Podcasts about Medical toxicology

This week's show is with Dr. Daniel M. Ingram, MD MSPH, a retired emergency medicine physician who works to improve the global relationship of science, clinical practice, mental health and the public to the phenomena that might be referred to as spiritual, meditative, energetic, mystical, psychedelic, magical, and related phenomena. To those ends, he is currently the founder, philanthropic supporter, and volunteer CEO and Board Chair of the Emergence Benefactors registered charity, and chief organizer and co-founder of the global Emergent Phenomenology Research Consortium. He is currently involved in neurophenomenological research of advanced meditative states with colleagues at Harvard and has been a participant in numerous fMRI and EEG studies of advanced meditators, including at Harvard, Yale, U Mass, and Vanderbilt. He has published scientific articles in Pediatrics, Child Abuse and Neglect, and the Journal of Medical Toxicology. He is the author of Mastering the Core Teachings of the Buddha, co-author of The Fire Kasina, and co-founder of the Dharma Overground. His work has been featured in The New York Times, Esquire, Vice, Wired, BBC Radio 4, Evolving Dharma, American Dharma: Buddhism Beyond Modernity, Dan Harris' 10% Happier Podcast, Slate Star Codex Blog, Buddha at the Gas Pump, Meaning of Life TV, Deconstructing Yourself, Spiritual Explained website, Guru Viking, Buddhist Geeks, Cosmic Tortoise, Startup Geometry, Imperfect Buddha Podcast, and many others. In this conversation, Lian and Daniel explore what awakening really means, weaving between the modern non-duality and Neo-Vedanta ideas such as "you're already awake" and the more structured progressive paths, filled with stages, techniques, and deepening insights. They gently reveal the hidden challenges and the powerful gifts each path offers, opening up a conversation that's both timeless and deeply relevant. Lian shares how awakening can happen spontaneously, profoundly reshaping lives, while Daniel draws from his extensive experience in various spiritual communities and traditions. Together, they explore the subtle nuances of spiritual growth, shadow integration, and the vital practice of staying present to this very moment. Their personal experiences effortlessly blend with mythic and traditional wisdom, highlighting the beautiful paradox of human growth. They also discuss practical tools like the five Buddha families, attachment styles, and why working with our shadows is essential. Daniel stresses how important personalised practice and honest community feedback are on this journey. Their conversation gently challenges the seductive myth of spiritual perfectionism, offering instead a grounded, compassionate invitation towards continual transformation and deeper self-awareness. We'd love to know what YOU think about this week's show. Let's carry on the conversation… please leave a comment wherever you are listening or in any of our other spaces to engage. What You'll Learn From This Episode: How clearly seeing the strengths and limits of modern non-dual teachings and progressive spiritual approaches helps you create a spiritual practice that's deeply meaningful, nourishing, and aligned with who you really are. Why recognising and embracing your shadows—those hidden emotional patterns and parts of yourself—is essential for reclaiming your wholeness, bringing more emotional freedom and a deeper sense of authenticity. How using personality frameworks like the five Buddha families and attachment styles can help you personalise your spiritual journey in a way that genuinely honours your unique nature. Resources and stuff spoken about: If you want to focus on Daniel's scientific work related to spirituality and the organisation he helps support: Emergent Phenomenology Research Consortium The EPRC YouTube Channel Emergence Benefactors If you want to focus on Daniel's work related to meditation practice and its effects: Daniel M. Ingram YouTube Channel Mastering The Core Teachings of Buddha For Books: Fire Kasina: The Fire Kasina Meditation Site for books and more on meditation Daniels Personal Website: Integrated Daniel Daniels Online Community: The Dharma Overground Emerge Wiki: emergewiki.org Join UNIO, the Academy of Sacred Union. This is for the old souls in this new world… Discover your kin & unite with your soul's calling to truly live your myth. Be Mythical Join our mailing list for soul stirring goodness: https://www.bemythical.com/moonly Discover your kin & unite with your soul's calling to truly live your myth: https://www.bemythical.com/unio Go Deeper: https://www.bemythical.com/godeeper Follow us: Facebook Instagram TikTok YouTube Thank you for listening! There's a fresh episode released each week here and on most podcast platforms - and video too on YouTube. If you subscribe then you'll get each new episode delivered to your device every week automagically. (that way you'll never miss a show).

Dr. Saima Khan is a physician with over 27 years of experience and a deeply personal story of resilience and transformation. Diagnosed with narcolepsy in 2016 after stepping away from medicine due to chronic fatigue and excessive sleepiness, she found herself navigating the healthcare system not as a doctor but as a patient. When conventional treatments failed, she took her health into her own hands, uncovering and addressing multiple causes of brain inflammation including mold illness, Lyme disease and coinfections, chronic SIBO, mast cell activation, autoimmunity and much more. Dr. Saima holds a Doctor of Medicine from Aga Khan University, known as the "Harvard of Pakistan." She completed her Pediatric Residency at Children's Hospital of Michigan, and fellowship in Medical Toxicology at Wayne State University. She is board-certified in Pediatrics and certified in Functional Medicine from the Institute for Functional Medicine. She also has advanced training in chronic illnesses like Lyme and coinfections, and mold. As the founder of Rebalance Family Health, a virtual practice based in Florida, Dr. Saima specializes in helping adults and children with complex illnesses with a focus on lyme and coinfections, mold illness, autoimmunity and inflammatory brain disorders. Her mission is to alleviate suffering by uncovering root causes, connecting the dots, and empowering patients to live vibrant, healthy lives. Some of the topics we discussed were: How to identify mold illness in the body What people do to fix their environment if they have mold illness What to do to identify the issue in the environment that is causing the illness Where to find an environmental inspector to evaluate a building for environmental illnessWhen it is safe to live somewhere after a mold infestation The difference in the spectrum of sensitivity to mold exposure How to assess if a new environment will be safe for those sensitive to mold illness when house hunting The important role functional and integrative medicine can play in helping people with long COVIDDr. Khan's practitioner based experience of the connection between COVID and mold exposure How mold illness dysregulates the immune system and can impact long COVID symptoms 3 pieces of advice for physicians who are interested in learning and starting a functional and integrative medicine practice Where physicians can start learning more about functional and integrative medicine How functional medicine can help physicians feeling limited by conventional medicine and wanting to do more to help patients with chronic illnesses Where to find a mentor for your area of interest in the functional and integrative medicine space And more! Learn more about me or schedule a FREE coaching call:https://www.joyfulsuccessliving.com/  Join the Voices of Women Physicians Facebook Group:https://www.facebook.com/groups/190596326343825/   Connect with Dr. Khan: Website:www.rebalancefamilyhealth.com Instagram:@drsaimakhanmd 

Dr. Saima Khan is a physician with over 27 years of experience and a deeply personal story of resilience and transformation. Diagnosed with narcolepsy in 2016 after stepping away from medicine due to chronic fatigue and excessive sleepiness, she found herself navigating the healthcare system not as a doctor but as a patient. When conventional treatments failed, she took her health into her own hands, uncovering and addressing multiple causes of brain inflammation including mold illness, Lyme disease and coinfections, chronic SIBO, mast cell activation, autoimmunity and much more. Dr. Saima holds a Doctor of Medicine from Aga Khan University, known as the "Harvard of Pakistan." She completed her Pediatric Residency at Children's Hospital of Michigan, and fellowship in Medical Toxicology at Wayne State University. She is board-certified in Pediatrics and certified in Functional Medicine from the Institute for Functional Medicine. She also has advanced training in chronic illnesses like Lyme and coinfections, and mold. As the founder of Rebalance Family Health, a virtual practice based in Florida, Dr. Saima specializes in helping adults and children with complex illnesses with a focus on lyme and coinfections, mold illness, autoimmunity and inflammatory brain disorders. Her mission is to alleviate suffering by uncovering root causes, connecting the dots, and empowering patients to live vibrant, healthy lives. Some of the topics we discussed were: Being a mold-literate and lyme-literate physician Treating mold related illness and Lyme and coninfections from an integrative medicine perspective  How integrative medicine is useful for identifying root causes in people who are chronically sick and cannot seem to find answers Dr. Khan's path to completing her training in functional medicine What functional medicine teaches us and why these concepts are so important to cover in medical school curriculums How the process of treating patients on the drivers of illness differs from the conventional model of diagnosis What the mental, spiritual, and emotional piece of one's life manifests as in their health Functional medicine's role in evaluating the different aspects of a patient who is suffering and is not well When Dr. Khan realized she had mold exposure and what she did for treatment How Dr. Khan learned more about pediatric conditions for starting her functional and integrative medicine practice Where Dr. Khan received training for inflammatory brain conditions and how it linked to narcolepsy The pieces of Dr. Khan's journey to recovery and education in functional and integrative medicine How Dr. Khan expanded to treating adults in addition to children The high need for more physicians trained in treating mold illness and Lyme and confections to meet the high demand of patients who are very suffering and cannot find help How Dr. Khan easily arranges for lab work and imaging to be done for her virtual practice The role of functional medicine in more simple treatments for ADHD that do not require medication And more!Learn more about me or schedule a FREE coaching call:https://www.joyfulsuccessliving.com/ Join the Voices of Women Physicians Facebook Group:https://www.facebook.com/groups/190596326343825/  Connect with Dr. Khan: Website:www.rebalancefamilyhealth.com Instagram:@drsaimakhanmd 

Dr. Saima Khan is a physician with over 27 years of experience and a deeply personal story of resilience and transformation. Diagnosed with narcolepsy in 2016 after stepping away from medicine due to chronic fatigue and excessive sleepiness, she found herself navigating the healthcare system not as a doctor but as a patient. When conventional treatments failed, she took her health into her own hands, uncovering and addressing multiple causes of brain inflammation including mold illness, Lyme disease and coinfections, chronic SIBO, mast cell activation, autoimmunity and much more. Dr. Saima holds a Doctor of Medicine from Aga Khan University, known as the "Harvard of Pakistan." She completed her Pediatric Residency at Children's Hospital of Michigan, and fellowship in Medical Toxicology at Wayne State University. She is board-certified in Pediatrics and certified in Functional Medicine from the Institute for Functional Medicine. She also has advanced training in chronic illnesses like Lyme and coinfections, and mold. As the founder of Rebalance Family Health, a virtual practice based in Florida, Dr. Saima specializes in helping adults and children with complex illnesses with a focus on lyme and coinfections, mold illness, autoimmunity and inflammatory brain disorders. Her mission is to alleviate suffering by uncovering root causes, connecting the dots, and empowering patients to live vibrant, healthy lives. Some of the topics we discussed were: Dr. Khan's background in toxicology Where Dr. Khan found her information on toxins Dr. Khan's next steps to address the root cause of her narcolepsy Mold and microtoxin illness How Dr. Khan's narcolepsy symptoms have vastly improved What the last missing piece was for Dr. Kahn in recovering from her narcolepsy And more!Learn more about me or schedule a FREE coaching call:https://www.joyfulsuccessliving.com/ Join the Voices of Women Physicians Facebook Group: https://www.facebook.com/groups/190596326343825/  Connect with Dr. Khan: Website:www.rebalancefamilyhealth.com Instagram:@drsaimakhanmd 

Dr. Saima Khan is a physician with over 27 years of experience and a deeply personal story of resilience and transformation. Diagnosed with narcolepsy in 2016 after stepping away from medicine due to chronic fatigue and excessive sleepiness, she found herself navigating the healthcare system not as a doctor but as a patient. When conventional treatments failed, she took her health into her own hands, uncovering and addressing multiple causes of brain inflammation including mold illness, Lyme disease and coinfections, chronic SIBO, mast cell activation, autoimmunity and much more.Dr. Saima holds a Doctor of Medicine from Aga Khan University, known as the "Harvard of Pakistan." She completed her Pediatric Residency at Children's Hospital of Michigan, and fellowship in Medical Toxicology at Wayne State University. She is board-certified in Pediatrics and certified in Functional Medicine from the Institute for Functional Medicine. She also has advanced training in chronic illnesses like Lyme and coinfections, and mold.As the founder of Rebalance Family Health, a virtual practice based in Florida, Dr. Saima specializes in helping adults and children with complex illnesses with a focus on lyme and coinfections, mold illness, autoimmunity and inflammatory brain disorders. Her mission is to alleviate suffering by uncovering root causes, connecting the dots, and empowering patients to live vibrant, healthy lives.Some of the topics we discussed were:How Dr. Khan's journey into functional and integrative medicine began from her narcolepsyDr. Khan's first steps for finding a solution to her narcolepsy Why stimulants and conventional medicine designed to keep you awake can only help so much with narcolepsyNarcolepsy being an autoimmune condition How reducing inflammation through Dr. Khan's diet reduced her narcolepsy symptomsWhat intervention Dr. Khan says helped her the most if she had to choose only oneWhy detoxifying the body and environment is like fixing a plumbing problemHow detoxifying reduces narcolepsy symptomsAnd more!Learn more about me or schedule a FREE coaching call:https://www.joyfulsuccessliving.com/Join the Voices of Women Physicians Facebook Group:https://www.facebook.com/groups/190596326343825/Connect with Dr. Khan:Website:www.rebalancefamilyhealth.comInstagram:@drsaimakhanmd

In this podcast episode, Corey Zeigler, CIO of Helio Health, and Dr. Ross W. Sullivan from SUNY Upstate Medical University discuss an innovative program tackling opioid use disorder (OUD). The episode covers the implementation of a universal screening protocol, the success of the two-item conjoint screen (TICS) method, and the impact of the Bridge Clinic initiative. Dr. Sullivan shares insights on overcoming challenges and achieving improved patient outcomes, including reduced emergency department visits. Discover how healthcare IT is playing a crucial role in transforming addiction treatment and addressing the opioid crisis.What You'll Learn:Introduction to SUNY Upstate's Comprehensive Program: Gain insights into a holistic approach combining universal screening protocols and dedicated clinics to address opioid use disorder (OUD).Effective Screening Methods: Understand the implementation and efficacy of the two-item conjoint screen (TICS) method for identifying OUD across diverse healthcare settings like outpatient and emergency departments.Implementation Challenges and Solutions: Learn about the obstacles encountered while rolling out a universal screening protocol in a large healthcare system and strategies for overcoming them.Impactful Results: Discover the tangible outcomes of the program, such as reduced length of inpatient stays and a significant decrease in opioid-related ED visits.Collaborative Care Model: Explore how dedicated OUD teams collaborate with existing patient care teams and social workers to enhance treatment and post-hospitalization care.Sustainability and Future Expansions: Get acquainted with the plans for maintaining and expanding successful initiatives like the Bridge Clinic and TICS screening protocol.MODERATOR: Corey ZeiglerCIO, Helio Health Bio: Corey has been with Helio Health for about 5 years. They are a large substance use and behavioral health organization with 70 different locations throughout Central New York spanning from Albany in the eastern side to Rochester on the western side, down to the Pennsylvania border to the south and almost to Canada in the North. Their services include inpatient, outpatient, residential, affordable housing, homelessness and a lot of the health and human services functions in New York State.  GUEST: Ross W. Sullivan, MD, FASAM Executive Medical Director, Helio Health Assistant Assistant Professor, Emergency Medicine, Toxicology, Addiction Medicine, SUNY Upstate Medical UniversityBio: Dr. Sullivan is the Executive Medical Director at Helio Health in Central New York and a recognized expert in addiction medicine. He completed his medical education, residency in Emergency Medicine, and toxicology fellowship at SUNY Upstate Medical University. Dr. Sullivan also serves as a faculty member in Emergency Medicine and directs the Medical Toxicology fellowship at SUNY Upstate. He has co-authored several publications on overdose and addiction and contributes his expertise to various advisory panels and workgroups, including NY-OASAS and the NY-DOH buprenorphine work group. Additionally, he is the Treasurer and Board Member of the New York Society of Addiction Medicine (NYSAM).

