in these instructions in the future.  Sarah reminds us that we should start thinking about this evidence as expert opinion evidence rather than elevating the presumptive weight that should be given to the evidence.  Sarah directs us to the judgment of Lord Peter Jackson in D, Re (Children: Interim Care Order: Hair Strand Testing) [2024] EWCA Civ 498 (10 May 2024)https://www.bailii.org/ew/cases/EWCA/Civ/2024/498.html.  Sarah points out the numbers from a test is the science but what those numbers mean is just someone's opinion like any other expert evidence.  During the discussion, Sarah and James refer to:  The incorporation of drugs into hair: relationship of hair color and melanin concentration to phencyclidine incorporation M H Slawson, D G Wilkins, D E Rollins J Anal Toxicol 1998 Oct 22. The effect of hair color on the incorporation of codeine into human hair. Rollins DE, Wilkins DG, Krueger GG, Augsburger MP, Mizuno A, O'Neal C, Borges CR, Slawson MH.J Anal Toxicol. 2003 Nov-Dec;27(8):545–51. doi: 10.1093/jat/27.8.545. Cuypers E, Flanagan RJ. The interpretation of hair analysis for drugs and drug metabolites. Clin Toxicol (Phila). 2018 Feb;56(2):90-100.  Forensic Science Internation (2018)

Contributor: Taylor Lynch MD Educational Pearls: Anticholinergics are found in many medications, including over-the-counter remedies Medications include: Diphenhydramine Tricyclic antidepressants like amitriptyline Atropine Antipsychotics like olanzapine Antispasmodics - dicyclomine Jimsonweed Muscaria mushrooms Mechanism of action involves competitive antagonism of the muscarinic receptor Symptomatic presentation is easily remembered via the mnemonic: Dry as a bone - anhidrosis due to cholinergic antagonism at sweat glands Red as a beet - cutaneous vasodilation leads to skin flushing Hot as a hare - anhidrotic hyperthermia Blind as a bat - pupillary dilation and ineffective accommodation Mad as a hatter - anxiety, agitation, dysarthria, hallucinations, and others Clinical management ABCs Benzodiazepines for supportive care, agitation, and seizures Sodium bicarbonate for TCA toxicity due to widened QRS Activated charcoal if patient present < 1 hour after ingestion Temperature monitoring Contact poison control with questions Physostigmine controversy Acetylcholinesterase inhibitor Black box warning for asystole and seizure Contraindicated in TCA overdoses Crosses blood-brain barrier, so useful for TCA overdoses Indicated only in certain anticholinergic overdose with delirium Disposition Admission criteria include: symptoms >6 hours, CNS findings, QRS prolongation, hyperthermia, and rhabdomyolysis ICU admission criteria include: delirium, dysrhythmias, seizures, coma, or requirement for physostigmine drip References 1. Arens AM, Shah K, Al-Abri S, Olson KR, Kearney T. Safety and effectiveness of physostigmine: a 10-year retrospective review. Clin Toxicol (Phila). 2018;56(2):101-107. doi:10.1080/15563650.2017.1342828 2. Nguyen TT, Armengol C, Wilhoite G, Cumpston KL, Wills BK. Adverse events from physostigmine: An observational study. Am J Emerg Med. 2018;36(1):141-142. doi:10.1016/j.ajem.2017.07.006 3. Scharman E, Erdman A, Wax P, et al. Diphenhydramine and dimenhydrinate poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol. 2006;44(3):205-223. doi:10.1080/15563650600585920 4. Shervette RE 3rd, Schydlower M, Lampe RM, Fearnow RG. Jimson "loco" weed abuse in adolescents. Pediatrics. 1979;63(4):520-523. 5. Woolf AD, Erdman AR, Nelson LS, et al. Tricyclic antidepressant poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol. 2007;45(3):203-233. doi:10.1080/15563650701226192 Summarized by Jorge Chalit, OMSIII | Edited by Jorge Chalit  

MedLink Neurology Podcast is delighted to feature selected episodes from BrainWaves, courtesy of James E Siegler MD, its originator and host. BrainWaves is an academic audio podcast whose mission is to educate medical providers through clinical cases and topical reviews in neurology, medicine, and the humanities, and episodes originally aired from 2016 to 2021. Originally released: November 8, 2018 A patient comes into the emergency department. They've got a headache. You get some basic labs, a chest x-ray, and a CT scan. And then you get a drug screen. But does this information even help you? And could it hurt the patient? This week on the BrainWaves podcast, Dr. Emily Rosenthal shares her experience with Dr. Kelley Humbert on the ethics of toxicology "screening" and how she manages patients with a substance use disorder. Produced by Emily Rosenthal, Kelley Humbert, and Jim Siegler. Music by Montplaisir, Lee Rosevere, and Kevin McLeod. Sound effects by Mike Koenig, Daniel Simion. BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision-making. Be sure to follow us on Twitter @brainwavesaudio for the latest updates to the podcast. REFERENCES Bates GP, Dorsey R, Gusella JF, et al. Huntington disease. Nat Rev Dis Primers 2015;1:15005. PMID 27188817Eisen JS, Sivilotti ML, Boyd KU, Barton DG, Fortier CJ, Collier CP. Screening urine for drugs of abuse in the emergency department: do test results affect physicians' patient care decisions? CJEM 2004;6(2):104-11. PMID 17433159Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med 2010;363(24):2320-31. PMID 21142534Lager PS, Attema-de Jonge ME, Gorzeman MP, Kerkvliet LE, Franssen EJ. Clinical value of drugs of abuse point of care testing in an emergency department setting. Toxicol Rep 2017;5:12-17. PMID 29270362Silver B, Miller D, Jankowski M, et al. Urine toxicology screening in an urban stroke and TIA population. Neurology 2013;80(18):1702-9. PMID 23596074Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A single-question screening test for drug use in primary care. Arch Intern Med 2010;170(13):1155-60. PMID 20625025Tenenbein M. Do you really need that emergency drug screen? Clin Toxicol (Phila) 2009;47(4):286-91. PMID 19514875 We believe that the principles expressed or implied in the podcast remain valid, but certain details may be superseded by evolving knowledge since the episode's original release date.

La toxicité sérotoninergique est une condition de santé principalement induite par cause médicamenteuse qui est loin d'être méconnue. Toutefois, son incidence dans la pratique n'est pas clairement rapportée. Quand faut-il véritablement s'en méfier et comment assurer un traitement optimal? Trait pharmacien en discute avec Mathieu Desgroseilliers, pharmacien au CISSS de la Montérégie-Est, membre de nos deux Regroupements de pharmaciens experts en urgence et en soins intensifs et détenteur de la certification américaine en soins critiques du BPS. Références : - Chiew AL, Buckley NA. The serotonin toxidrome: Shortfalls of current diagnostic criteria for related syndromes. Clin Toxicol (Phila) 2022;60(2):143-58. - Francescangeli J, Karamchandani K, Powell M et coll. The serotonin syndrome: From molecular mechanisms to clinical practice. Int J Mol Sci 2019;20(9):2288. - Poian LR, Chiavegatto S. Serotonin syndrome: The role of pharmacology in understanding its occurrence. Cureus 2023;15(5):e38897.