What you need to know about awakening… it's not all love and light! This week's show is with Dr. Daniel M. Ingram, MD MSPH, a retired emergency medicine physician who works to improve the global relationship of science, clinical practice, mental health and the public to the phenomena that might be referred to as spiritual, meditative, energetic, mystical, psychedelic, magical, and related phenomena. To those ends, he is currently the founder, philanthropic supporter, and volunteer CEO and Board Chair of the Emergence Benefactors registered charity, and chief organiser and co-founder of the global Emergent Phenomenology Research Consortium. He is currently involved in neurophenomenological research of advanced meditative states with colleagues at Harvard and has been a participant in numerous fMRI and EEG studies of advanced meditators, including at Harvard, Yale, U Mass, and Vanderbilt. He has published scientific articles in Pediatrics, Child Abuse and Neglect, and the Journal of Medical Toxicology. He is the author of Mastering the Core Teachings of the Buddha, co-author of The Fire Kasina, and co-founder of the Dharma Overground. His work has been featured in The New York Times, Esquire, Vice, Wired, BBC Radio 4, Evolving Dharma, American Dharma: Buddhism Beyond Modernity, Dan Harris' 10% Happier Podcast, Slate Star Codex Blog, Buddha at the Gas Pump, Meaning of Life TV, Deconstructing Yourself, Spiritual Explained website, Guru Viking, Buddhist Geeks, Cosmic Tortoise, Startup Geometry, Imperfect Buddha Podcast, and many others. In this conversation, Lian and Daniel explored the challenges and pitfalls associated with spiritual awakening, particularly the dark nights of the soul that many seekers face on their path.  This is ancient wisdom that in some modern western spheres has been forgotten and is now being remembered - which you'll hear can be surprisingly controversial. We'd love to know what YOU think about this week's show. Let's carry on the conversation… please leave a comment wherever you are listening or in any of our other spaces to engage. What you'll learn from this episode: Spiritual awakening can lead to significant challenges and disruptions in life - historical texts have long acknowledged the challenges of spiritual practices. Recognising this means we can seek traditions that include guidance and remedies for difficult experiences. Community support and normalisation of experiences can help individuals feel less isolated in their difficult spiritual experiences, and provide help in navigating them. Resources and stuff spoken about: If you want to focus on Daniel's scientific work related to spirituality and the organisation he helps support: Emergent Phenomenology Research Consortium The EPRC YouTube Channel Emergence Benefactors If you want to focus on Daniel's work related to meditation practice and its effects: Daniel M. Ingram YouTube Channel Mastering The Core Teachings of Buddha For Books: Fire Kasina: The Fire Kasina Meditation Site for books and more on meditation Daniels Personal Website: Integrated Daniel Daniels Online Community: The Dharma Overground Emerge Wiki: emergewiki.org Join UNIO, the Academy of Sacred Union. This is for the old souls in this new world… Discover your kin & unite with your soul's calling to truly live your myth. Be Mythical Join our mailing list for soul stirring goodness: https://www.bemythical.com/moonly UNIO: The Academy of Sacred Union: https://www.bemythical.com/unio Go Deeper: https://www.bemythical.com/godeeper Follow us: Facebook Instagram TikTok YouTube Thank you for listening! There's a fresh episode released each week here and on most podcast platforms - and video too on YouTube - if you subscribe then you'll get each new episode delivered to your device every week automagically (that way you'll never miss an episode).  

What would you do if your job ended tomorrow? Even though you might want to say, “Take this job and shove it,” that won't help build stepping stones to your next job.In this episode, we discuss: what it's like for physician coaches who regularly work with docs in this situation, getting fired, dealing with unexpected events that shake up professional stability, planning for career disruption, the importance of networking, and finding your clinical practice N plus one.

Medical Toxicology and Poison Prevention in Pediatrics with Dr. Anthony Pizon

This week's show is with Dr. Daniel M. Ingram, MD MSPH, a retired emergency medicine physician who works to improve the global relationship of science, clinical practice, mental health and the public to the phenomena that might be referred to as spiritual, meditative, energetic, mystical, psychedelic, magical, and related phenomena. To those ends, he is currently the founder, philanthropic supporter, and volunteer CEO and Board Chair of the Emergence Benefactors registered charity, and chief organizer and co-founder of the global Emergent Phenomenology Research Consortium. He is currently involved in neurophenomenological research of advanced meditative states with colleagues at Harvard and has been a participant in numerous fMRI and EEG studies of advanced meditators, including at Harvard, Yale, U Mass, and Vanderbilt. He has published scientific articles in Pediatrics, Child Abuse and Neglect, and the Journal of Medical Toxicology. He is the author of Mastering the Core Teachings of the Buddha, co-author of The Fire Kasina, and co-founder of the Dharma Overground. His work has been featured in The New York Times, Esquire, Vice, Wired, BBC Radio 4, Evolving Dharma, American Dharma: Buddhism Beyond Modernity, Dan Harris' 10% Happier Podcast, Slate Star Codex Blog, Buddha at the Gas Pump, Meaning of Life TV, Deconstructing Yourself, Spiritual Explained website, Guru Viking, Buddhist Geeks, Cosmic Tortoise, Startup Geometry, Imperfect Buddha Podcast, and many others. In this conversation, Daniel and Lian explored the intersection of magic, spirituality, science, and healthcare. Daniel shares his personal journey and the three aspects of himself that led him to explore this integration within and without via the work of the Emergent Phenomenology Research Consortium, which aims to bridge the gap between the clinical mainstream and the emergent world. The conversation explores the importance of understanding phenomenology, establishing diagnostic categories, and conducting epidemiological studies. As well as the topics of neurodivergence and shamanic sickness, highlighting the need for understanding and support in these areas, and the challenges of recognising and relating to unusual experiences, as well as the tension between regulation and accessibility in alternative healing practices. Finally, Daniel shares his vision for the future, where knowledge and capabilities in these areas are equitably distributed and supported by scientific research. We'd love to know what YOU think about this week's show. Let's carry on the conversation… please leave a comment below or share in our fb group. What you'll learn from this episode: The integration of magic, spirituality, science, and healthcare can lead to transformative experiences and intentional healing. Understanding phenomenology and establishing diagnostic categories are crucial for bridging the gap between the clinical mainstream and the emergent world. Epidemiological studies can provide insights into the impact of transformative experiences on mental wellbeing and society. Special projects related to military, security, space, and big data require careful consideration and ethical approaches. Normalization and connection with others who have had similar experiences can be healing and provide support. Understanding and support for neurodivergence and shamanic sickness are important in the context of spiritual and mystical experiences. Recognizing and relating to unusual experiences can be challenging, but pattern recognition and training can help healthcare professionals provide better care. There is a tension between regulation and accessibility in alternative healing practices, and it is important to find a balance that allows for both safety and inclusivity. The vision for the future includes a global clinical mainstream that has a sophisticated understanding of alternative healing practices and the ability to provide equitable access to knowledge and support. Resources and stuff that we spoke about: If you want to focus on my scientific work related to spirituality and the organization I help support: Emergent Phenomenology Research Consortium The EPRC YouTube Channel Emergence Benefactors If you want to focus on my work related to meditation practice and its effects: Daniel M. Ingram YouTube Channel Mastering The Core Teachings of Buddha For Boo For Books: Fire Kasina: The Fire Kasina Meditation Site for books and more on meditation Daniels Personal Website: Integrated Daniel Daniels Online Community: The Dharma Overground   Be Mythical Join our mailing list: https://www.bemythical.com/moonly "How do you think the concepts of morals and ethics influence our daily lives, and what role do you believe storytelling plays in shaping our understanding of empathy and ethical decision-making?" UNIO: The Academy of Sacred Union: Doors opening soon! To get your special invitation register HERE. Go Deeper: https://www.bemythical.com/godeeper   Follow us: Facebook Instagram TikTok YouTube   Thank you for listening! There's a fresh episode each week, if you subscribe then you'll get each episode delivered to your device every week automagically (that way you'll never miss an episode).

Renee Schmid, DVM, DABT, DABVT, is the Manager, Veterinary Medicine and Professional Services, Pet Poison Helpline and Senior Veterinary Toxicologist for Pet Poison Helpline /SafetyCall International. She has been with the organization since 2013 during which time she has had the opportunity to lead the team of veterinarians that span across the country and contribute to the management of the daily operations of Pet Poison Helpline. Schmid graduated from Kansas State University with a BS degree in Agriculture/Animal Science as well as a Doctor of Veterinary Medicine degree. While at Pet Poison Helpline, Schmid has managed over 20,000 cases involving animal poisoning and has presented on leadership and various toxins at both regional and national conferences.  Schmid has published scientific book chapters on the topics of thyroid supplements, diuretic drug intoxication, xylitol intoxication, general poisoning therapy, strychnine toxicosis, Compound 1080 toxicosis, anticoagulant rodenticide poisoning, cholecalciferol rodenticide poisoning, toxicities from human drugs – cardiovascular and poisonous plants: house plants and ornamentals. Schmid has also published peer-reviewed scientific articles on xylitol and mirabegron poisoning in dogs, as well as anesthesia induction in cats (Schmid et al. Acute Hepatic Failure in a Dog after Xylitol Ingestion and Schmid et al. Mirabegron Toxicosis in Dogs: A Retrospective Study, both in Journal of Medical Toxicology. Schmid et al. Comparison of anesthetic induction in cats by use of isoflurane in an anesthetic chamber with a conventional vapor or liquid injection technique, JAVMA). 

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.

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.

Kelby Kiefer and Dave Flewelling join Jamie to talk about the Iowa LICA Field Days coming up on July 26 & 27 in Melbourne, Iowa. The Water Table Podcast will be there with our mobile recording studio to get in on all the action. Find out why Iowa LICA chapter is one of the biggest and best in the country and hear about the farm they've owned for 20 years. They've used 80 acres to clean up a 1000 acre watershed and want to share their practices with you!The LICA Farm: https://ialica-my.sharepoint.com/:v:/p/director/EdUXGtODslhKun8n3oByicMBnlQpOaAWJVbO6s68qWOmigAttend LICA on July 26th and 27th: https://www.facebook.com/IALICA/Chapters & Episode Topics: 00:00   Intro00:32   This week on The Water Table…00:57   Welcome Kelby and Dave02:00   What's so different about Iowa?03:30   It's all about loyalty…04:45   …and passion06:10   A fraternity of relationships07:20   The Iowa LICA Farm08:30   See conservation practices first-hand09:15   Terraces, wetlands and buffers, oh my!10:25   All the testing and all the results12:00   80 acres cleaning up 1000 acres13:10   Field day! July 26 & 2714:10   Come play in the dirt…15:30   This year – tiling, saturated buffers, grading…demos galore!17:40   Schedule info19:00   EVERYONE is invited20:20   Three goals21:00   The Water Table on the road!Follow us on social media! Facebook Twitter Find us on Apple Podcasts Subscribe to our Spotify Listen on Google Podcasts Visit our website to explore more episodes & water management education:https://www.watertable.ag/the-podcast/ About the Guests:Kelby Kiefer has been the Iowa LICA Executive Director since May of 2022.  She grew up in Southeastern Iowa in the Wellman/Kalona area where she still resides.  She has been employed by the University of Iowa Hospitals and Clinics for the past 16 years and has been in the Department of Emergency Medicine as part of the Education Leadership Team for the past 7.5 years. She is a Program Coordinator for their Physician Assistant Residency and six departmental Fellowships (Emergency Medical Services, Emergency Ultrasound, Medical Education, Medical Toxicology, Research, and Social Medicine).  She also serves as Division Coordinator for their Divisions of Emergency Medical Services and Medical Toxicology.Dave Flewelling has served on the Iowa Land Improvement Contractors Association board for the past 10 years and currently serves as the state president. Dave developed a true passion for building conservation structures while growing up in a small family-run multi-generational earthmoving company from Northwest Iowa. After taking over the business in 2007 and joining the Iowa LICA Association shortly afterwards, he realized how important it is to belong to a group that has a strong impact on the industry and has made it his goal to help educate the next generation of contractors how to conserve the earth for future use.

Medical Toxicology and Poison Prevention in Pediatrics with Dr. Anthony Pizon

Apologies for being MIA for a month now. Been busy! But am back and in this episode talk about calcium channel blocker toxicity. The physiology behind it, a little pharmacology and then the treatment. Busting some myths and reinforcing the need for proactive emergency medicine evidence based treatment. You can check out these papers and do more research for yourselves too - 1. Wightman RSHRA. Cardiologic Principles II: Hemodynamics. In: Nelson LS, Howland MA, Lewin NA, et al, editors. Goldfrank's toxicologic emergencies. 11th Edition. New York City, NY: McGraw Hill; 2019. p. 260–7 2. Levine M, Brent. Beta-Receptor Antagonists. In: Brent J, Burkhart K, Daragan P, et al, editors. Critical care toxicology. New York City, NY: Mosby; 2017. p. 771–86. Wallukat G. The beta-adrenergic receptors. Herz 2002;27(7):683–90. 4. Ranniger C, Roche C. Are one or two dangerous? Calcium channel blocker exposure in toddlers. J Emerg Med 2007;33(2):145–54 5. Gummin DD, Mowry JB, Beuhler MC, et al. 2019 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 37th Annual Report. Clin Toxicol 2020;58(12):1360–541. 6. Holger JS, Engebretsen KM, Obetz CL, et al. A comparison of vasopressin and glucagon in beta-blocker induced toxicity. Clin Toxicol 2006;44(1):45–51 7. Jang DH, Donovan S, Nelson LS, et al. Efficacy of methylene blue in an experimental model of calcium channel blocker-induced shock. Ann Emerg Med 2015;65(4):410–5. 8. Laes JR, Williams DM, Cole JB. Improvement in hemodynamics after methylene blue administration in drug-induced vasodilatory shock: a case report. J Med Toxicol 2015;11(4):460–3. 9. Wang GS, Levitan R, Wiegand TJ, et al. Extracorporeal membrane oxygenation (ECMO) for severe toxicological exposures: review of the toxicology investigators consortium (ToxIC). J Med Toxicol 2016;12(1):95–9 10. Hayes BD, Gosselin S, Calello DP, et al. Systematic review of clinical adverse events reported after acute intravenous lipid emulsion administration. Clin Toxicol 2016;54(5):365–404 11. American College of Medical Toxicology. ACMT position statement: guidance for the use of intravenous lipid emulsion. J Med Toxicol 2017;13(1):124–5. 12. Kerns W 2nd. Management of beta-adrenergic blocker and calcium channel antagonist toxicity. Emerg Med Clin North Am. 2007 May;25(2):309-31; abstract viii. doi: 10.1016/j.emc.2007.02.001. PMID: 17482022. 13. Cole JB, Arens AM. Cardiotoxic Medication Poisoning. Emerg Med Clin North Am. 2022 May;40(2):395-416. doi: 10.1016/j.emc.2022.01.014. Epub 2022 Apr 5. PMID: 35461630.

This week's show is with Dr. Daniel M. Ingram. Dr. Daniel M. Ingram, MD MSPH, is a retired emergency medicine physician who works to improve the global relationship of science, clinical practice, mental health and the public to the phenomena that might be referred to as spiritual, meditative, energetic, mystical, psychedelic, magical, and related phenomena. To those ends, he is currently the founder, philanthropic supporter, and volunteer CEO and Board Chair of the Emergence Benefactors registered charity, and chief organizer and co-founder of the global Emergent Phenomenology Research Consortium. He is currently involved in neurophenomenological research of advanced meditative states with colleagues at Harvard and has been a participant in numerous fMRI and EEG studies of advanced meditators, including at Harvard, Yale, U Mass, and Vanderbilt. He has published scientific articles in Pediatrics, Child Abuse and Neglect, and the Journal of Medical Toxicology. He is the author of Mastering the Core Teachings of the Buddha, co-author of The Fire Kasina, and co-founder of the Dharma Overground. His work has been featured in The New York Times, Esquire, Vice, Wired, BBC Radio 4, Evolving Dharma, American Dharma: Buddhism Beyond Modernity, Dan Harris' 10% Happier Podcast, Slate Star Codex Blog, Buddha at the Gas Pump, Meaning of Life TV, Deconstructing Yourself, Spiritual Explained website, Guru Viking, Buddhist Geeks, Cosmic Tortoise, Startup Geometry, Imperfect Buddha Podcast, and many others. In this conversation, Daniel and I explored the topic of where magic and spirituality meet, how they can seem at odds, even though magical phenomena are found in many mystical traditions, how Daniel found his way to a life and work in which they belong together, and how he sees they have an important role in understanding and working to improve mental health. We'd love to know what YOU think about this week's show. Let's carry on the conversation… please leave a comment below or share in our fb group. What you'll learn from this episode: Daniel's story illustrates how in many spiritual traditions, magical effects are considered almost a distraction and not something to focus on, whereas his path took him into the conscious practice of magick too - Daniel discovered Kasina and elemental practices from the ancient Buddhist texts could actually be a powerful aid in his ceremonial magic practice, showing that meditative traditions and magick can happily co-exist I love what Daniel said… “There is a there - if you get your concentration and intention right.” (very overly simplistically paraphrased!) We spoke about the seeming dichotomy between the rational, scientific worldview and the magical worldview - which just like magic and spirituality, doesn't have to be choice between one or the other. I love what Daniel said about there being no other culture in the history of the world that has this completely non-spiritual take on mental health, in the way we do in this modern culture. For this to change we probably need to create the choice and research to compare mainstream frameworks and approaches vs spiritual ones. Resources and stuff that we spoke about: If you want to focus on my scientific work related to spirituality and the organization I help support: Emergent Phenomenology Research Consortium The EPRC YouTube Channel Emergence Benefactors If you want to focus on my work related to meditation practice and its effects: Daniel M. Ingram YouTube Channel Mastering The Core Teachings of Buddha For Boo For Books: Fire Kasina: The Fire Kasina Meditation Site for books and more on meditation Daniels Personal Website: Integrated Daniel Daniels Online Community: The Dharma Overground Thank you for listening! There's a fresh episode each week, if you subscribe then you'll get each new episode automagically delivered to your phone every Wild Wednesday (that way you'll never miss an episode): Subscribe on Apple Podcasts/iTunes Subscribe on Android Thank you! Lian and Jonathan

Renee Schmid, DVM, DABT, DABVT, is the Manager, Veterinary Medicine and Professional Services and Senior Veterinary Toxicologist for Pet Poison Helpline/SafetyCall International. She has been with the organization since 2013 during which time she has had the opportunity to lead the team of veterinarians that span across the country and contribute to veterinary outreach and daily operations of Pet Poison Helpline. Dr. Schmid graduated from Kansas State University with a BS degree in Agriculture/Animal Science as well as a Doctor of Veterinary Medicine degree. While at Pet Poison Helpline, Dr. Schmid has managed over 25,000 cases involving animal poisoning and has presented on leadership and various toxins at both state, regional and national conferences as well as national webinars. Dr. Schmid has published scientific book chapters on the topics of thyroid supplements, diuretic drug intoxication, xylitol intoxication, general poisoning therapy, strychnine toxicosis, Compound 1080 toxicosis, anticoagulant rodenticide poisoning, cholecalciferol rodenticide poisoning, toxicities from human drugs – cardiovascular and poisonous plants: house plants and ornamentals. Dr. Schmid has also published peer-reviewed scientific articles on intermediate syndrome after suspected organophosphate poisoning in a dog, xylitol and mirabegron poisoning in dogs, as well as anesthesia induction in cats (Schmid et al. Suspected intermediate syndrome in a dog after organophosphate poisoning, JVECC. Schmid et al. Acute Hepatic Failure in a Dog after Xylitol Ingestion and Schmid et al. Mirabegron Toxicosis in Dogs: A Retrospective Study, both in Journal of Medical Toxicology. Schmid et al. Comparison of anesthetic induction in cats by use of isoflurane in an anesthetic chamber with a conventional vapor or liquid injection technique, JAVMA). Most recently, Dr. Schmid has joined the Editorial Advisory Board for DVM360.

Renee Schmid, DVM, DABT, DABVT, is the Manager, Veterinary Medicine and Professional Services and Senior Veterinary Toxicologist for Pet Poison Helpline/SafetyCall International. She has been with the organization since 2013 during which time she has had the opportunity to lead the team of veterinarians that span across the country and contribute to veterinary outreach and daily operations of Pet Poison Helpline. Dr. Schmid graduated from Kansas State University with a BS degree in Agriculture/Animal Science as well as a Doctor of Veterinary Medicine degree. While at Pet Poison Helpline, Dr. Schmid has managed over 25,000 cases involving animal poisoning and has presented on leadership and various toxins at both state, regional and national conferences as well as national webinars. Dr. Schmid has published scientific book chapters on the topics of thyroid supplements, diuretic drug intoxication, xylitol intoxication, general poisoning therapy, strychnine toxicosis, Compound 1080 toxicosis, anticoagulant rodenticide poisoning, cholecalciferol rodenticide poisoning, toxicities from human drugs – cardiovascular and poisonous plants: house plants and ornamentals. Dr. Schmid has also published peer-reviewed scientific articles on intermediate syndrome after suspected organophosphate poisoning in a dog, xylitol and mirabegron poisoning in dogs, as well as anesthesia induction in cats (Schmid et al. Suspected intermediate syndrome in a dog after organophosphate poisoning, JVECC. Schmid et al. Acute Hepatic Failure in a Dog after Xylitol Ingestion and Schmid et al. Mirabegron Toxicosis in Dogs: A Retrospective Study, both in Journal of Medical Toxicology. Schmid et al. Comparison of anesthetic induction in cats by use of isoflurane in an anesthetic chamber with a conventional vapor or liquid injection technique, JAVMA). Most recently, Dr. Schmid has joined the Editorial Advisory Board for DVM360.

Dr. Jeanmarie Perrone is the Director of the Division of Medical Toxicology and Addiction Medicine Initiatives and a Professor of Emergency Medicine at the University of Pennsylvania, as well as a successful published research author. In this episode, we discuss Dr. Perrone's role as a national leader in efforts to address the opioid epidemic through her thoughts on stigmas in emergency medicine, equitable access to care through spearheading Penn's CareConnect “warmline,” the stigma around using lifesaving medications to treat substance use disorder, and Dr. Perrone's hope for the larger impact of her work.   Hosted by Heather Major, Executive Director, Independence Blue Cross Foundation. Recovery is possible, and help is available. Please visit our website for more information, resources and inspiration: www.ibxfoundation.org/SYK TM 2022 Someone You Know®. All Rights Reserved. Disclaimers This podcast contains opinionated content and may not reflect the opinions of any organizations this podcast is affiliated with. This podcast discusses opioid use, opioid treatment, and physical and psychological trauma, which may be triggering for some listeners. Listener discretion is advised. This podcast is solely for informational purposes. Listeners are advised to do their own diligence when it comes to making decisions that may affect their health. Patients in need of medical advice should consult their personal health care provider. The purpose of this podcast is to educate and to inform. It is not a substitute for professional care by a doctor or other qualified medical professional.

Renee Schmid, DVM, DABT, DABVT, is the Manager, Veterinary Medicine and Professional Services, Pet Poison Helpline and Senior Veterinary Toxicologist for Pet Poison Helpline/SafetyCall International. She has been with the organization since 2013 during which time she has had the opportunity to lead the team of veterinarians that span across the country and contribute to the management of the daily operations of Pet Poison Helpline. Schmid graduated from Kansas State University with a BS degree in Agriculture/Animal Science as well as a Doctor of Veterinary Medicine degree.     While at Pet Poison Helpline, Schmid has managed over 25,000 cases involving animal poisoning and has presented on leadership and various toxins at both regional and national conferences.  Dr. Schmid has published scientific book chapters on the topics of thyroid supplements, diuretic drug intoxication, xylitol intoxication, general poisoning therapy, strychnine toxicosis, Compound 1080 toxicosis, anticoagulant rodenticide poisoning, cholecalciferol rodenticide poisoning, toxicities from human drugs—cardiovascular and poisonous plants: house plants and ornamentals. Schmid has also published peer-reviewed scientific articles on xylitol and mirabegron poisoning in dogs, as well as anesthesia induction in cats (Schmid et al. Acute Hepatic Failure in a Dog after Xylitol Ingestion and Schmid et al. Mirabegron Toxicosis in Dogs: A Retrospective Study, both in Journal of Medical Toxicology.  Schmid et al. Comparison of anesthetic induction in cats by use of isoflurane in an anesthetic chamber with a conventional vapor or liquid injection technique, JAVMA). 