Dengue CDC. Clinical assessment. Centers for Disease Control and Prevention. Cdc.gov. https://www.cdc.gov/dengue/training/cme/ccm/page73112.html CDC. Dengue. Centers for Disease Control and Prevention. Published August 15, 2023. https://www.cdc.gov/dengue/index.html Rigby J. First Pill for Dengue Shows Promise in Human Challenge Trial. Medscape: Emergency Medicine. Published October 23, 2023. https://www.medscape.com/s/viewarticle/997558?ecd=wnlscitech231101MSCPEDIT_etid6007373&uac=255848DR&impID=6007373 Schnirring L. California confirms 2nd local dengue case. Center for infectious disease research and policy. University of Minnesota. Umn.edu. Published November 2, 2023. https://www.cidrap.umn.edu/dengue/california-confirms-2nd-local-dengue-case Penis Pain Lizza E. Peyronie Disease. Medscape.com. Published August 17, 2023. https://emedicine.medscape.com/article/456574-overview Malloy M, Sinert R. Dysuria and Discharge After a New Sexual Partner. Medscape. Published November 20, 2023. https://reference.medscape.com/viewarticle/847159 Promethazine 2018-2019 Targeted Medication Safety Best Practices for Hospitals. Ismp.org. https://www.ismp.org/sites/default/files/attachments/2019-01/TMSBP-for-Hospitalsv2.pdf Drug Shortage Detail: Promethazine Injection. Ashp.org. Updated November 21, 2023. https://www.ashp.org/drug-shortages/current-shortages/drug-shortage-detail.aspx?id=872 Fass O. Antiemetics and QT prolongation. Clinicalcorrelations.org. Published January 15, 2021. https://www.clinicalcorrelations.org/2021/01/15/antiemetics-and-qt-prolongation/ Ozempic Korte C. Ozempic side effects could lead to hospitalization — and doctors warn that long-term impacts remain unknown. CBS News. Published June 10, 2023. https://www.cbsnews.com/news/ozempic-side-effects-weight-loss-drugs-wegovy-mounjaro-doctors-warn/ Krishnan L, Dhatariya K, Gerontitis D. No clinical harm from a massive exenatide overdose – a short report. Clin Toxicol (Phila). Clinical Toxicology. Published December 11, 2012. https://www.tandfonline.com/doi/pdf/10.3109/15563650.2012.752495 MedWatch: The FDA Safety Information and Adverse Event Reporting Program. FDA: U.S. Food and Drug Administration. Published September 15, 2022. https://www.fda.gov/medwatch Nakanishi R, Hirose T, Tamura Y, et.al. Attempted suicide with liraglutide overdose did not induce hypoglycemia. Diabetes Research and Clinical Practice. Diabetesresearchclinicalpractice.com. Published November 12, 2012. https://www.diabetesresearchclinicalpractice.com/article/S0168-8227(12)00384-1/fulltext Ozempic® (semaglutide) injection for Type 2 Diabetes. Ozempic.com. https://www.ozempic.com/ Hearing Loss Ahmed OH, Gallant SC, Ruiz R, Wang B, Shapiro WH, Voigt EP. Validity of the Hum Test, a Simple and Reliable Alternative to the Weber Test. Ann Otol Rhinol Laryngol. NIH: National Library of Medicine: National Center for Biotechnology Information. Published June 2018. https://pubmed.ncbi.nlm.nih.gov/29776326/#:~:text=Results%3A%20When%20examining%20the%20ability,respectively%2C%20with%20low%20pitched%20humming. Clinical Practice Guideline: Sudden Hearing Loss (Update). American Academy of Otolaryngology – Head and Neck Surgery. Entnet.org. https://www.entnet.org/quality-practice/quality-products/clinical-practice-guidelines/sudden-hearing-loss-update/ Hearing loss in adults: assessment and management. National Guideline Centre (UK). Immediate, Urgent and Routine Referral. National Institute for Health and Care Excellence; 2018. NIH: National Library of Medicine: National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK536553/#:~:text=If%20the%20hearing%20loss%20developed,service%20or%20an%20emergency%20department. Mroz M. Do you know the three main types of hearing loss? Healthy Hearing. Published April 17, 2014. https://www.healthyhearing.com/help/hearing-loss/types Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. thesgem.com. http://www.thesgem.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!

Did you know that salicylate containing substances alone were responsible for over 6,000 cases of pediatric poison exposures in 2020? Dr. Arden Conway, a Pediatric Critical Care Physician, joins Medical Students Morgan Franklin and Ifrah Waris to discuss the evaluation and management for salicylate overdose in a pediatric patient. Specifically, they will:  • Review the pathophysiology of salicylate toxicity • Review the basic assessment skills for acutely ill pediatric patients • Discuss the diagnostic options and evaluation for a child presenting with a potential salicylate overdose • Discuss the management and monitoring of salicylate overdose • Medications and treatments reviewed: activated charcoal, elimination enhancement, hemodialysis  • Discuss the potential complications of salicylate overdose Special thanks to Dr. Rebecca Yang and Dr. Jennifer Tucker for peer reviewing this episode. FREE CME Credit (requires free sign-up): Link Coming Soon! References:  Anderson, M. (2021). Initial management of suspected poisoning in children and young people. Paediatrics and Child Health, 31(10), 382-387. Chyka PA, Erdman AR, Christianson G, Wax PM, Booze LL, Manoguerra AS, Caravati EM, Nelson LS, Olson KR, Cobaugh DJ, Scharman EJ, Woolf AD, Troutman WG; Americal Association of Poison Control Centers; Healthcare Systems Bureau, Health Resources and Sevices Administration, Department of Health and Human Services. Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(2):95-131. doi: 10.1080/15563650600907140. Darracq, M. A., & Cantrell, F. L. (20136). Hemodialysis and extracorporeal removal after pediatric and adolescent poisoning reported to a state poison center. The Journal of Emergency Medicine., 44(6), 1101–1107. https://doi.org/10.1016/j.jemermed.2012.12.018 Espírito Santo, R., Vaz, S., Jalles, F., Boto, L., & Abecasis, F. (2017). Salicylate Intoxication in an Infant: A Case Report. Drug safety - case reports, 4(1), 23. https://doi.org/10.1007/s40800-017-0065-9 Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Bronstein AC, Rivers LJ, Pham NPT, Weber J. 2020 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 38th Annual Report. Clin Toxicol (Phila). 2021 Dec;59(12):1282-1501. doi: 10.1080/15563650.2021.1989785. Mukerji V, Alpert MA, Flaker GC, Beach CL, Weber RD. Cardiac conduction abnormalities and atrial arrhythmias associated with salicylate toxicity. Pharmacotherapy. 1986 Jan-Feb;6(1):41-3. doi: 10.1002/j.1875-9114.1986.tb03449.x. Palmer, B. F., & Clegg, D. J. (2020). Salicylate toxicity. New England Journal of Medicine, 382(26), 2544-2555. Runde TJ, Nappe TM. Salicylates Toxicity. [Updated 2021 Jul 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499879/

Contributor: Aaron Lessen MD Educational Pearls: What is Carbamazepine (Tegretol)? Carbamazepine is an anti-epileptic drug with mood-stabilizing properties that is used to treat bipolar disorder, epilepsy, and neuropathic pain. It functions primarily by blocking sodium channels which can prevent repetitive action potential firing. What are the symptoms of an overdose? Common initial signs include diminished conscious state, nystagmus, ataxia, hyperreflexia, CNS depression, dystonia, and tachycardia Severe toxicity can cause seizures, respiratory depression, decreased myocardial contractility, pulmonary edema, hypotension, and dysrhythmias. How is an overdose treated? An overdose is treated with large doses of activated charcoal and correction of electrolyte disturbances. Be ready to intubate given the potential for respiratory depression. Carbamazepine is moderately dialyzable and dialysis is recommended in severe overdoses. Additional educational pearl: Individuals in correctional facilities can occasionally self-administer medications which means that medication overdose should still be on the differential for any of these individuals. References Epilepsies in children, Young People and adults: NICE guideline [NG217]. National Institute for Health and Care Excellence. (2022, April 27). https://www.nice.org.uk/guidance/ng217  Ghannoum M, Yates C, Galvao TF, Sowinski KM, Vo TH, Coogan A, Gosselin S, Lavergne V, Nolin TD, Hoffman RS; EXTRIP workgroup. Extracorporeal treatment for carbamazepine poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila). 2014 Dec;52(10):993-1004. doi: 10.3109/15563650.2014.973572. Epub 2014 Oct 30. PMID: 25355482; PMCID: PMC4782683. Seymour JF. Carbamazepine overdose. Features of 33 cases. Drug Saf. 1993 Jan;8(1):81-8. doi: 10.2165/00002018-199308010-00010. PMID: 8471190. Spiller HA. Management of carbamazepine overdose. Pediatr Emerg Care. 2001 Dec;17(6):452-6. doi: 10.1097/00006565-200112000-00015. PMID: 11753195. Tran NT, Pralong D, Secrétan AD, Renaud A, Mary G, Nicholas A, Mouton E, Rubio C, Dubost C, Meach F, Bréchet-Bachmann AC, Wolff H. Access to treatment in prison: an inventory of medication preparation and distribution approaches. F1000Res. 2020 May 13;9:357. doi: 10.12688/f1000research.23640.3. PMID: 33123347; PMCID: PMC7570324. Summarized by Jeffrey Olson, MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII  

Ms Lisa Beck, assistant professor of nursing and a clinical nurse specialist in the department of physical medicine and rehabilitation, shares her experiences over a career in caring for persons with intrathecal baclofen pumps for managing spinal cord injury related spasticity. Baclofen related complications such as withdrawal and overdose can both be fatal and pump specific complications as well require timely expertise from the emergency care team – but not often discussed in emergency medicine. Check out the episode to learn more! CONTACTS Twitter - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Singh NK, Agarwal A, Salazar L, Henkle JQ. Osborn waves in hypothermia induced by baclofen overdose. BMJ Case Rep 2009; 2009. Sullivan R, Hodgman MJ, Kao L, Tormoehlen LM. Baclofen overdose mimicking brain death. Clin Toxicol (Phila) 2012;50:141 Alden TD, Lytle RA, Park TS, et al. Intrathecal baclofen withdrawal: a case report and review of the literature. Childs Nerv Syst 2002;18:522

Join FlightBridgeEDs new Chief Medical Director, Mike Lauria, as we launch the FlightBridgeED MDCast. Dr. Lauria will hijack these episodes for a new perspective on current topics in critical care medicine. In this episode, Dr. Lauria looks at Eric's previously published podcast [episode 224] on ASA Overdose and gives his insight, practical application, and overall thoughts on these difficult-to-manage patients. Don't miss this episode! So much good stuff! Please like, subscribe, and leave any questions or comments. References for Acute Salicylate Intoxication Anderson RJ, Potts DE, Gabow PA, Rumack BH, Schrier RW. Unrecognized adult salicylate intoxication. Ann Intern Med. Dec 1976;85(6):745-8. doi:10.7326/0003-4819-85-6-745 Chyka PA, Erdman AR, Christianson G, et al. Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(2):95-131. doi:10.1080/15563650600907140 Dargan PI, Wallace CI, Jones AL. An evidence-based flowchart to guide the management of acute salicylate (aspirin) overdose. Emerg Med J. May 2002;19(3):206-9. doi:10.1136/emj.19.3.206 Delaney TM, Helvey JT, Shiffermiller JF. A Case of Salicylate Toxicity Presenting with Acute Focal Neurologic Deficit in a 61-Year-Old Woman with a History of Stroke. Am J Case Rep. Feb 15 2020;21:e920016. doi:10.12659/AJCR.920016 Espírito Santo R, Vaz S, Jalles F, Boto L, Abecasis F. Salicylate Intoxication in an Infant: A Case Report. Drug Saf Case Rep. Nov 27 2017;4(1):23. doi:10.1007/s40800-017-0065-9 Goldberg MA, Barlow CF, Roth LJ. The effects of carbon dioxide on the entry and accumulation of drugs in the central nervous system. J Pharmacol Exp Ther. Mar 1961;131:308-18. Juurlink DN, Gosselin S, Kielstein JT, et al. Extracorporeal Treatment for Salicylate Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup. Ann Emerg Med. Aug 2015;66(2):165-81. doi:10.1016/j.annemergmed.2015.03.031 Kuzak N, Brubacher JR, Kennedy JR. Reversal of salicylate-induced euglycemic delirium with dextrose. Clin Toxicol (Phila). Jun-Aug 2007;45(5):526-9. doi:10.1080/15563650701365800 McCabe DJ, Lu JJ. The association of hemodialysis and survival in intubated salicylate-poisoned patients. Am J Emerg Med. Jun 2017;35(6):899-903. doi:10.1016/j.ajem.2017.04.017 Miyahara JT, Karler R. Effect of salicylate on oxidative phosphorylation and respiration of mitochondrial fragments. Biochem J. Oct 1965;97(1):194-8. doi:10.1042/bj0970194 Oliver TK, Jr., Dyer ME. The prompt treatment of salicylism with sodium bicarbonate. AMA J Dis Child. May 1960;99:553-65. doi:10.1001/archpedi.1960.02070030555001 Oualha M, Dupic L, Bastian C, Bergounioux J, Bodemer C, Lesage F. [Local salicylate transcutaneous absorption: an unrecognized risk of severe intoxication: a case report]. Arch Pediatr. Oct 2012;19(10):1089-92. Application cutanée localisée d'acide salicylique : un risque méconnu d'intoxication : à propos d'un cas. doi:10.1016/j.arcped.2012.07.012 Palmer BF, Clegg DJ. Salicylate Toxicity. N Engl J Med. Jun 25 2020;382(26):2544-2555. doi:10.1056/NEJMra2010852 Penniall R. The effects of salicylic acid on the respiratory activity of mitochondria. Biochim Biophys Acta. Nov 1958;30(2):247-51. doi:10.1016/0006-3002(58)90047-7 Shively RM, Hoffman RS, Manini AF. Acute salicylate poisoning: risk factors for severe outcome. Clin Toxicol (Phila). Mar 2017;55(3):175-180. doi:10.1080/15563650.2016.1271127 Stolbach AI, Hoffman RS, Nelson LS. Mechanical ventilation was associated with acidemia in a case series of salicylate-poisoned patients. Acad Emerg Med. Sep 2008;15(9):866-9. doi:10.1111/j.1553-2712.2008.00205.x Thurston JH, Pollock PG, Warren SK, Jones EM. Reduced brain glucose with normal plasma glucose in salicylate poisoning. J Clin Invest. Nov 1970;49(11):2139-45. doi:10.1172/JCI106431 See omnystudio.com/listener for privacy information.