In this very in-depth podcast, we take a deep dive into the history and science of GMOs and pesticides within the food and agriculture world. We discuss some misconceptions and important concerns raised against their use.  BIO Dr. Liza Dunn is an emergency medicine physician and medical toxicologist with a long-standing interest in global health. After completing her toxicology fellowship at NYU in 2006, Dr. Dunn returned to Washington University in St. Louis and started an ACGME accredited fellowship in Medical Toxicology. Over the following ten years, Dr. Dunn became increasingly involved with global health and humanitarian relief projects. She organized a relief mission to Haiti after the 2010 earthquake, started the scholar track in Global Health for the Washington University Division of Emergency Medicine, and is one of the Global Health Scholars for the Department of Internal Medicine. Over the years, Dr. Dunn began to realize that in order to have a sustainable impact on global health, there needed to be an effort to focus on creative ways of addressing malnutrition and insect-borne illness, two of the most commonly encountered public health problems in developing countries. With that in mind, Dr. Dunn started working as the Medical Affairs Lead for Bayer, a global seed and chemical company with innovative technology that has great potential to remediate malnutrition. Dr. Dunn has lectured nationally and internationally on a diverse range of topics in medical toxicology and global health. TIMESTAMPS 1:00 Latest event for Ketogeek 2:24 Ketogeek and Energy Pod information 3:40 New Infinity Series Energy Pod series 8:18 Innovative 3D printed displays for vendors and retailers 14:18 Dr. Liza's compelling story 23:09 Top misconceptions around pesticides among physicians and the masses 24:16 Are there thousands of unregulated chemicals in the market? 27:31 Is the way we produce food responsible for modern chronic disease(eg. diabetes, cancer, heart disease etc.)? 32:09 What changed your mind regarding pesticides and chemicals in the food supply chain? 36:35 History and deep explanation of insecticides, herbicides, and fungicides 40:45 Should I be concerned about pesticide residue on produce at a grocery store? 57:38 What about the concerns of pesticides creating resistance towards those pesticides? 1:07:11 How do you decide whether to use GMOs or pesticides in a certain environment? 1:10:11 The general perception of GMOs in the world 1:16:36 How can consumers learn more about GMOs and pesticides? 1:19:39 Final plugs PLUGS GUEST: Twitter: Liza Dunn (@DrLizaMD) / Twitter Bayer Website: Bayer – Global Home | Bayer global HOST: Ketogeek: KetoGeek | Official Site

Dr. Lewis Nelson myth busts alleged fentanyl overdose cases in passive handlers. He explains the nocebo effect, opposite the placebo effect. It is true that 2 grains of fentanyl can kill, but it have to be 2 grain of pure fentanyl and it has to be consumed. Touching fentanyl does not kill - people who deal drugs as well as healthcare workers touch fentanyl regularly and do not overdose. "Dose makes the Poison" is the hallmark of medical toxicology. Lewis S. Nelson, MD is Professor and Chair of the Department of Emergency Medicine, Chief of Service of the University Hospital Emergency Department, and Chief of the Division of Medical Toxicology at Rutgers New Jersey Medical School, all in Newark, NJ. He is also a Senior Consultant to the New Jersey Poison Information & Education System. He is board certified in emergency medicine, medical toxicology, and addiction medicine. Dr. Nelson is an editor of the medical toxicology textbook Goldfrank's Toxicologic Emergencies and on the editorial boards of several peer-reviewed journals. He is a member of the board of the American Board of Emergency Medicine and several other academic organizations and is Past President of American College of Medical Toxicology. Dr. Nelson serves as a long-standing consultant to CDC, DHS, and FDA. Some of his areas of interest include non-opioid pain relief strategies, opioid overdose and management, addiction and withdrawal management, and health policy focused on issues related to medication safety and substance use.

We are taking a short break from recording new episodes this month. I hope you enjoy this previously released episode on Toxicology in the ICU. This is part two of a two part series. Today's episode will focus on specific toxic ingestions and their management. Our guest is Dr. Jerrold B. Leikin. Dr. Leikin is the Director of Medical Toxicology at North Shore University Health System-OMEGA which includes several hospitals in Illinois. In addition, he is a Clinical Professor of Medicine at the Pritzker School of Medicine (University of Chicago) and Professor of Medicine and Pharmacology at Rush Medical College. Additional Resources: Link to the website for the American Association of Poison Control Centers: https://aapcc.org/ A three part review series published in CHEST on Toxicology in the ICU: https://www.ncbi.nlm.nih.gov/pubmed/21896525 https://www.ncbi.nlm.nih.gov/pubmed/21972388 https://www.ncbi.nlm.nih.gov/pubmed/22045882 Albums Mentioned in this Episode: The Beatles Live at the BBC: Dr. Leikin's recommendation for the one album he would take on a deserted island: https://amzn.to/2vIrX5M

We are taking a short break from recording new episodes this month. I hope you enjoy this previously released episode on Toxicology in the ICU. This is part one of a two part series. Today's episode will focus on an overview of toxic ingestions and their general management. Our guest is Dr. Jerrold B. Leikin. Dr. Leikin is the Director of Medical Toxicology at North Shore University Health System-OMEGA which includes several hospitals in Illinois. In addition, he is a Clinical Professor of Medicine at the Pritzker School of Medicine (University of Chicago) and Professor of Medicine and Pharmacology at Rush Medical College. Additional Resources: Link to the website for the American Association of Poison Control Centers: https://aapcc.org/ A three-part review series published in CHEST on Toxicology in the ICU. https://www.ncbi.nlm.nih.gov/pubmed/21896525 https://www.ncbi.nlm.nih.gov/pubmed/21972388 https://www.ncbi.nlm.nih.gov/pubmed/22045882 Books mentioned in this episode: Biographies on Louis Armstrong: https://amzn.to/3wsdT0z https://amzn.to/38DfEP5 Albums by Louis Armstrong: https://amzn.to/3Pt40qO

In this episode, we discuss issues that were problems long before anyone ever heard of COVID-19: alcohol use disorder and opioid overdose. Both seem to have gotten worse during the pandemic. Alcohol sales rose during the early days of lockdown, and they've remained high. Laura J. Bierut, MD, the Alumni Endowed Professor of Psychiatry, says another issue is that with some people losing their jobs while millions more have worked from home, some of the guardrails that have kept people from drinking too much have just gone away. She expects the fallout from the pandemic, in terms of alcohol use, will continue being felt for years to come. And just as the pandemic has fueled alcohol problems, deaths from drug overdoses have continued to climb, with more than 107,000 overdose deaths reported in the U.S. during a recent 12-month period. One issue, according to Kevin Xu, MD, a resident in psychiatry and Evan S. Schwarz, MD, an associate professor of emergency medicine and director of the Division of Medical Toxicology, is that many who use opioids are not prescribed a drug that can reduce cravings and lower risk of future overdose. That drug, buprenorphine, is prescribed for only about half of the patients treated for opioid use disorder, and it's used even less frequently in people who use opioids along with other substances, such as cocaine, alcohol or methamphetamine. The podcast, “Show Me the Science,” is produced by the Office of Medical Public Affairs at Washington University School of Medicine in St. Louis.

The possibility of being sued following a medical error is a major source of anxiety for physicians. While there are numerous educational items devoted to medical malpractice risk, these are sometimes limited in scope. Moreover, medicolegal training in residency is frequently insufficient.    Our special guest today is Heath Jolliff, DO, Board Certified in Emergency Medicine and Medical Toxicology, national speaker, educator, and certified executive coach.  Over the course of his career, he has observed many physicians grappling with the stress and burnout of clinical documentation, administration overload, and the threat of malpractice.   In 2020, Dr. Jolliff, along with his colleagues, conducted a mock trial, recreating an actual chest pain malpractice case and revealing insights and burnout prevention lessons for all physicians. The major purpose of this study was to provide participants with practical advice on how to enhance patient safety and documentation while also reducing their medicolegal risk. To learn more about this, the video of the Mock Trial and the Study of this learning experience is available at the links below.   Episode Highlights: (01:54) The objective of the mock trial (03:26) Methodology; Availability for public viewing (07:20) Change in medical practice and documentation  (13:03) Mandatory class for residents and training programs   Connect with Dr. Heath Jolliff: LInkedin: https://www.linkedin.com/in/thephysiciancoach/   Resources: The Study: See You In Court: Practice And Documentation Change From A Mock Trial J Urgent Care Med. 2022;16(5):23-27. Study Link:https://www.jucm.com/see-you-in-court-practice-and-documentation-change-from-a-mock-trial/   Complete Mock Trial  Video: https://www.atls2020.com/atls2020   Learn more about Dr. Dike and The Happy MD: https://linktr.ee/dikedrummond     We would love to hear your feedback. Send us your review on Apple Podcasts/Itunes, or in other directories through this link: https://www.podchaser.com/podcasts/physicians-on-purpose-1546320

The world of emergency medicine is commonly known for its 2 AM chest pain visits, motor vehicle accidents and trauma admissions, and foreign objects that require removal from different orifices. However, there is actually so much more specialization within this specialty in itself! Through additional training from 1 to 2 years of fellowship, one can sub-specialize in realms that expand even beyond the four corners of the emergency room, such as Critical Care, EMS/Disaster, Wilderness Medicine, Pediatrics, Hyperbaric Medicine, Medical Toxicology, and even Ultrasound! The last is true for our episode guest today, Dr. Siri ("Hey Siri MD") Chamarti, an Emergency Medicine physician who is near-ending her Ultrasound fellowship!Receiving her bachelor's degree in Neuroscience from UCLA in 2013, attaining her medical degree from the Medical College of Georgia at August University in 2017, and having completed her emergency medicine residency at Maimonides Hospital in 2020, Dr. Siri now stands as a New York doctor who promotes evidenced-based education on her social media space by recalling her gruesome experiences as the first line of defense during the spike of the pandemic during the City's epicenter during Spring 2020.From her advice for pre-medical to juggling enjoyment with medical school to moving across the country to pursue medicine to finally becoming an attending doctor now teaching the next generation of physicians and to her love for good food and traveling, Dr. Siri is a testament to how much of life can truly be a fun adventure even as a doctor. Just as she stresses the importance of mastering anatomy to excel in ultrasound medicine, Dr. Siri also stresses the importance of mastering the discovery of what makes you happy and excited to live life. "Hey Siri! What...makes you happy?"Livestream Air Date: August 12, 2021Dr. Sirivalli Chamarti: IG @heysirimdFriends of Franz: IG @friendsoffranzpodChristian Franz (Host): IG @chrsfranz & YT Christian Franz

The opioid and fentanyl epidemics have touched every one of our lives.The opioid and fentanyl epidemics have touched every one of our lives. Addiction does not discriminate. So let's take a look at the problem from not only the addiction and user perspective but from a medical and neurological point of view as well.Dr. Lewis Nelson is Professor and Chair of the Department of Emergency Medicine and Chief of the Division of Medical Toxicology at Rutgers New Jersey Medical School, all in Newark, NJ. He is also a Senior Consultant to the New Jersey Poison Information & Education System. He is board-certified in emergency medicine, medical toxicology (human poisoning and overdose), and addiction medicine.Dr. Nelson serves as a long-standing consultant to CDC, DHS, and FDA on issues related to opioid use and misuse, drug safety, and health policy. He sits down with Erica to discuss the origins of the opioid crisis and how it has changed over the past 25 years, how tolerance develops and grows over time, fast pain fixes, and the CDC's proposed new guidelines to remove the recommended dosage caps on opioids for acute and chronic pain

Robert Hendrickson, MD Emergency Services Physician & Program Director, Fellowship of Medical Toxicology, OHSU Medical Director, OHSU's Emergency Management Program and the Oregon Poison Center

Robert Hendrickson, MD Emergency Services Physician & Program Director, Fellowship of Medical Toxicology, OHSU Medical Director, OHSU's Emergency Management Program and the Oregon Poison Center

Dr. Jenkins has had a long-standing interest in snake bite treatment and frequently speaks on the subject of treatment in wild settings.  He welcomes Dr. Spencer Greene to Snake Talk for a deeper discussion on the subject of treating snake bites.  They talk about the field of Medical Toxicology, what to do (and not to do) when treating a snake bite, and they go into treatment of pregnant snake bite victims.  Chris introduces his friend Lisa Damron who reveals her life changing experience of receiving a rattlesnake bite while she was pregnant.  Be sure to listen until the very end - this is an informative and emotional episode.Connect with Spencer on his website.Connect with Chris on Facebook, Instagram or at The Orianne Society.Shop Snake Talk merch.

In this episode Dr. Gillian Beauchamp sits down with Dr. Michael Chary to discuss the role of artificial intelligence in medical toxicology.

Emergency Department Pharmacist Catherine Platt joins the show today to discuss Epinephrine including some ways we use it as EMTs, AEMTs and Paramedics. We also will break down three different clinical trials that have shaped how we administer the drug leading to best practices in and out of the hospital. The studies used in this show are listed below for your reference.  Simons, F. Estelle R., and Xiaochen Gu. “Epinephrine Absorption in Adults: Intramuscular versus Subcutaneous Injection.” www.jacionline.org/Article, J ALLERGY CLIN IMMUNOL, 5 Aug. 2001, www.jacionline.org/article/S0091-6749(98)701903/fulltext.  Perkins, Gavin D., et al. “A Randomized Trial of Epinephrine in out-of-Hospital Cardiac Arrest: Nejm.” New England Journal of Medicine, 23 Aug. 2018, www.nejm.org/doi/full/10.1056/NEJMoa1806842#article_references.  Cole, J. B., Knack, S. K., Karl, E. R., Horton, G. B., Satpathy, R., & Driver, B. E. (2019). Human Errors and Adverse Hemodynamic Events Related to “Push Dose Pressors” in the Emergency Department. Journal of medical toxicology : official journal of the American College of Medical Toxicology, 15(4), 276–286. https://doi.org/10.1007/s13181-019-00716-z

Essential oils, household cleaners, medications, and lawn care chemicals. We have so many things around our homes that could be dangerous if ingested by children. What should we and should not be worried about? Today Dr. Daria Falkowitz and I are reviewing the most common household substances that children are exposed to, what to do if your child eats or drinks a medication or household product, and much more.    Daria Falkowitz DO is a full time board certified emergency medicine physician and medical toxicologist who specializes in poisonings, overdoses, and environmental/occupational toxins. She is the Director of the Division of Medical Toxicology in the Department of Emergency Medicine at Hackensack University Medical Center in NJ and is also a mother of two young daughters.   In this episode we discuss: -Common household substances that children are exposed to and more likely to ingest -Unexpected causes of children being admitted to the ER -How extensively you should baby-proof your home -The first steps to take if your child has an exposure to something dangerous -Whether or not there is a danger in using common things such as fluoride toothpaste, stain removers on clothing, essential oils, etc.   Resources mentioned: -Poison Control Hotline: 1-800-222-1222 -Dr. Daria's Instagram: @em.tox.mom   Connect with me on Instagram @motherhoodmeetsmedicine. For full show notes, head to lynzyandco.com/motherhood-meets-medicine-the-podcast/   Join the Motherhood Meets Medicine community at patreon.com/motherhoodmeetsmedicine.   Disclaimer: This podcast does not provide medical advice. The information on this podcast is for informational purposes only. No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. 