In this podcast, Dr. Jon Cole - an emergency medicine physician with Hennepin Healthcare and medical director with Minnesota Poison Control Center and Samantha Lee, PharmD - managing director with Minnesota Poison Control Center discuss the poison control system - past and present; along with a disscusion around toxicology - the big, the bad, and the ugly. Enjoy the podcast. Objectives:Upon completion of this podcast, participants should be able to: Describe the purpose of the Minnesota Poison Control Center, and how it works. Name the most common call types coming into MN Poison Control Center. Summarize the management of toxicological exposures for APAP, bupropion and calcium channel blockers. CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at Education@ridgeviewmedical.org. Click the link below, to complete the activity's evaluation. CME Evaluation (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker's outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event. Thank-you for listening to the podcast. SHOW NOTES:  *See the attachment for additional information.  HISTORY of MN POISON CONTROL CENTER TOXICOLOGYCalcium Channel Blockers - Diltiazem, Verapamil, Amlodipine - Causes bad distributive shock - Pulmonary edema is an issue - Norepinephrine infusion is recommended in setting of shock with high dose insulin simultaneously - "Red, white and blue" therapy for refractory Ca++ blocker overdose - Activated charcoal - not for all patients, give if patient not at risk of aspiration for potentially lethal ingestions Bupropion - Chemical structure similar to amphetamine and bath salts - Sympathomimetic effects (tachycardia, agitation, seizures, ultimately cardiogenic shock) - Treatment with benzodiazepines - usually high dose - may need intubation - Norepinephrine for cardiogenic shock - ECMO may be needed Sodium Nitrite - Salt used to cure meats - Internet suicide phenomenon - Effect: Life threatening methemoglobinemia (chocolate colored blood, pallor, low O2 sats) - Very rapid onset of symptoms - Methylene Blue use N-acetylcysteine (NAC) for acetaminophen poisoning - Transitioning from 3 bag Prescott regimen to a 2 bag regimen - Rumack-Matthew nomogram is the same Article Resources:Cole JB, Lee SC, Prekker ME, Kunzler NM, Considine KA, Driver BE, Puskarich MA, Olives TD. Vasodilation in patients with calcium channel blocker poisoning treated with high-dose insulin: a comparison of amlodipine versus non-dihydropyridines. Clin Toxicol (Phila). 2022 Nov;60(11):1205-1213. doi: 10.1080/15563650.2022.2131565. Epub 2022 Oct 25. PMID: 36282196.   Cole JB, Olives TD, Ulici A, Litell JM, Bangh SA, Arens AM, Puskarich MA, Prekker ME. Extracorporeal Membrane Oxygenation for Poisonings Reported to U.S. Poison Centers from 2000 to 2018: An Analysis of the National Poison Data System. Crit Care Med. 2020 Aug;48(8):1111-1119. doi: 10.1097/CCM.0000000000004401. PMID: 32697480. Coralic Z, Kapur J, Olson KR, Chamberlain JM, Overbeek D, Silbergleit R. Treatment of Toxin-Related Status Epilepticus With Levetiracetam, Fosphenytoin, or Valproate in Patients Enrolled in the Established Status Epilepticus Treatment Trial. Ann Emerg Med. 2022 Sep;80(3):194-202. doi: 10.1016/j.annemergmed.2022.04.020. Epub 2022 Jun 17. PMID: 35718575. Kline JA, Tomaszewski CA, Schroeder JD, Raymond RM. Insulin is a superior antidote for cardiovascular toxicity induced by verapamil in the anesthetized canine. J Pharmacol Exp Ther. 1993 Nov;267(2):744-50. PMID: 8246150.   Thanks to Dr. Jon Cole and Samantha Lee, PharmD for their knowledge and contribution to this podcast. Please check out the additional show notes for more information/resources.

MedLink Neurology Podcast is delighted to feature selected episodes from BrainWaves, courtesy of James E. Siegler MD, its originator and host. BrainWaves is an academic audio podcast whose mission is to educate medical providers through clinical cases and topical reviews in neurology, medicine, and the humanities, and episodes originally aired from 2016 to 2021. Originally released: July 18, 2017Heavy metal poisoning is increasingly rare in the US, but in patients with multi-organ dysfunction and unclear exposure history, you should be suspicious. In this episode of BrainWaves, we discuss the most common metals associated with central and peripheral nerve dysfunction, the symptoms they produce, imaging features, and treatment. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. This episode was vetted and approved by Francis DeRoos. REFERENCES 1. Staff NP and Windebank AJ. Peripheral neuropathy due to vitamin deficiency, toxins, and medications. Continuum (Minneap Minn). 2014;20:1293-306. 2. Cao Y, Skaug MA, Andersen O and Aaseth J. Chelation therapy in intoxications with mercury, lead and copper. J Trace Elem Med Biol. 2015;31:188-92. 3. Sun TW, Xu QY, Zhang XJ, Wu Q, Liu ZS, Kan QC, Sun CY and Wang L. Management of thallium poisoning in patients with delayed hospital admission. Clin Toxicol (Phila). 2012;50:65-9.We believe that the principles expressed or implied in the podcast remain valid, but certain details may be superseded by evolving knowledge since the episode's original release date.

This is the first meta-analysis published in seven years to examine dose-response associations between caffeine or coffee consumption and pregnancy loss.ResourcesBlehar MC, Spong C, Grady C, Goldkind SF, Sahin L, Clayton JA. Enrolling pregnant women: issues in clinical research. Womens Health Issues. 2013;23(1):e39-e45. doi:10.1016/j.whi.2012.10.003Jafari A, Naghshi S, Shahinfar H, et al. Relationship between maternal caffeine and coffee intake and pregnancy loss: A grading of recommendations assessment, development, and evaluation-assessed, dose-response meta-analysis of observational studies. Front Nutr. 2022;9:886224. Published 2022 Aug 9. doi:10.3389/fnut.2022.886224New World Encyclopedia contributors, "Caffeine," New World Encyclopedia, , https://www.newworldencyclopedia.org/p/index.php?title=Caffeine&oldid=794371 (accessed November 27, 2022).Sasaki S, Limpar M, Sata F, Kobayashi S, Kishi R. Interaction between maternal caffeine intake during pregnancy and CYP1A2 C164A polymorphism affects infant birth size in the Hokkaido study. Pediatr Res. 2017;82(1):19-28. doi:10.1038/pr.2017.70White JR Jr, Padowski JM, Zhong Y, et al. Pharmacokinetic analysis and comparison of caffeine administered rapidly or slowly in coffee chilled or hot versus chilled energy drink in healthy young adults. Clin Toxicol (Phila). 2016;54(4):308-312. doi:10.3109/15563650.2016.1146740Yang A, Palmer AA, de Wit H. Genetics of caffeine consumption and responses to caffeine. Psychopharmacology (Berl). 2010;211(3):245-257. doi:10.1007/s00213-010-1900-1

On this week's podcast, Drs.Feigenbaum and Baraki talk about the he effects of coffee and caffeine on health and performance. References: Cornelis MC. The Impact of Caffeine and Coffee on Human Health. Nutrients. 2019;11(2):416. Published 2019 Feb 16. doi:10.3390/nu11020416 Del Coso J, Lara B, Ruiz-Moreno C, Salinero JJ. Challenging the Myth of Non-Response to the Ergogenic Effects of Caffeine Ingestion on Exercise Performance. Nutrients. 2019;11(4):732. Published 2019 Mar 29. doi:10.3390/nu11040732 Institute of Medicine (US) Committee on Military Nutrition Research. Caffeine for the Sustainment of Mental Task Performance: Formulations for Military Operations. Washington (DC): National Academies Press (US); 2001. 2, Pharmacology of Caffeine. Grgic J, Trexler ET, Lazinica B, Pedisic Z. Effects of caffeine intake on muscle strength and power: a systematic review and meta-analysis. J Int Soc Sports Nutr. Mar 2018;15:11. Grgic J, Grgic I, Pickering C, et al. Wake up and smell the coffee: caffeine supplementation and exercise performance—an umbrella review of 21 published meta-analyses. British Journal of Sports Medicine. March 2019 Skinner, Tina L, et al. “Women Experience the Same Ergogenic Response to Caffeine as Men.” Medicine and Science in Sports and Exercise, vol. 51, no. 6, 2 June 2019, pp. 1195–1202., Waller G, Dolby M, Steele J, Fisher JP. A low caffeine dose improves maximal strength, but not relative muscular endurance in either heavier-or lighter-loads, or perceptions of effort or discomfort at task failure in females. PeerJ. 2020;8:e9144. Published 2020 May 14. doi:10.7717/peerj.9144 White JR Jr, Padowski JM, Zhong Y, et al. Pharmacokinetic analysis and comparison of caffeine administered rapidly or slowly in coffee chilled or hot versus chilled energy drink in healthy young adults. Clin Toxicol (Phila). 2016;54(4):308-312. doi:10.3109/15563650.2016.1146740 Wickham KA, Spriet LL. Administration of Caffeine in Alternate Forms. Sports Med. 2018;48(Suppl 1):79-91. doi:10.1007/s40279-017-0848-2 McGuire S. Institute of Medicine. 2014. Caffeine in Food and Dietary Supplements: Examining Safety—Workshop Summary. Washington, DC: The National Academies Press, 2014. Adv Nutr. 2014;5(5):585-586. doi:10.3945/an.114.006692 Duncan Turnbull, Joseph V. Rodricks, Gregory F. Mariano, Farah Chowdhury, Caffeine and cardiovascular health, Regulatory Toxicology and Pharmacology, Volume 89, 2017, Pages 165-185, ISSN 0273-2300, https://doi.org/10.1016/j.yrtph.2017.07.025. Lorenzo Calvo, J.; Fei, X.; Domínguez, R.; Pareja-Galeano, H. Caffeine and Cognitive Functions in Sports: A Systematic Review and Meta-Analysis. Nutrients 2021, 13, 868. https://doi.org/10.3390/nu13030868 WheyRx https://www.barbellmedicine.com/shop/supplements/gainzzz-rx-whey-protein-isolate/ Seminars https://www.barbellmedicine.com/seminars/ For more of our stuff: App: https://tinyurl.com/muus5pfn Podcasts: goo.gl/X4H4z8 Website: www.barbellmedicine.com Instagram: @austin_barbellmedicine @jordan_barbellmedicine @leah_barbellmedicine @vanessa_barbellmedicine @untamedstrength @derek_barbellmedicine @hassan_barbellmedicine @charlie_barbellmedicine @alex_barbellmedicine @tomcampitelli @joe_barbellmedicine @rheece_barbellmedicine @cam_barbellmedicine @claire_barbellmedicine @ben_barbellmedicine @cassi.niemann @caleb_barbellmedicine Email: info@barbellmedicine.com Supplements/Templates/Seminars: www.barbellmedicine.com/shop/ Forum: forum.barbellmedicine.com/

Educational Pearls: Glucagon can be used to treat hypoglycemia and esophageal foreign body, but it can also be used in beta-blocker toxicity to bypass cardiac beta-blockade The superior option for treating bradycardia due to beta-blocker toxicity is glucagon Glucagon has decreased efficacy in patients with heart failure, so increased doses up to 10 mg might be required in the event of beta-blocker toxicity References Khalid MM, Galuska MA, Hamilton RJ. Beta-Blocker Toxicity. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448097/ Rotella JA, Greene SL, Koutsogiannis Z, et al. Treatment for beta-blocker poisoning: a systematic review. Clin Toxicol (Phila). 2020;58(10):943-983. doi:10.1080/15563650.2020.1752918 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today!

The ALL ME® Podcast Contamination and Adulteration of Dietary Supplements – Dr. Pieter Cohen                    Do you really know what's in the dietary supplements you're taking? Would you be surprised if you found out that your multivitamin contained an anabolic steroid or if the pre-workout you were taking contained a banned amphetamine like compound? How concerned would you be if the product you were taking also contained the anti-depressant Lexapro? With over 50% of the US population taking dietary supplements, it's important to not only know what you're taking but most importantly understand if it's safe for consumption. In this podcast, I speak with Dr. Pieter Cohen whose work is dedicated to researching the dietary supplement adulteration industry. We'll discuss the FDA and their lack of regulation along with what they can do to improve policing the industry, what dietary supplement adulteration is and what type of harmful ingredients that are being found in dietary supplements that are not tested. Pieter Cohen, MD Dr. Pieter Cohen, a graduate of Yale School of Medicine, is an associate professor of Medicine at Harvard Medical School and a practicing internist at Cambridge Health Alliance (Somerville, Massachusetts) whose area of research is the safety of dietary supplements. -- particularly investigating the safety of sports and weight loss supplements.  Along with analytic chemistry colleagues he has spent the last decade exploring the boundaries between drugs and supplements.  His work has been published in the , , ,  and . Biography Biography: Research Links Cohen PA, Sharfstein J, Kamugisha A, Vanhee C. Analysis of Ingredients of Supplements in the National Institutes of Health Supplement Database Marketed as Containing a Novel Alternative to Anabolic Steroids. JAMA Netw Open. 2020 Apr 01; 3(4):e202818. PMID:  Cohen PA. The FDA and Adulterated Supplements-Dereliction of Duty. JAMA Netw Open. 2018 10 05; 1(6):e183329: PMID: Cohen PA, Travis JC, Keizers PHJ, Boyer FE, Venhuis BJ. The stimulant higenamine in weight loss and sports supplements. Clin Toxicol (Phila). 2019 02; 57(2):125-130.PMID: Cohen PA, Travis JC, Keizers PHJ, Deuster P, Venhuis BJ. Four experimental stimulants found in sports and weight loss supplements: 2-amino-6-methylheptane (octodrine), 1,4-dimethylamylamine (1,4-DMAA), 1,3-dimethylamylamine (1,3-DMAA) and 1,3-dimethylbutylamine (1,3-DMBA). Clin Toxicol (Phila). 2018 06; 56(6):421-426. PMID:   Keywords DMAA – Dimethylamylamine or 1,3-dimethylamylamine is a drug made synthetically  a . It was originally used as a . Today, dimethylamylamine is sold as a dietary supplement used for  deficit-hyperactive disorder (), , improving athletic performance, and body building. DMBA – Dimehtylbutylamine or 1,3 – dimethylbutylamine is an ingredient in some pre-workout and weight-loss supplements. In 2015, the Food and Drug Administration (FDA) stated that DMBA is not approved for use in dietary supplements. No reliable scientific studies have been conducted to establish the safety of health effects of DMBA. As its name (1,3-dimethybutylamine) suggests, DMBA is similar to the illegal ingredient DMAA (1,3-dimethylamylamine): Both are synthetic stimulants with potentially dangerous side effects, but they are not the same chemical. Higenamine - Higenamine is a stimulant with cardiovascular properties recently prohibited in sport by the World Anti-Doping Agency (WADA). Higenamine is also a natural constituent of several traditional botanical remedies and is listed as an ingredient in weight loss and sports supplements sold over-the-counter in the United States. Proprietary Blend – this is when a dietary supplement company combines a variety of ingredients but does not disclose the dosage of each ingredient. This is common in many pre-workout supplements or supplements with a variety of ingredients in order for the company to often hide a weak formula or a banned or prohibited substance. Did You Know? The Taylor Hooton Foundation has an education program on Nutrition and Dietary Supplement Safety Up to 25% of Dietary Supplements are contaminated with illegal drugs and banned substances. Follow Us: Twitter:  @theTHF Instagram:  @theTHF Facebook: Taylor Hooton Foundation #ALLMEPEDFREE Contact Us:  Email:  Phone: 214-449-1990  

We discuss the (F)utility(?) of ED Utox screens with our very own Dr. Phil DiSalvo. Hosts: Bree Tse, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Urine_Drug_Screen_final.mp3 Download Leave a Comment Tags: Toxicology Show Notes Special Thanks To: Dr. Philip DiSalvo, MD Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue New York City Poison Control Center   References: Christian MR, et al. Do rapid comprehensive urine drug screens change clinical management in children? Clin Toxicol (Phila). 2017;57:977-980.