What is scomiting? Dr. Jeff LaPoint explains scomiting, also known as cannabis hyperemesis syndrome. LaPoint is an emergency physician and toxicologist. He practices at Kaiser Hospital in San Diego and is the Director of the Division of Medical Toxicology. He extensive publications on Cannabis Hyperemesis Syndrome in peer reviewed research and medical textbooks. LaPoint went to medical school at Western University of Health Sciences in Pomona and is emergency medicine training at Upstate University Hospital. He trained as a fellow at the New York Poison Control Center at Bellevue Hospital. Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline. Western Journal of Emergency Medicine. 2018.

Today's episode is dedicated to PICU applications of lipid emulsion therapy. Join us as we discuss the patient case, symptoms, and treatment.  Joining us is Dr. Ziad N. Kazzi, Associate Professor of Emergency Medicine at Emory University School of Medicine, Director of the International Toxicology Fellowship Program at Emory, and Assistant Medical Director of the Georgia Poison Center. Dr. Kazzi is also a board member of the American College of Medical Toxicology and current president of the Middle East North Africa Toxicology Association.  https://www.dropbox.com/s/htbyhre5zictxke/Lipid%20Emulsion%20Therapy.jpg?dl=1 (>>Click here to download the PICU card for this episode

In this episode, Faith C. Quenzer, DO, emergency medicine research fellow at UC San Diego and past AAEM/RSA At-Large Director, and Molly Estes, MD FACEP FAAEM, Assistant Professor at Loma Linda University Medical Center and past YPS At-Large Board Member, speaks with Peter Akpunonu, MD FAAEM, Director or Medical Toxicology at University of Kentucky, Department of Emergency Medicine. Intro music by RogerThat, 'Uplifting Positive Corporate,' powered by JAMENDO.

In this episode, Faith C. Quenzer, DO, emergency medicine research fellow at UC San Diego and past AAEM/RSA At-Large Director, and Molly Estes, MD FACEP FAAEM, Assistant Professor at Loma Linda University Medical Center, WiEM Section Work Group Education Lead and AAEM Education Committee Member, speaks with Peter Akpunonu, MD FAAEM, Director or Medical Toxicology at University of Kentucky, Department of Emergency Medicine. Intro music by RogerThat, 'Uplifting Positive Corporate,' powered by JAMENDO.

Fascinating discussion with Dr. Marino about medical toxicology and what that means in terms of patients he diagnoses and treats, his frustration with misunderstandings and misinformation about drug addiction and his ongoing fight with the hashtag #WTFentanyl and as he indicates on his Twitter, he's frequently in a state of just WTF. This discussion really shines a light on the truth about drugs and his advocacy for patients with harm reduction measures to save lives.

Gillian Beauchamp, MD, was born in Tokyo, Japan and has also lived in Taipei, Hong Kong, Dubai, Edinburgh, Dublin, and in several US cities. She danced professionally with Dance Alloy, LabCo, and Dance Theatre of Ireland between 1992 and 2003. She trained as an emergency medical technician, is a nationally certified yoga instructor, and is a physician board certified in emergency medicine, medical toxicology, and addiction medicine. She is currently a member of the Medical Toxicology Fellowship and Emergency Medicine Residency faculty, as well as Assistant Director of Research in Medical Toxicology at Lehigh Valley Health Network Department of Emergency and Hospital Medicine, Division of Medical Toxicology, and an assistant professor and faculty member at University of South Florida Morsani College of Medicine. Dr. Beauchamp is also co-host of the podcast Tox in Ten. Listen in as we chat about growing up overseas, moving so much, family, acclimation, dancing professionally, emergency medicine, toxicology and addiction, Covid, travel, podcasting, and much more! Gillian can be reached at: Twitter- @gillianbchum Facebook- https://www.facebook.com/gillian.beau... Instagram- gbinstagram000 Podcast- Tox in Ten --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/ben-voegele7/support

Welcome home, listeners! Sit back, relax, and join Dan (@drusyniak) &Howard (@heshiegreshie) as they learn how to prevent scorpions from coming home, explore pharmacogenetics, and explore the incredible importance of mentorship, representation, diversity, and equality with Dr. Ayrn O'Connor (@MedToxPGx). Stay safe, wash your hands, physically distance, and wear a mask. Happy Holidays and Happy New Year! Delicious Links Just in case you move to Arizona, here are 5 Simple Ways to Deter Scorpions. Not my face! Some unusual locations for snakebites have been reported. Some information related to the business of Medical Toxicology, including billing and reimbursement for bedside toxicology practice, a medical toxicology admitting service or dedicated toxicology unit, the impact of a toxicology service on the ICU, or among inpatients discharged with a poisoning-related diagnosis, lessons learned and the impact of a specialty code on private practice. Women In Toxicology and the move Towards Gender Equality in Medical Toxicology. There is a beneficial impact of patient-physician racial concordance that impacts infant and maternal mortality, HIV care, cancer screening, provider visits and overall communication. Mentorship in the health professions, and doing it with intention. So now I'm a mentor, what's in it for me? Special Thanks Thank you for your continued support. We missed you and hope to provide more in 2021. As always, we are looking for feedback - comments, questions, suggestions, recipes, etc. Let us know. Reach us at @toxandhound. We want to hear from you! We love doing this podcast, and hope you do as well. If you like what you hear, maybe you'd like to buy us a cup of coffee! Thank you to our house band Pretty Simple Duo (@prettysimpleduo), now reincarnated as Bloomington Delta Music (@BloomDeltaMusic), our announcer Josh Shelov (@shelovj), and Reverend Matt Winston and High Priestess Amy Winston of Witness Protection Products. Ad at 27:23 . . . Acknowledgements Music "Funkorama" by Kevin MacLeod. License: CC BY. Sound effects from bbc.co.uk – © copyright BBC, and zapsplat.com. Do Infinite Good by Nick Fewings and We Have Coffee by Leon Bublitz both on unsplash.com. Interested in #FOAMtox? Like this podcast? Take a gander at The Tox and The Hound. It's like a podcast, but for your eyes. Listen on iTunes or Spotify! Earholes happy? Rate and review! Show the love!

December 24, 2020 — The synthetic opioid fentanyl is a huge problem in the US right now, according to Sheriff Matt Kendall, who sees some of the social effects first-hand. “It is the biggest problem,” he says, because fentanyl is so much cheaper than methamphetamine or heroin to make. “I believe there’s more fentanyl on the streets right now than heroin,” he added. “This is going to be the new epidemic.” It’s a scary substance. In 2018, the CDC, in partnership with the National Institute of Occupational Safety and Health, put out a video from police body cams that purported to show police officers in Virginia being accidentally exposed to fentanyl. Closer to home, the sheriff reported earlier this month that a deputy at the jail had accidentally been exposed to the drug while cleaning a cell where an inmate had suffered a severe overdose from fentanyl that had somehow been smuggled in. The deputy started feeling woozy, received a dose of Narcan, and was taken to the hospital for observation. He was wearing PPE, including a mask, gloves, and long sleeves. He was also wearing eyeglasses, but not protective goggles. Kendall says it’s impossible to be exposed to fentanyl through the skin, but he thinks the deputy may have been affected by powder that got into a cut on his skin, into his eyes, or by inhaling it. But Dr. Rachel Winograd, a clinical psychologist who works as an associate research professor at the University of Missouri St. Louis, the Missouri Institute of Mental Health, says that sounds impossible. Her work revolves around the role of opioids in what she and others in the field call “the worsening poisoning crisis.” She’s especially concerned with effective, equitable treatments for addiction. In August of this year, she led a team that researched and published an article on misinformation about the risks of accidental fentanyl contact. ”I suppose if you walked into a cloud of fentanyl dust in the air, then technically when you breathe it in, it would get into your system,” she conceded. But typically, getting affected by the drug requires something much more intentional. Users inject it, snort it, insert it rectally, or apply a fentanyl patch, which last is the most common legal use. Kendall says the substance that was found in the inmate’s cell, including on the bed sheets, had preliminary tests done on it before it was shipped off to the California Department of Justice for a full analysis, which has not come back yet. Any toxicology tests that may have been performed on the deputy would be privileged medical information. “You’ll notice that in all the anecdotal reports and accounts of first responders falling ill to overdose from incidental fentanyl exposure, there are zero reports of toxicology that match the anecdote,” Winograd says. “It’s not what’s happening. Something else might be happening, maybe more related to some panic, or nerves, fear, anxiety...but it’s not an overdose.” In a 2017 position paper on incidental fentanyl exposure to first responders, the American College of Medical Toxicology and the American Academy of Clinical Toxicology agree that “the risk of clinically significant exposure to emergency responders is extremely low.” The paper goes on to say that, while terrorists in Russia killed 125 people with a weaponized aerosolized carfentanil mixture, an unprotected individual exposed to “the highest airborne concentration encountered by workers” would require 200 minutes of such exposure to reach a dangerous dose. Absorption of liquid fentanyl does increase with broken skin. The paper cites a veterinarian who was quickly affected after being splashed in the eyes and mouth with a dart containing a mixture of carfentanil and xylazine, but says that facial contact with liquid or powder opioids is unlikely. Winograd’s team has started incorporating accurate information about the hazards of incidental exposure, or lack thereof, into a law enforcement training program. She says lives could be on the line. “By the end of our training, we had pretty overwhelming results that we were able to bust this myth in the minds of those who attended our trainings,” she reported. “And the idea there, why that matters, is that if first responders are really scared that they are going to overdose themselves, or put themselves in harm’s way when they go to save someone’s life from an overdose, then that’s going to deter them from doing it...or it will at least slow them down if they feel like they need to put on a bunch of protective equipment...if you take an extra two minutes to don a bunch of PPE, that could cost someone their life.”