Cześć! W dzisiejszym odcinku poznacie związki, z którymi mamy często do czynienia, a które są wykorzystywane przez Rosjan do pozbywania się swoich wrogów politycznych. Poznacie całą historię wykorzystywania bojowych trucizn, jak ewoluowały od I WW aż do dzisiaj. Dodatkowo, Adrian opowie dlaczego każdy zamek z piasku musi się w końcu rozpaść. Jak to się ma do rozrzuconych po pokoju brudnych skarpet? Czym jest entropia i dlaczego zawsze schładza mi herbatę? Życzymy miłego słuchania! Patryk o toksykologii związków fosforoorganicznych: 6:57 Adrian o (nie)zapisanym porządku wszechświata: 1:19:18 Źródła internetowe: https://bit.ly/36UpCZm https://bit.ly/36VQbNx https://bit.ly/3nHwvTy https://bit.ly/31cnlFl Bibliografia W. Seńczuk, “Toksykologia Współczesna”, Wydawnictwo Lekarskie PZWL, 2017 J. Pach, “Zarys Toksykologii Klinicznej” Wydawnictwo Uniwersytetu Jagiellońskiego, 2009 M. Śliwińska-Mossoń, A. Bizoń, H. Milnerowicz, “Toksykologia Środowiskowa i Kliniczna” Uniwersytet Medyczny im. Piastów Śląskich we Wrocławiu, 2013 C.D. Klaassen, J.B. Watkins III “Casarett & Doull Podstawy toksykologii” MedPharm Polska, 2014 L.G.Costa, Clin Chim Acta 366, 2006, 1-13 P.R.Chai et al., Toxicol Commun. 2, 2018, 45-48 E. Nepovimova, K. Kuca, Food Chem Toxicol. 121, 2018, 343-350 J.A. Vale et al., Clin Toxicol (Phila). 56, 2018, 1093-1097 P. W. Atkins, Chemia fizyczna, Wydawnictwo Naukowe PWN, Warszawa, 2015

Buying as much loperamide as you possibly can Loperamide history1969- Synthesized (1)1976 FDA Approved as schedule V (2)Jaffe trial of "abuse potential"- https://pubmed.ncbi.nlm.nih.gov/7438696/1982- Descheduled (3)2010-Annually Increasing in # of poison center calls, cases of arrhythmia and hospitalization (4,5,6)2016- Submission to DEA for rescheduling of loperamide denied (7)2019- FDA works with manufactures to reduce package size to 48 tablets (8)Pharmacist knowledge of abuse remains low https://pubmed.ncbi.nlm.nih.gov/32641253/Toxic MechanismFun theories about co evolution of PGP and CYP https://pubmed.ncbi.nlm.nih.gov/10837556/Inhibition of sodium channels, and to a higher affinity, Human Ether a Go-Go Related (HERG) channel leads to prolonged repolarization (9)IC50 for HERG Ikr ~ 40 nm/l (1908 ng/dl), inhibits as low as 10 nm/l (10)Case reports of conduction disturbance with level of 22 ng/ml (14)Levels in fatalities vary but  reported as high as 270 ng/ml in some studies  (15)Prolonged re polarization leads to torsadesEarly after depolarizations may trigger, which are then propagated torsades via re entrant rhythms (11)TreatmentACMT loperamide guidelines (12)Supportive careArrhythmia managementTorsades (13)Electrical cardioversion (terminates re entrant rhythm)Magnesium (prevents early after depolarization)Target Mg >2 and K >4Lidocaine-> Recommended in 2006 Sudden cardiac death guidlines, not mentioned in 2017, however one of the only VT recommended antiarryhtmics that do not prolong QTc (others, sotalol, amiodarone, and procainamide, do)If preceded by bradycardia, Overdrive pacing with isoproterenol to target HR~ 100Beta blockers are recommended in patients with LQTSSodium channel blockade induced wide QRS complex tachycardia (12)Hypertonic sodium to over whelm sodium channel blockade (1-2 amps of 8.4% Sodium Bicarbonate given IV)Where do we go in the future?More research will help us understand the true incidence of how often this occurs and what impact the FDA decisions will haveAny concerned citizen can submit for rescheduling of loperamide. Interested? Reach out at toxtalk1@gmail.comDrug Enforcement Agency. The Controlled Substances Act. Available at: https://www.dea.gov/controlled-substances-act.Florey, Klaus (1991). Profiles of Drug Substances, Excipients and Related Methodology, Volume 19. Academic Press. p. 342. ISBN9780080861142."IMODIUM FDA Application No.(NDA) 017694". U.S. Food and Drug Administration (FDA). 1976.https://www.deadiversion.usdoj.gov/schedules/orangebook/orangebook.pdf.Miller H, Panahi L, Tapia D, Tran A, Bowman JD. Loperamide misuse and abuse. J Am Pharm Assoc (2003). 2017;57(2S):S45eS50.Feldman R, Everton E. National assessment of pharmacist awareness of loperamide abuse and ability to restrict sale if abuse is suspected [published online ahead of print, 2020 Jul 5]. J Am Pharm Assoc (2003). 2020;S1544-3191(20)30264-8. doi:10.1016/j.japh.2020.05.021Eggleston W, Marraffa JM, Stork CM, et al. Notes from the Field: Cardiac Dysrhythmias After Loperamide Abuse — New York, 2008–2016. MMWR Morb Mortal Wkly Rep 2016;65:1276–1277. DOI: http://dx.doi.org/10.15585/mmwr.mm6545a7https://www.chpa.org/PDF/09_05_17_CommentsCitizenPetitionLoperamide.aspxhttps://www.fda.gov/drugs/drug-safety-and-availability/fda-limits-packaging-anti-diarrhea-medicine-loperamide-imodium-encourage-safe-useKang J, Compton DR, Vaz RJ, Rampe D. Proarrhythmic mechanisms of the common anti-diarrheal medication loperamide: revelations from the opioid abuse epidemic. Naunyn Schmiedebergs Arch Pharmacol. 2016;389(10):1133-1137. doi:10.1007/s00210-016-1286-7Klein MG, Haigney MCP, Mehler PS, Fatima N, Flagg TP, Krantz MJ. Potent Inhibition of hERG Channels by the Over-the-Counter Antidiarrheal Agent Loperamide. JACC Clin Electrophysiol. 2016;2(7):784-789. doi:10.1016/j.jacep.2016.07.008https://www.sciencedirect.com/science/article/pii/S1880427611800050Eggleston W, Palmer R, Dubé PA, et al. Loperamide toxicity: recommendations for patient monitoring and management. Clin Toxicol (Phila). 2020;58(5):355-359. doi:10.1080/15563650.2019.1681443Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in J Am Coll Cardiol. 2018 Oct 2;72(14):1760]. J Am Coll Cardiol. 2018;72(14):e91-e220. doi:10.1016/j.jacc.2017.10.054Marraffa JM, Holland MG, Sullivan RW, et al. Cardiac conduction disturbance after loperamide abuse. Clin Toxicol (Phila). 2014;52(9):952-957. doi:10.3109/15563650.2014.969371Miller H, Panahi L, Tapia D, Tran A, Bowman JD. Loperamide misuse and abuse. J Am Pharm Assoc (2003). 2017;57(2S):S45-S50. doi:10.1016/j.japh.2016.12.079

Contributor: Don Stader, MD Educational Pearls: Gout is an arthritis caused by the deposition of urate crystals into the joint space Colchicine works by disrupting microtubules and prevents white blood cells from getting into the joint space which stops the inflammatory response  Colchicine has a high rate of adverse events, in particular explosive diarrhea The drug also has a very narrow therapeutic index and overdose is nearly universally fatal, with no antidote or effective treatment option available Alternative agents such as steroids, which reduce the inflammatory response to urate crystals, along with NSAIDs may be better options for treatment References Angelidis C, Kotsialou Z, Kossyvakis C, et al. Colchicine Pharmacokinetics and Mechanism of Action. Curr Pharm Des. 2018;24(6):659-663. doi:10.2174/1381612824666180123110042 Finkelstein Y, Aks SE, Hutson JR, et al. Colchicine poisoning: the dark side of an ancient drug. Clin Toxicol (Phila). 2010;48(5):407-414. doi:10.3109/15563650.2010.495348 Dalbeth N, Merriman TR, Stamp LK. Gout. Lancet. 2016;388(10055):2039-2052. doi:10.1016/S0140-6736(16)00346-9 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Contributor: Nick Tsipis, MD Educational Pearls: Significant cyanide exposure most commonly occurs from fire/smoke exposure particularly when plastics are involved Cyanide binds to cytochrome oxidase leading to the use of anaerobic metabolism which causes a profound lactic acidosis Classic toxicity includes a rapid loss of consciousness, hypotension, bradycardia, respiratory depression, and seizures Mild exposures can lead to nausea/vomiting, headaches, and other nonspecific symptoms. Sometimes patients will complain of an almond taste. Cyanide toxicity will manifest on labs by a profound anion gap acidosis with elevated lactate (but don't wait for them to ponder the diagnosis) Antidote is hydroxocobalamin and sodium thiosulfate Severe cyanide exposure will likely need ICU level care until the blood gas levels return to their baselines and the lactic acidosis resolves References Nickson Chris C, Australian Centre for Health Innovation at Alfred Health. Cyanide Poisoning • LITFL • CCC Toxicology. Life in the Fast Lane • LITFL • Medical Blog. https://litfl.com/cyanide-poisoning-ccc/. Published April 2, 2019. Accessed June 11, 2020. Parker-Cote JL, Rizer J, Vakkalanka JP, Rege SV, Holstege CP. Challenges in the diagnosis of acute cyanide poisoning. Clin Toxicol (Phila). 2018;56(7):609‐617. doi:10.1080/15563650.2018.1435886 MacLennan L, Moiemen N. Management of cyanide toxicity in patients with burns. Burns. 2015;41(1):18‐24. doi:10.1016/j.burns.2014.06.001   Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD

Key pointsBleach mixed with various chemicals can make many toxic substancesBleach + acid= chlorine gasBartholette original Cl2 + H2O ⇄ HCl + HClOTo drive the reaction to the right, a base was added, to neutralize HCl and reduce the amount of productThe reaction is reversed when an acid is addedhttp://www.chm.bris.ac.uk/motm/bleach/Sodium%20Hypochlorite%20-%20Molecule%20of%20the%20Month%20October%202011.pdfBleach + ammonia= chloramine gasBleach + rubbing alcohol (isopropyl)= chloroformBleach +  soap= carbon tetrachlorideChlorine gas  is a high solubility irritant, it dissolves quickly in the mucous membranes and causes severe irritation of upper airway, eyes and nose (moist mucous membranes), effects are noticed quicklyTreatment for most chemical inhalation injuries involves removal from ongoing exposure, maintenance of a patent airway, and supportive careOxygen for hypoxemiaBronchodilators (albuterol)Intubation if neededIf the exposure is to chlorine gas there may be a role for nebulized sodium bicarbonate.Due to  initial irritation, exposure may present looking vary severe, but may turn around with good supportive careIf you accidentally make chlorine gas, get to fresh air, open windows if you can and call your local poison center or 911Bleach  ingestion are basic and can cause a liquefactive necrosisSome may result in oral irritationTreatment involves assessing the injury to determine risk of stricture  and possible esophageal stentingBrief summary of steroid use with irritant gases:  Reproduced with permission from : Pape KO, Feldman R. Smoke inhalation and Toxic Exposure. Chapter In: Erstad B, ed. Critical Care Pharmacotherapy. Lenexa: American College of Clinical Pharmacy. January 2020.Steroid use in pulmonary irritant induced pneumonitis is not well evaluated in randomized controlled trials. Reviews of animal data suggest no significant benefit for poorly water soluble or high doses of water-soluble irritants. They may also have a negative effect on the recovery phase (deLange 2011).Numerous case reports exist detailing positive outcomes from use of steroids in patients exposed to pulmonary irritants (deLange 2011).However, without an appropriate comparator it is not known if symptom resolution is related to the intervention or the natural progression of the disease. Small human crossover trials evaluating the effects of mild ozone exposure found a reduction in bronchiolar lavage inflammatory markers with inhaled fluticasone or budesonide but no difference in clinical effects (deLange 2011, Nightingale 2000, Alexis 2008, Vagaggini 2001). Due to the absence of well controlled trials, steroids are not routinely recommended for chemical pneumonitis. However, there is also a lack of negative data and institutional protocols or patient specific factors may govern their use.1. De Lange DW, Meulenbelt J. Do corticosteroids have a role in preventing or reducing acute toxic lung injury caused by inhalation of chemical agents? Clin Toxicol (Phila) 2011;49:61-71. 2. Vagaggini B, Taccola M, Conti I, et al. Budesonide reduces neutrophilic but not functional airway response to ozone in mild asthmatics. Am J Respir Crit Care Med 2001;164:2172–6.3. Alexis NE, Lay JC, Haczku A, et a. Fluticasone propionate protects against ozone-induced airway inflammation and modified immune cell activation markers in healthy volunteers. Environ Health Perspect 2008;116:799–805.4. Nightingale JA, Rogers DF, Chung KF, et al. No effect of inhaled budesonide on the response to inhaled ozone in normal subjects. Am J Respir Crit Care Med 2000;61:479–86.New story from initial case- https://www.msdsonline.com/2015/02/27/fatal-accident-in-ca-even-small-quantities-of-chlorine-pose-danger/HistoryClaude Bertholtte- https://www.britannica.com/biography/Claude-Louis-BertholletAntoine Labarraque- https://peoplepill.com/people/antoine-germain-labarraque/Data on sodium bicarbonate in CL2 gasSystematic reviewHuynh Tuong A, Despréaux T, Loeb T, Salomon J, Mégarbane B, Descatha A. Emergency management of chlorine gas exposure - a systematic review. Clin Toxicol (Phila). 2019;57(2):77‐98. doi:10.1080/15563650.2018.1519193Summary of many trialshttps://chemm.nlm.nih.gov/countermeasure_sodium-bicarbonate.htmSodium bicarbonate probably doesn’t help Chloramine gas exposurePascuzzi TA, Storrow AB. Mass casualties from acute inhalation of chloramine gas. Mil Med. 1998;163(2):102‐104.Chloramine physical propertieshttps://pubchem.ncbi.nlm.nih.gov/compound/ChloramineReactions of Sodium Hypochlorite wit other compounds to make nasty products -Odabasi M. Halogenated volatile organic compounds from the use of chlorine-bleach-containing household products. Environ Sci Technol. 2008;42(5):1445‐1451. doi:10.1021/es702355uGood review of the basics of caustic ingestions such as bleachHoffman RS, Burns MM, Gosselin S. Ingestion of Caustic Substances. N Engl J Med. 2020;382(18):1739‐1748. doi:10.1056/NEJMra1810769Pulmonary irritants- Nelson LS, Odujebe OA. Simple asphyxiants and pulmonary irritants. In: Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR, eds.Goldfrank's Toxicologic Emergencies, 11e New York, NY: McGraw-Hill; 2019.Incidence dataGummin DD, Mowry JB, Spyker DA, et al. 2017 Annual report of the American association of poison control centers’ national poison data system (NPDS): 34th annual report. Clin Toxicol (Phila) 2017;55:1072–254. 