Episode 29: OSA with Clau The sun rises over the San Joaquin Valley, California, today is September 25, 2020.As allopathic doctors, medications are our most potent tools to fight and prevent diseases. Today, we want to remind everyone about substance abuse and give you an update on a procoagulant agent. Substance abuse is a growing problem. Due to increased stress, anxiety, depression, and unemployment, drug abuse is on the rise during the current pandemic[1]. Some medications may not be considered a “drug of abuse” when prescribed alone, but they can be combined with other medications to cause a potentially addictive effect. Such is the case of promethazine[2,3], which is usually combined with codeine, dextromethorphan and  expectorants for cough. Promethazine is also used as an antiemetic, for procedural sedation, and for allergic reactions. Promethazine-containing products are abused for their sedative effects. Specifically, when promethazine is combined with opioids, it potentiates euphoria, alleviates withdrawal symptoms and relieves opioid-induced nausea. So, be aware of drugs that can potentially be misused or abused, even when they are not scheduled. Other examples include quetiapine, baclofen, gabapentin, fluoxetine, and more. Examples of OTC medications that can also be misused are diphenhydramine and loperamide.Now, let’s talk briefly about tranexamic acid. You may remember this medication as a treatment for menorrhagia, and to control bleeding in general. UptoDate stated in December 2019 that this medication is now recommended in patients with moderate Traumatic Brain Injury (TBI) presenting within 3 hours of the event[4]. Interestingly, tranexamic acid is a potent neurotoxin with a mortality rate of 50%, but ONLY when given accidentally via intraspinal route. Remember, it’s safe IV and oral, but NOT intraspinal. Survivors of intraspinal injection often experience seizures, permanent neurological injury, ventricular fibrillation, and paraplegia. Container mix-ups were involved in 3 recent cases[5]. So, this is why checking medication labels is critical._____________________________This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. “A life without a cause is a life without effect.” ― Paulo CoelhoThink about your purpose in life, what motivates you? Where do you want to be? Start now to direct your life to get you where you want to be. Claudia Carranza is here with us today, a Wednesday after didactics to discuss another topicWho are you? My name is Claudia Carranza; you might recognize my voice from the “Espanish word of the week”, I am a PGY3 resident in our Rio Bravo Family Medicine residency program. I am married to an internal medicine resident, we have 2 dogs and they keep us really busy going to the dog park, long walks and jogging.  What did you learn this week? This week I learned about obstructive sleep apnea (OSA). I actually had a patient recently with obstructive sleep apnea which persisted despite prior tonsillectomy. I also learned that obstructive sleep apnea in children can present with symptoms similar to ADHD. I thought, I definitely need to read more about management and I would like to focus mostly on pediatrics.  A lot of patients ask me: what is obstructive sleep apnea? And I would tell them in my own words that “it’s a condition in which something blocks your upper airway and it makes you sometimes snore and wake up multiple times at night because you are unable to breath”. A fancier definition is “a complete or partial upper airway obstruction which can result in gas exchange abnormalities”.  This doesn’t sound very pleasant and patients won’t necessarily come to you complaining that they are waking up at night. Instead, it can be presented to you as different complaints such as snoring, daytime sleepiness with car rides or at school, nocturnal enuresis, and in particular in children it can manifest as inattention, learning problems, hyperactivity, impulsivity, rebelliousness and even aggression. But wait; these last few symptoms sound a lot like attention deficit hyperactivity disorder or ADHD.  So here where SCREENING becomes very important, and usually you will ask your patient or their parent: does your child snore? More often than not the parents will know; sometimes I have even had a patient’s brother or sister in the room who says: “yes he/she snores!” Another part of your yearly check-ups will be looking at the oropharynx and you will see whether the patient has enlarged tonsils. Remember: not everyone who snores will have enlarged tonsils and not everyone who has enlarged tonsils will snore.  But any child who snores 3 or more nights per week, has loud snoring and has pauses in breathing should undergo a full diagnostic evaluation for Obstructive Sleep Apnea. Once you OSA has been diagnosed and treated it is still important to monitor children as they can have residual symptoms or recurrence. Look out for weight gain.  Question number 3: Why is that knowledge important for you and your patients? Not only can undiagnosed OSA lead to sometimes unnecessary ADHD treatment but it can also lead to failure to thrive if OSA is severe; cardiopulmonary problems including ventricular dysfunction, systemic HTN, endothelial dysfunction. It has also been associated to a lesser degree with pulmonary HTN.  Now that we know how serious OSA can be and that you need to order a full work up when it is suspected I want to quickly go over the next steps in clinic:Focused sleep history and physical exam including detailed oropharynx exam, close attention to blood pressure, BMI, craniofacial abnormalities, shape of mouth/palate/jaw and size of tonguePolysomnography (PSG) or referral to a specialist such as ENT or sleep medicine for further evaluation and treatment For those of us in Family medicine, treating adult patients, keep in mind that children and adults have different risk factors to look out for: Risk factors of pediatrics sleep apnea in children: Adenotonsillar hypertrophy and obesity (in otherwise healthy children). If OSA appears in infancy the child likely has anatomic or genetic abnormality. Risk factors of OSA in adults: older age, male sex, obesity, craniofacial and upper airway abnormalities (short mandibular size, wide craniofacial base and tonsillar and adenoid hypertrophy. How did you get that knowledge? I think the more patients I see the more knowledge I accumulate and it comes from a combination of sources like my attendings, UptoDate and my fellow residents. Where did that knowledge come from?I read Uptodate, and article from Thorax titled “Ambulatory blood pressure in children with obstructive sleep apnoea: a community based study” Tal et al, which showed that children with OSA had significant elevation in BP both while sleeping and awake. Also, “Diagnosis and management of childhood obstructive sleep apnea syndrome” published on Pediatrics. _______________________________Speaking Medical: Adventitious Breath Soundsby Xeng Xai Xiong, MS3Hey, what’s cooking?  Did you hear that? It was the sound of bacon sizzling in the fresh cozy morning. Now, this is the sound of the sound of fine crackles coming from the lungs.  I’m not sure whether hearing sizzling bacon reminds me of fine crackles of the lungs [delete repeated sentence] or fine crackles of the lungs remind me of bacon. Either way, you would agree that bacon tastes good.  I am getting too carried away with this now so I’m going to jump straight to the point. As a medical student, it was intimidating to differentiate the different lung sounds. Maybe I need an ear check, or maybe I haven’t listened to enough lungs. The latter sounds more probable since the first two years of medical school was spent listening to standardized patients' lungs.  Today, I’m going to share with you four of the most common abnormal lung sounds. But before we talk about the abnormal, let’s review the vesicular breath sound, which is the normal breath sound, just in case you forgot about it: https://www.youtube.com/watch?v=VtnMRG0ORLs Wheezing is a high-pitched whistling noise that can happen on inspiration or expiration. It’s usually a sign that something is making your airways narrow or keeping air from flowing through them. Although there can be many things that cause wheezing, two of the most common causes are chronic obstructive pulmonary disease and asthma. Here is a sound bite of expiratory wheezing: 1:50-1:57 https://www.youtube.com/watch?v=KRtAqeEGq2Q Stridor is a harsh, noisy, squeaking sound that happens with every breath. It can be high or low, and it’s usually a sign that something is blocking your airways. It can be heard in laryngomalacia, croup, and more. Here is an example of stridor: 3:03-3:11 https://www.youtube.com/watch?v=KRtAqeEGq2Q. Crackles (rales) is a series of short, explosive sounds. They can also sound like bubbling, rattling, or clicking. You can have fine crackles, which are shorter and higher in pitch, or coarse crackles, which are lower. Either can be a sign that there’s fluid in the air sacs. Here is the sound of a course crackling (0:55-1:01 https://www.youtube.com/watch?v=KRtAqeEGq2Q). Here are fine crackles (1:08-1:15) Rhonchi is a low-pitched wheezing sounds sound like snoring and usually happen when you breathe out. They can be a sign that your bronchial tubes are thickening because of mucus. Rhonchi sounds can be a sign of bronchitis or COPD. Here is the sound of rhonchi (2:35-2:43). For your undivided attention, here is a bonus lung sound (silent for 3 seconds). Yep, that was an absent lung sound; it can mean air or fluid in or around the lungs such as pleural effusion or pneumothorax. Lung sounds can be intimidating at first, but they can be easily differentiated if you spend some time to study them. That’s it for now hasta la vista baby.____________________________Espanish Por Favor: Dormir by Claudia CarranzaThis is Dr Carranza again bringing you the “Espanish word of the week”. This week’s word is “Dormir”. Dormir is one of our favorite activities, especially when we are tired; for any residents out there “Dormir” must sound very appealing, especially after a long shift. “Dormir” comes from the latin word “dormire” which means Sleep or rest.  Since we just talked about sleep apnea, one important question you can ask your patient is “ senor, puede DORMIR bien en la noche” which means “ sir, do you sleep well at night?”.  A different question you can ask is “Señor, ¿tiene problemas para DORMIR?” which means, “sir, do you have difficulty sleeping?”. Also remember that if you want to ask about their child you can replace the “señor” with “su niño”. Now you know the Spanish work of the week “DORMIR.” Have a great weekend!____________________________For your Sanity: Define mittleschmerzby Dr Steven Saito and Dr Sally WonderlyDr Three pregnant women were waiting in the doctor’s waiting room for an antenatal check-up and were all knitting garments for their respective babies.Suddenly the first expectant mother stops knitting, checks her watch, pulls a bottle of pills from her handbag and takes one."What was that?", the other two ask, curiously."Calcium tablet. Good for mommy, good for baby", she replies, patting her stomach affectionately.Satisfied, all three continue with their knitting. Five minutes later, the second one stops knitting, checks her watch, takes a bottle of pills from her handbag and takes one."What was that?", the other two enquire."Vitamin tablet", she replies, “Good for mommy, good for baby" and she pats her stomach affectionately.All three smile and continue busily with their knitting. Five minutes later, the last woman stops knitting, checks her watch, takes a bottle of pills from her handbag and takes one."What was that?" ask the other two."Thalidomide. I can’t knit sleeves." Dr Arreaza: Thalidomide was a teratogenic medication linked to phocomelia, or congenital malformation of the limbs)Dr Wonderly: Listen up! Today we have a gift for those who believe that learning is not only fun, but can also bring rewards. Yes, this time we want to reward the listener who sends the most creative definition of mittleschmerz. Yes, mittleschmerz is used in English too. Your definition of mittleschmerz will be used in our next episode of Rio Bravo qWeek. Type your definition of mittleschmerz, keep it brief and interesting, maybe 1 or 2 paragraphs, and send it to rbresidency@clinicasierravista.org ASAP. Looking for your five minutes of fame? Well, you can also record your definition of mittleschmerz for our next episode. Don’t send an audio, let us know if you want to record it and we will give you a call. ___________________________________Now we conclude our episode number 29 “OSA with Clau.” Dr Carranza reminded us to think about Obstructive Sleep Apnea in kids as part of the work up of ADHD. Xeng eloquently explained the four most common adventitious breath sounds, and reminded us that crackles may sound like sizzling bacon. Claudia then explained what you want to do after your night shift, dormir, which means sleep. Don’t forget our contest. Send your definition of mittleschmerz to rbresidency@clinicasierravista.org, and if you want to record it, we’ll give you a call.Conclusion: Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Golriz Asefi, Claudia Carranza, Mariel Chan, Xeng Xiong, Sally Wonderly and Steven Saito. Audio by Suraj Amrutia. See you next week! _____________________References:Sparkman, David, Drug Abuse on the Rise Because of COVID-19, EHS Today, August 29, 2020, https://www.ehstoday.com/covid19/article/21139889/drug-abuse-on-the-rise-because-of-the-coronavirus Promethazine Abuse: A Growing Problem? Tox Tid Bits, Maryland Poison Center, University of Maryland School of Pharmacy, March 2017, https://www.mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2017/March%202017%20ToxTidbits.pdf Klein-Schwartz, Wendy, PharmD, MPH, et al, Abuse of Nonscheduled Medications and Nonprescription Drugs, American College of Medical Toxicology, Online Library, https://www.acmt.net/_Library/2019_Israeli_Conference/Non-prescription_-_Klein.pdf Eichler, April F, MD, MPH, and Sadhna R Vora, MD, Practice Changing UpDates, Up to Date, https://www.uptodate.com/contents/practice-changing-updates, Last updated: Sep 09, 2020. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial, The Lancet, Vol 394, Issue 10210, P1713-1723, November 09, 2019, Open Access Published: October 14, 2019, DOI: https://doi.org/10.1016/S0140-6736(19)32233-0   National Alert Network, Dangerous wrong-route errors with tranexamic acid,  https://www.ismp.org/sites/default/files/attachments/2020-09/NAN%20Alert%2020200909.pdf, accessed on Sep 24, 2020. Paruthi, Shalini, MD, et al, Evaluation of suspected obstructive sleep apnea in children, UptoDate, Last updated: Mar 19, 2020, https://www.uptodate.com/contents/evaluation-of-suspected-obstructive-sleep-apnea-in-children?search=osa%20children&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2 Li AM, Au CT, Sung RYT, et al, Ambulatory blood pressure in children with obstructive sleep apnoea: a community based study, Thorax 2008;63:803-809. https://thorax.bmj.com/content/63/9/803 Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome, Pediatrics April 2002, 109 (4) 704-712; https://pediatrics.aappublications.org/content/109/4/704 Robinson, Jennifer, MD, “Lung Sounds: What Do They Mean?” WebMD Medical Reference, reviewed on June 12, 2020, https://www.webmd.com/lung/lung-sounds, accessed on Sep 16, 2020.  Audio of sizzling bacon, courtesy of http://www.texashighdef.net, courtesy of yogaduke YouTube Channel, https://www.youtube.com/watch?v=e-5GirZe_jY Audio of lung sounds, courtesy of EMTPrep YouTube Channel: https://www.youtube.com/watch?v=KRtAqeEGq2Q  

Is the detox of all detoxes really a detox that you want?This mouthful is exactly what you need to ponder when using activated charcoal. The compound — which is used in hospitals when people overdose on certain drugs — has risen to popularity. It became a hot nutritional fad in the LA restaurant scene a few years ago, and it’s picked up momentum ever since. Some claim it’s the ultimate detox. Others say it will improve general health. And, even the beauty industry has joined in, as it’s commonly touted as an effective “teeth-whitener.”In this episode of That’s Healthy, Right?, we’ll look at the clinical uses of activated charcoal, the negative side effects of long-term use, and a study that proves all you’re doing for your teeth is brushing them with the stuff from the grill.To ask a question, read the transcript, or learn more, visit bornfitness.com/thats-healthy-right.Don’t forget to Subscribe to the show, and Rate or Review wherever you tune in!Resources:Is Activated Charcoal Healthy for You? — Born FitnessActivated charcoal for acute overdose: a reappraisal — British Journal of Clinical PharmacologyOral activated charcoal in the treatment of intoxications. Role of single and repeated doses — Medical Toxicology and Adverse Drug ExperienceWhitening toothpaste containing activated charcoal, blue covarine, hydrogen peroxide or microbeads: which one is the most effective? — Journal of Applied Oral ScienceCharcoal and charcoal-based dentifrices: A literature review — Journal of the American Dental Association Position paper: Single-dose activated charcoal — Clinical ToxicologyActivated Charcoal for Acute Poisoning: One Toxicologist’s Journey — Journal of Medical Toxicology New York City Department Of Health Bans Black Foods That Contain Activated Charcoal — Tech TimesThe Hype Machine: Do Detoxes Really Work? — Born Fitness

EMM would like to extend a large thank you to the Pain Management and Addiction Medicine section of the American College of Emergency Physicians for allowing us to post their webinar panel discussion facilitated by EMM’s own Don Stader, MD, FACEP on Buprenorphine use after Naloxone. This episode discusses the nuances of emergency physicians inducing patients on Buprenorphine following an opioid overdose and covers key considerations including dosing, precipitated withdrawal and contraindications to Buprenorphine administration.   Panelists include: Rachel Haroz, MD - EM physician boarded in Medical Toxicology and Addiction working in Camden, NJ Andrew Herring, MD - EM physician boarded in Pain and Addiction working in Oakland, CA and leads California’s Bridge program that helps hospitals start Buprenorphine programs  Eric Ketcham, MD, FACEP - EM physician who is a cofounder and chair of ACEP’s Pain Management and Addiction Medicine section working in New Mexico            

Dr. Chris Hoyte is an ED physician, toxicologist and researcher based in Denver, CO. He was featured in Bring Em’ All: Chaos. Care. Stories from Medicine’s Front Line, a book celebrating emergency physicians through personal testimonies and photography on the frontlines captured by legendary photographer, Eugene RIchards.    Time Stamps: 01:25 - Dr. Hoyte’s Origin Story 05:01 - What Drew Dr. Hoyte to Medical Toxicology? 08:22 - Dr. Hoyte’s Most Interesting Toxicology Cases 08:52 - King Cobra Bite 13:31 - Verapamil Overdose 16:47 - Mass Cyanide Poisoning 19:16 - The Looming Threat of Biological Warfare and the Need for Emergency Preparedness 25:07 - How COVID-19 Affected Dr. Hoyte’s Job as a Toxicologist 30:19 - How Does the Rocky Mountain Poison and Drug Center Handle Its Large Workload 35:56 - Cannabinoid Exposures 42:05 - The Future of Toxicology   Publications from Dr. Hoyte: A Characterization of Synthetic Cannabinoid Exposures Reported to the National Poison Data System in 2010 https://pubmed.ncbi.nlm.nih.gov/22575211/ An Outbreak of Exposure to a Novel Synthetic Cannabinoid https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3983965/ The Continued Impact of Marijuana Legalization on Unintentional Pediatric Exposures in Colorado https://pubmed.ncbi.nlm.nih.gov/30288992/ Pediatric Death Due to Myocarditis After Exposure to Cannabis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965161/ Anaphylaxis to Black Widow Spider Antivenom https://pubmed.ncbi.nlm.nih.gov/21641165/ Intro Music: Backbay Lounge Kevin MacLeod (incompetech.com) Licensed under Creative Commons: By Attribution 3.0 License http://creativecommons.org/licenses/by/3.0/  

In this episode Dr. Gillian Beauchamp sits down with Dr. Kavita Babu to discuss incorporating medico-legal consultation into your medical toxicology practice. 