Author: Aaron Lessen, MD Educational Pearls: A problem of take-home-naloxone is the administration of it by an able-bodied bystander Australian study looked at consecutive opioid overdose deaths in a single year to identify characteristics of overdose and potential for bystander administered naloxone Of the 235 fatal heroin overdoses reviewed, 83% were alone with only 17% (38 cases) having another person present Half of those in the presence of others had a bystander that was not impaired Take-home-naloxone needs a competent person to administer it. Make sure to review this along with other harm reduction strategies when prescribing/dispensing it to patients References Stam NC, Gerostamoulos D, Smith K, Pilgrim JL, Drummer OH. Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia. Clin Toxicol (Phila). 2019 May;57(5):325-330. doi: 10.1080/15563650.2018.1529319. Epub 2018 Nov 17. PubMed PMID: 30451007. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author:  Julian Orenstein, MD Educational Pearls:   Severe clonidine ingestion can present as a fluctuating mental status between typically accompanied by changes in vital signs (hypotension/bradycardia) Respiratory depression requiring intubation is not uncommon   References Isbister GK, Heppell SP, Page CB, Ryan NM. Adult clonidine overdose: prolonged bradycardia and central nervous system depression, but not severe toxicity. Clin Toxicol (Phila). 2017 Mar;55(3):187-192. doi: 10.1080/15563650.2016.1277234. Epub 2017 Jan 20. PubMed PMID: 28107093. Spiller HA, Klein-Schwartz W, Colvin JM, Villalobos D, Johnson PB, Anderson DL. Toxic clonidine ingestion in children. J Pediatr. 2005 Feb;146(2):263-6. PubMed PMID: 15689921. Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Author: Aaron Lessen, MD Educational Pearl: A double ingestion of a single pill is typically a benign event but several drug classes may cause problems A published review of 10 years of single medication double dose ingestion found 12 out of 876 cases had adverse events. The drugs and events were: Propafenone ingestion leading to ventricular tachycardia Beta blocker ingestion leading to bradycardia and hypotension Calcium channel blocker leading to bradycardia and hypotension Bupropion ingestion leading to seizures Tramadol ingestion leading to ventricular tachycardia Editor’s Note: References: Correia MS, Whitehead E, Cantrell FL, Lasoff DR, Minns AB. A 10-year review of single medication double-dose ingestions in the nation's largest poison control system. Clin Toxicol (Phila). 2019 Jan;57(1):31-35. doi: 10.1080/15563650.2018.1493205. Epub 2018 Nov 28. PubMed PMID: 30484705. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Shownotes: Cardiovascular medication poisoning can produce markedly unstable patient presentations. Dr. Patrick and Brad Ward review some of the basics and more recent therapeutic developments in the treatment and management of beta-blocker and calcium channel blocker toxicity. References: 1. St-Onge M, Anseeuw K, Cantrell FL, et al. Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults. Critical Care Medicine. 2017;45(3):e306-e315. 2. Wax P, Erdman A, Chyka P, et al. Beta-blocker ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005; 43(3):131-146.

Author: Katie Sprinkle, MD Educational Pearls:   The fascia iliaca block is useful for hip and proximal femur fractures. Typically involves injecting 40-60 mL of diluted bupivacaine (0.25%) under the fascia iliaca (or other anesthetic) Anesthesia is achieved of the femoral, obturator, and lateral femoral cutaneous nerves. Monitor for signs of bupivacaine toxicity (paresthesias, AMS, seizures, arrhythmias) Intralipid can be an effective treatment for life-threatening toxicity   References: Hoegberg LC, Bania TC, Lavergne V, Bailey B, Turgeon AF, Thomas SH, Morris M, Miller-Nesbitt A, Mégarbane B, Magder S, Gosselin S; Lipid Emulsion Workgroup.. Systematic review of the effect of intravenous lipid emulsion therapy for local anesthetic toxicity. Clin Toxicol (Phila). 2016 Mar;54(3):167-93. doi: 10.3109/15563650.2015.1121270. Epub 2016 Feb 6. Review. PubMed PMID: 26853119. https://www.acepnow.com/article/control-hip-fracture-pain-without-opioids-using-ultrasound-guided-fascia-iliaca-compartment-block/?singlepage=1&theme=print-friendly Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

A patient comes into the emergency department. They've got a headache. You get some basic labs, a chest x-ray, a CT scan. And then you get a drug screen. But does this information even help you? And could it hurt the patient? This week on the BrainWaves podcast, Dr. Emily Rosenthal shares her experience with Dr. Kelley Humbert on the ethics of toxicology "screening" and how she manages patients with a substance use disorder. Produced by Emily Rosenthal, Kelley Humbert, and Jim Siegler. Music by Montplaisir, Lee Rosevere, and Kevin McLeod. Sound effects by Mike Koenig, Daniel Simion. BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision making. Be sure to follow us on Twitter @brainwavesaudio for the latest updates to the podcast. REFERENCES Bates GP, Dorsey R, Gusella JF, Hayden MR, Kay C, Leavitt BR, Nance M, Ross CA, Scahill RI, Wetzel R, Wild EJ and Tabrizi SJ. Huntington disease. Nat Rev Dis Primers. 2015;1:15005. Silver B, Miller D, Jankowski M, Murshed N, Garcia P, Penstone P, Straub M, Logan SP, Sinha A, Morris DC, Katramados A, Russman AN, Mitsias PD and Schultz LR. Urine toxicology screening in an urban stroke and TIA population. Neurology. 2013;80:1702-9. Eisen JS, Sivilotti ML, Boyd KU, Barton DG, Fortier CJ and Collier CP. Screening urine for drugs of abuse in the emergency department: do test results affect physicians' patient care decisions? CJEM. 2004;6:104-11. Smith PC, Schmidt SM, Allensworth-Davies D and Saitz R. A single-question screening test for drug use in primary care. Archives of internal medicine. 2010;170:1155-60. Lager PS, Attema-de Jonge ME, Gorzeman MP, Kerkvliet LE and Franssen EJF. Clinical value of drugs of abuse point of care testing in an emergency department setting. Toxicol Rep. 2018;5:12-17. Tenenbein M. Do you really need that emergency drug screen? Clin Toxicol (Phila). 2009;47:286-91. Jones HE, Kaltenbach K, Heil SH, Stine SM, Coyle MG, Arria AM, O'Grady KE, Selby P, Martin PR and Fischer G. Neonatal abstinence syndrome after methadone or buprenorphine exposure. The New England journal of medicine. 2010;363:2320-31.

Heavy metal poisoning is increasingly rare in the US, but in patients with multi-organ dysfunction and unclear exposure history, you should be suspicious. In this episode of BrainWaves, we discuss the most common metals associated with central and peripheral nerve dysfunction, the symptoms they produce, imaging features, and treatment. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. Any cases discussed in this episode are fictional and do not contain any patient health identifying information. This episode was vetted and approved by Francis DeRoos. REFERENCES 1. Staff NP and Windebank AJ. Peripheral neuropathy due to vitamin deficiency, toxins, and medications. Continuum (Minneap Minn). 2014;20:1293-306. 2. Cao Y, Skaug MA, Andersen O and Aaseth J. Chelation therapy in intoxications with mercury, lead and copper. J Trace Elem Med Biol. 2015;31:188-92. 3. Sun TW, Xu QY, Zhang XJ, Wu Q, Liu ZS, Kan QC, Sun CY and Wang L. Management of thallium poisoning in patients with delayed hospital admission. Clin Toxicol (Phila). 2012;50:65-9.