"If people have the right to spread disinformation on social media, then it's equally my right to spread information" Dr. Ryan Marino is a medical Toxicologist and a power voice against medical disinformation on social media. We discuss the multiple roles a toxicologist plays, the battle against "detox" products, & pushing back against false narratives on social media. Ryan is outstanding at this work, there is much to learn from him. #DoctorsSpeakUp Please subscribe and rate Explore The Space on Apple Podcasts or wherever you download podcasts. Email feedback or ideas to mark@explorethespaceshow.com Follow on Twitter @ETSshow, Instagram @explorethespaceshow Key Learnings 1. Managing "the poisoned patient" as a medical Toxicologist 2. The wonder of Poison Control 3. What makes up bread and butter clinical toxicology 4. Engaging with the public as a toxicologist and the level of understanding 5. The insidious way "toxins" have infiltrated public discourse 6. What techniques has Ryan found helpful in discussing vaccines with people who are hesitant and what to avoid 7. Why Ryan is so committed to pushing back against false narratives on Twitter 8. Recognizing that changing one mind and impacting one person's behavior is a tremendous victory Links Twitter @ryanmarino American College of Medical Toxicology website #toxicology, #poison, #poisoncontrol, #detox, #toxin, #vaccine, #vaccines, #vaping, #fentanyl, #podcast, #podcasting, #healthcare, #digitalhealth, #health, #leadership, #mentorship, #coaching, #FOAmed, #doctor, #nurse, #meded, #education, #hospital, #hospitalist, #innovation, #innovate, #medicalstudent, #medicalschool, #resident, #physician

In this episode, Hank and Michael speak with Dr. Joseph D'Orazio. Board certified in Emergency Medicine, Medical Toxicology, and Addiction Medicine - he is an expert on the current Opioid Epidemic. We discuss why he thinks the opioid crisis is so prevalent today, possible ways to combat it – and the right ways for physicians to prescribe opioids in the first place. We also talk about the language and proper terminology surrounding substance use disorder. Finally, we discuss what we can all be doing to help.(Note: this episode was recorded on September 17, 2019)Instagram: @narrativesofnorthbroadTwitter: @NarrativesofNB

Course: Vaping Related Lung Injury Course Director: Tony R Tarchichi M.D.  - Assistant Professor in Dept of Pediatrics Course Director: Joshua Shulman M.D. Assistant Professor in the Dept of Pediatrics Emergency, Division of Medical Toxicology  Disclosures: None This Podcast series was created for Pediatric Hospitalists or those healthcare professionals who take care of hospitalized children.  This episode is Vaping Related Lung Injury. As always there is free CME credit of up to 1 AMA category 1 for listening to this podcast and going to the Univ of Pitt site. See the link below.  ______________________________________________________ Objectives: Upon completion of this activity, participants will be able to: Review the Epidemiology of Vaping Related Lung Injury Review the presentation and workup for patients with Vaping Related Lung Injury Review the treatments for patients with Vaping Related Lung Injury ______________________________________________________ Released:  12/31/2019, Reviewed 12/31/2019, Expire: 12/31/2020 If you are new to the Internet-based Studies in Education and Research (ISER) website (which is how you will get your CME credit), you will first need to create an account: Step 1. Create an Account https://www.hsconnect.pitt.edu/HSC/home/create-account.do If you have used the ISER website in the past, you can click on the link below and then log onto in order to complete the evaluation for this training: Step 2. To access the test for CME credit: https://cme.hs.pitt.edu/ISER/app/learner/loadModule?moduleId=21233 Accreditation Statement: The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The University of Pittsburgh School of Medicine designates this enduring material for a maximum of  (1)  AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Taking innovative approaches and scaling them to a large healthcare setting For the show notes, full transcript, links, and resources please visit us at show link: https://bit.ly/2HqkE6Z

Objectives: Outline the scope of the opioid epidemic as it relates to Emergency Medicine Detail innovative treatment options for opioid use disorder and overdose Discuss strategies and barriers to implementing ED-based Medication for Opioid Use Disorder (MOUD) Provide possible future strategies and necessary policy changes   Take-home points:  Opioid use disorder is a disease that is often chronic and relapsing Prescribing buprenorphine is easy and it only takes one person to start doing it. See the show notes for resources to help.  It’s helpful to have a champion for OUD treatment in the ED. The medical director is well positioned for this.  Find a community champion who can help continue treatment outside of the ED Stigma affects both providers and patients. Learn your terms and try to be consistent with their use: opioid use disorder (OUD), Medication for Addiction Therapy (MAT), and Medication for Opioid Use Disorder (MOUD).  Treatment for OUD can be with naltrexone, methadone, and buprenorphine. Buprenorphine is a partial opioid agonist and the best-suited for ED treatment.  You can use the COWS score to assess your patients for opioid withdrawal.   Outside resources:  Emergency Department Contribution to the Prescription Opioid Epidemic https://www.ncbi.nlm.nih.gov/pubmed/29373155 What Role Has Emergency Medicine Played in theOpioid Epidemic: Partner in Crime or Canary in theCoal Mine? https://www.annemergmed.com/article/S0196-0644(18)30046-5/pdf ACEP opioid resources https://www.acep.org/by-medical-focus/mental-health--substance-abuse/opioids/#sm.0001e74hrth2sdxcqs82pd3l195ch Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial https://www.ncbi.nlm.nih.gov/pubmed/25919527   Resources that support medication-based treatment in the ED https://medicine.yale.edu/edbup/ https://www.bridgetotreatment.org/   Contributors: John Purakal Maureen Gang Caleb Scarth Nate Coggins Guests: Gail D’Onofrio, MD, MS, is the chair of emergency medicine at Yale Medicine. She is internationally known for her work in substance use disorders, women’s cardiovascular health, and mentoring physician scientists in developing independent research careers. For the past 25 years she has developed and tested interventions for alcohol, opioids and other substance use disorders, serving as the principal investigator (PI) on several large NIH, SAMSHA, and CDC studies. She is a founding Board member of Addiction Medicine, now recognized as a new specialty, subspecialty by the American Board of Medical Specialties. Lewis Nelson, MD, is Professor and Chair of the Department of Emergency Medicine and Chief of the Division of Medical Toxicology at Rutgers New Jersey Medical School in Newark, NJ. He is a member of the Board of Directors of the American Board of Emergency Medicine and a Past-President of the American College of Medical Toxicology. He is actively involved with several governmental and professional organizations and is an editor of Goldfrank’s Toxicologic Emergencies. His areas of specific interest include consequences of opioids, pain management, and emerging drugs of abuse.

Drs. Teran and Abella discuss the role of TTM for patients following cardiac arrest caused by opioid overdose. Several recent observational studies are reviewed to understand the demographics of patients who suffer opioid-related cardiac arrest, their outcomes, and whether TTM may be beneficial during post-arrest for these patients.   Key readings: Salcido DD et al, “Regional incidence and outcome of out-of-hospital cardiac arrest associated with overdose.” Resuscitation 2016; 99:13-19.http://dx.doi.org/10.1016/j.resuscitation.2015.11.010 Katz AZ et al, “Outcomes of patients resuscitated from cardiac arrest in the setting of drug overdose.” Resuscitation 2015; 94:23-27.http://dx.doi.org/10.1016/j.resuscitation.2015.06.015 Khan S et al, “Impact of Targeted Temperature Management on ED Patients with Drug Overdose–Related Cardiac Arrest.”, Journal of Medical Toxicology 2019; 15:22–29. https://doi.org/10.1007/s13181-018-0686-0

A conversation with Michael Ganetsky, MD to discuss Opioid Management. Dr. Ganetsky is the Director of the Division of Medical Toxicology at the Beth Israel Deaconess Medical Center and core faculty of Emergency Medicine Residency and Harvard Medical Toxicology fellowships. He also teaches medical toxicology to undergraduate medical students.

In this episode, we discuss toxicology in the ICU. This is part one of a two-part series. Today’s episode will focus on an overview of toxic ingestions and their general management. Our guest is Dr. Jerrold B. Leikin. Dr. Leikin is the Director of Medical Toxicology at North Shore University Health System-OMEGA, which includes several hospitals in Illinois. In addition, he is a Clinical Professor of Medicine at the Pritzker School of Medicine (University of Chicago) and Professor of Medicine and Pharmacology at Rush Medical College. Additional Links: American Association of Poison Control Centers Website: https://aapcc.org/ A three-part review series published in CHEST on Toxicology in the ICU. Part 1: https://bit.ly/2OhO2k5 Part 2: https://bit.ly/2UuLQY1 Part 3: https://bit.ly/2OiGM7A Books and Albums Mentioned in This Episode: Pops: A Life of Louis Armstrong by Terry Teachout: https://amzn.to/2IBYB1w Louis Armstrong: An Extravagant Life by Laurence Bergreen: https://amzn.to/2PnkvWC Complete Hot Five & Hot Seven Recordings 2 by Louis Armstrong: https://amzn.to/2Vjvbep

In this episode, we discuss Toxicology in the ICU. This is part two of a two-part series. Today’s episode will focus on specific toxic ingestions and their management. Our guest is Dr. Jerrold B. Leikin. Dr. Leikin is the Director of Medical Toxicology at North Shore University Health System-OMEGA, which includes several hospitals in Illinois. In addition, he is a Clinical Professor of Medicine at the Pritzker School of Medicine (University of Chicago) and Professor of Medicine and Pharmacology at Rush Medical College. Additional Links: American Association of Poison Control Centers Website: https://aapcc.org/ A three-part review series published in CHEST on Toxicology in the ICU. Part 1: https://bit.ly/2OhO2k5 Part 2: https://bit.ly/2UuLQY1 Part 3: https://bit.ly/2OiGM7A Albums Mentioned in this Episode: Live at the BBCby The Beatles: https://amzn.to/2vIrX5M

How is your workplace impacted by employees with medical issues that impact their ability to be at work, stay at work and perform the work? What about these questions that plagued employers on a daily basis? • Developing a workers' compensation ecosystem where employers, injured workers, providers, and insurers can thrive with mutual cooperation. • Marijuana and the workplace: A framework on how to approach workplace drug use policies when marijuana laws across the country are rapidly changing. • Fraud in the Workers' comp: A doctor's perspective. • What to do about Vaping in and around the workplace: Who is impacted and how do we manage this new evolution? • Are we a Narcotic Nation? Solutions to America's opioid addiction. Join me, Dr. Debra Dupree, The Mindset Doctor, as we explore the workplace world where laws are a changing with the insight and medical expertise from one of the best . Dr. Browning received his MD degree from the University of Texas Medical School at San Antonio, his Master of Public Health degree from the Medical College of Wisconsin, and his Master of Business Administration degree from San Diego State University. He is Board Certified in Emergency Medicine and fellowship trained in Medical Toxicology. Dr. Browning has over 25 years of experience in Occupational Medicine and is the Chief Medical Officer for WorkPartners Occupational Health Specialists. He has numerous peer-reviewed publications in the fields of Occupational Medicine, Emergency Medicine, and Toxicology. Want more? Join us on May 16 at ELEVATE! For more information, visit EVENTS at https://relationships-at-work.com orwww.WorkPartnersOHS.com/ELEVATE on how to register.

 Host: CCNY President Vincent Boudreau   Guests: Dr. Howard Greller, Director of Research and Medical Toxicology, Emergency Department, at St. Barnabas Hospital Health Systems and a Medical Professor in the Department of Clinical Medicine at the CUNY School of Medicine at City College;   Nancy Sohler, Associate Medical Professor at the CUNY School of Medicine at City College;   John Palmer, PhD, Director of Community Affairs and Diversity at Touro College of Osteopathic Medicine and Chair of the Health Committee of the Greater Harlem Chamber of Commerce   Recorded: January 23, 2019 

 Host: CCNY President Vincent Boudreau   Guests: Dr. Howard Greller, Director of Research and Medical Toxicology, Emergency Department, at St. Barnabas Hospital Health Systems and a Medical Professor in the Department of Clinical Medicine at the CUNY School of Medicine at City College;   Nancy Sohler, Associate Medical Professor at the CUNY School of Medicine at City College;   John Palmer, PhD, Director of Community Affairs and Diversity at Touro College of Osteopathic Medicine and Chair of the Health Committee of the Greater Harlem Chamber of Commerce   Recorded: January 23, 2019 

Author: Katie Sprinkle, MD Educational Pearls: Medication Assisted Treatment (MAT) is the treatment of addiction with medications, commonly used for opioid use disorders A long held belief is MAT simply replaces one addiction for another, which is patently false MAT is one of the most affective methods to treat a patient with opioid addiction Unfortunately, outdated requirements for prescribers along further prevent its widespread use References: Salsitz E, Wiegand T. Pharmacotherapy of Opioid Addiction: “Putting a Real Face on a False Demon.” Journal of Medical Toxicology. 2016;12(1):58-63. doi:10.1007/s13181-015-0517-5. Duber HC, Barata IA, Cioè-Peña E, Liang SY, Ketcham E, Macias-Konstantopoulos W, Ryan SA, Stavros M, Whiteside LK. Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):420-431. doi: 10.1016/j.annemergmed.2018.04.007. Epub 2018 Jun 5. Review. PubMed PMID: 29880438. Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

Bibliography Implications of the New Centers for Disease Control and Prevention Blood Lead Reference Value Mackenzie S. Burns, MPH American Journal of Public Health Association of Childhood Blood Lead Levels with Cognitive Function and Socioeconomic Status at Age 38 Years and with IQ Change and Socioeconomic Mobility Between and Childhood and Adulthood Aaron Reuben, MEM JAMA, 2017 The Effect of Chelation Therapy with Succimer on Neuropsychological Development in Children Exposed to Lead Walter J. Rogan, MD New England Journal of Medicine (2001) Vol. 344, No. 19 The Scientific Basis for Chelation: Animal Studies and Lead Chelation Donald Smith Journal of Medical Toxicology, 2013 A comparison of sodium calcium edetate (edetate calcium disordium) and Succimer (DMSA) in the treatment of inorganic lead poisoning Sally Bradberry Clinical Toxicology, 2009

Jeff:  Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta and we’ll be taking you through the September 2018 issue of Emergency Medicine Practice - Emergency Department Management of North American Snake envenomations. Nachi: Although this isn’t something we encountered too frequently – it does seem like I’ve been hearing more about snake bites in the recent months. Jeff: I actually flew someone just the other day because the local ED ran out of CroFab after an envenomation in Western PA. Nachi: Yeah, this is definitely more than “just a boards topic,” and it’s really important to know about in those rare circumstances. In terms of incidence, there are actually about 10,000 ED visits in the US for snake bites each year, and 1/3 of these involve venomous species. Jeff:  That’s a good teaser, so let’s start by recognizing this month’s team – the two authors, Dr. Sheikh, a medical toxicologist, and Patrick Leffers, a pharmD, and emergency medicine and clinical toxicology fellow. Both are at the University of Florida Jacksonville, and they reviewed a total of 120 articles from 2006-2017, in addition to reviews from both Cochrane and Dare. Nachi: And don’t forget our peer reviewers this month, Dr. Daniel Sessions, a medical toxicologist working at the South Texas Poison Center, and our very own editor-in-chief, Dr. Andy Jagoda, who is also Chair of the Department of Emergency Medicine at Mount Sinai in New York City. Jeff: What a team! But, let’s get back to the snakes. As some background, from 2006-2015 there were almost 66,000 reported snake exposures and 31 deaths from snake envenomation in the US.  Of course, this number likely underestimates the true total. Nachi: And there are two key subfamilies of venomous snakes to be aware of – the Crotalinae – or pit vipers – which includes rattlesnakes, copperheads, and water moccasins; and the Elapidae – of which you really only need to know about the coral snake. Jeff:  And while those are the only two NATIVE snake subfamilies to be acutely aware of, don’t forget that exotic snakes, which are shockingly popular pets -- they can also cause significant morbidity and mortality. Nachi:  Oh, and one other quick note before we get into the epidemiology – most of the recommendations this month come from expert opinion, as high quality RCTs are obviously difficult.  In addition, many of the studies were based in other countries, where the snakes, the anti-venoms and their availability, and the general healthcare systems are different from those that most of us work in. Jeff:  Unless we have listeners abroad? Do we have listeners in other countries? Nachi: Oh we definitely do... but we are going to be a bit biased towards US envenomation today. In any case, venomous snake bites occur most frequently in men aged 18 to 49 during warmer months with provoked bites occurring more frequently in the upper extremities and unprovoked bites in the lower extremities. Jeff:  In one study of poison center data from the last decade, nearly half of all victims of snake bites were victims of unknown type snakes.  However, of those that were known, copperheads were the most common, while rattlesnakes caused the most fatalities – 19 of 31 in this dataset. Nachi:  In a separate study of snake bites in the early 2000s, 32% of exposures were from venomous snakes and 59% of those resulted in admission. That’s remarkably high. Jeff:  Snake bite severity depends on several key factors: the amount of venom, the composition of the venom, the body size of the bite victim, the victim's clothing, the size of the bite, comorbid conditions, and the timing and quality of medical care the victim receives. Nachi:  To be a bit more specific - First, the amount of venom will depend on the species of snake, with variations even occurring within the same species.  Secondly, while there is a correlation between rattlesnake size and bite severity, there is much more at play.  Some snakes can even vary the amount of venom based on threat risk – with defensive bites having different profiles than bites to strike prey. Jeff: I found it pretty interesting that  an estimated 10-25% of pit viper bites are considered dry bites, that is, ones in which no venom is released. Nachi:  Right, this is just one reason why all victims shouldn’t immediately get anti-venom, but we’ll get there. Jeff:  We definitely will.  As we already stated – venom composition varies greatly.  Pit vipers produce a predominantly hemotoxic venom.  Systemic effects include tachycardia, tachypnea, hypotension, nausea, vomiting, weakness, and diaphoresis.  Neurotoxicity is rare and is usually due to inter-breeding between species. Nachi:  While rattlesnake bites are associated with higher morbidity and mortality, the more common copperhead bites typically only cause local tissue effects.  More serious systemic findings such as coagulopathy and respiratory failure have been reported though. Jeff:  So that’s a solid background to get us started.  Let’s talk about the individual snakes.  Why don’t you start with the crotalinae family – aka the pit vipers. Nachi:  Sure – the crotalinae includes rattlesnakes, cottonmouths (also known as water moccasins), and copperheads.  These make up the vast majority of reports to the poison centers.  They can be identified by their heat sensing pits located behind their nostrils (hence pit vipers).  As a general rule, you can also identify the venomous snakes by their triangular or spade-like head, elliptical pupils, and hollow retractable fangs. Jeff:  wait, so you want me to walk up to the snake and ask to see if their fangs retract… yea, no thanks. Nachi: Haha, of course not, I’m just giving you some of the general principles here. In contrast, non-venomous pit vipers have rounded heads, round pupils, a double row of vertical scales, and they lack fangs. Jeff: In terms of location, rattlesnakes are found in all states but Hawaii, and cottonmouths and copperheads are distributed mostly throughout the southern and southeastern states, with copperheads also extending further north, even into Massachusetts. Nachi: Moving on to the Elapidae –  there are 3 species of coral snakes, only two of which you need to know about, Micrurus fulvius fulvius or the eastern coral snake and Micrurus tener or the Texas coral snake.  Of the two, the eastern or Micrurus fulvius fulvius produces more potent venom. Jeff:  As you may have guessed by their names, the eastern coral snake is found in the southeastern united states, specifically, east of the Mississippi -- whereas the Texas coral snake lives west of the Mississippi. Nachi:  Venomous North American coral snakes can be recognized by the red and yellow bands around their bodies whereas their nonvenomous counterparts can be recognized by their characteristic black band between the red and yellow bands. I’m sure you’ve heard the popular mnemonic for this… Red touch yellow kill a fellow, red touch black, venom lack. Jeff:  I have heard that one, and it’s not a bad mnemonic. Just remember that this is more of a guideline than a rule, as it doesn’t always hold true. Nachi: Coral snakes also tend to chew rather than bite thanks to their short, fixed, hollow fangs.  Locally, bites can lead to muscle destruction thanks to a certain myotoxin.  Systemic signs of infection include nausea, vomiting, abdominal pain, and dizziness.  Jeff: The venom also contains a neurotoxin which can lead to diplopia, difficulty swallowing and speaking and generalized weakness. Nachi: Complicating matters even further, the onset of these symptoms may be delayed for many hours. Jeff:  Alright, so I think that about wraps up the background.  Let’s move on to the meat and potatoes of this article, starting with the differential. Nachi:  For differential this month, we are really focusing on differentiating a venomous snake from a non-venomous one. Jeff: Oh yeah, this is where you want us to ask the snake if it can retract its fangs, right? Nachi: Ha very funny – Although the type of snake may be obvious if the patient owns the snake, for most cases you see in the ED, the type of snake won’t be clear. Try to get a description of the snake and consider your local geography. Some patients may even bring the snake in with them. Jeff: yea, no thanks. As for prehospital care, it’s actually pretty interesting stuff as recommendations have changed many times.  You may have heard of the recommendations for incision / excision, use of venom extraction devices, tourniquets, chill methods and even electroshock therapy – well these methods are all OUT. Nachi:  Not only are they out, they actually worsen outcomes, so definitely don’t pursue any of them.  Instead,  since no treatment has been shown to improve outcome, you should prioritize prompt transport. Jeff: And while we definitely don’t want to encourage ill-advised attempts at capturing the snake, taking pictures at a distance may be helpful in identifying it.  Oh and the authors do note- pretty terrifying stuff coming up here so brace yourself - even if the snake is dead the bite reflex is still intact… Nachi: And that’s why I work in city hospitals… Jeff:  There’s also a bit of controversy here with regards to pressure immobilization, which is definitely something I thought we were supposed to do in the prehospital setting. Apparently in other countries, like Australia, prehospital providers frequently employ pressure immobilization – that is, wrapping bandages proximally up a splinted limb to impede lymphatic toxin spread. Nachi:  Right, but in Australia, not only are the snakes more venomous but the hospital transport distances are much longer, so, basically they sacrifice the limb to potentially save a life.  In the US, with our current indigenous snake population and the relatively short transport distances, this isn’t justified at all! Jeff:  Take home: based on the current literature, the American College of Medical Toxicology, other experts, and Drs. Sheikh and Leffers recommend against pressure immobilization in lieu of prompt patient transport to definitive treatment. Nachi:  Good to know – alright so now we have the patient in the emergency department, let’s begin ED care.  As always – IV, O2, Monitor including end tidal CO2 if you suspect a neurotoxic or exotic snake bite.  Of course, avoid using the affected limbs for vitals… Jeff: If not done already, remove any constrictive clothing or jewelry and mark the leading edge of pain, edema, and erythema both above and below the bite.  If EMS has placed bandages, leave them in place until antivenom and resuscitative equipment is ready. Nachi:  And definitely involve the poison control center or a medical toxicology service early as they are an amazing resource. It’s an easy number to remember.. 1-800-222-1222. If you just type “poison control center” into google, that number will come up immediately. Jeff: Hypotension should be treated with isotonic fluids and, as usual, anaphylaxis should be treated with the usual cocktail of antihistamines and epinephrine at first IM and then via infusion if refractory. Note that antivenom will NOT reverse anaphylaxis on its own. Nachi:  When eliciting a history, there are a number of important factors to look out for, including – time and location of the bite, description of the snake, tetanus status, comorbid conditions, medications and allergies, any systemic or neurologic symptoms, muscle cramps, perioral tingling or numbness, metallic taste, history of previous snakebites and any reactions to previous envenomation or antivenom treatment. Jeff: Moving on to the physical exam, when examining the wound, look specifically for local tissue effects which occur in over 90% of patients after pit viper envenomations.  In such cases, you would expect pain, erythema, swelling, tenderness, and myonecrosis beginning at the wound site and then spreading via the lymphatic system. Nachi:  In addition, specifically with pit viper envenomations, monitor the patient for possible compartment syndrome as the venom can lead to local tissue destruction, increased cell permeability, third spacing of fluids, and bleeding.  And remember that while the local compartment may be hypertensive, the patient may also have systemic hypotension. Jeff: Just to reiterate what I said before – hypotension may indicate severe anaphylaxis and its not necessarily just due to third spacing.  Regardless, the treatment is the same – epinephrine. Nachi:  Good point, but let’s focus on compartment syndrome for a minute.  True compartment syndrome is actually quite rare --- its really subcutaneous hypertension with preservation of otherwise normal compartment pressures that you’re most likely to see.  Compartment syndrome should therefore only be diagnosed by actual compartment measurements and not just the exam.  However, if you are dealing with compartments that can’t be measured, like in the fingers, you’re only choice is to be guided by the exam… Jeff:  Risk factors for compartment syndrome in the setting of a snake bite include envenomations in small children, involvement of digits, application of ice or cold packs, and delayed or inadequate antivenom administration. Nachi: In terms of respiratory effects of envenomations – they aren’t common.  Both bites to the head or neck and neurotoxin containing venom are potential causes. In the setting of respiratory failure, be prepared with advanced airway maneuvers like nasotracheal intubation or cricothyroidotomy. Antivenom will not reverse respiratory failure. Jeff: Neurologic effects may be present upon arrival but may also be delayed up to 12 hours in the case of eastern coral snake bites. Nachi: It’s noteworthy that in one study of almost 400 eastern coral snake exposures, the onset of systemic symptoms occurred on average 5.6 hours after the bite.  So definitely remember that repeat exams and observation will be tremendously important. Jeff:  The actual neurologic symptoms to look for depend on the snake.  Coral snake venom can produce a descending flaccid paralysis characterized by motor weakness, especially of the cranial nerves.  Similarly pit vipers, especially the Mojave rattlesnake, have also been associated with muscular weakness of the cranial nerves and even respiratory insufficiency. Nachi:  Pit viper envenomation can also lead to myokymia which is repetitive small muscle fasciculations.  Unfortunately, this myokymia may not respond to antivenom administration and myokymia of the chest well and torso can necessitate intubation in extreme cases.  Both myokymia and myonecrosis may lead to rhabdo in the case of significant envenomations. Jeff:  Pit viper envenomation can also cause hematologic effects.  Fibrinolysis and platelet consumption at the bit site can lead to decreased fibrinogen and thrombocytopenia.  In severe cases this can lead to systemic bleeding and even hemorrhagic shock.  Those on anticoagulants and anti-platelet agents are at increased risk. Nachi:  Dermal effects such as edema, ecchymosis, bullae, and bleeding are not uncommon, but up to 50% of coral snake bite victims may have none of these. Jeff:  And to round out this section – just be aware that rare effects such as osteonecrosis, ischemic stroke, massive PE, and septic shock have all been reported. Nachi: Let’s move on to diagnostic studies.  Most patients require a CBC, coags, and a fibrinogen concentration.  Those with systemic toxicity should also have their electroyltes, CPK, creatinine, glucose, and urine tested. Jeff:  And while the data is somewhat mixed, one study suggests that all patients with pit viper envenomations need their coags checked, not just those with severe symptoms as in one series nearly 90% of patients had missed coagulation abnormalities.  The clinical consequences of this aren’t clearly explained, so the authors don’t make a specific recommendation. Nachi:  In terms of imaging, a chest x-ray should be obtained in those with respiratory symptoms and ultrasound may even have an expanding role here for tracking edema, looking for fluid collections, and assessing deep muscle compartments and vascular flow. Jeff: I feel like we should get some entry music for every ultrasound reference because it seems to make its way into just about every episode. Nachi: What would it sound like? You bring this up every month. I’ll look into something for a future episode. If any of our listeners have a suggestion, shoot us an e-mail at emplify@ebmedicine.net. In terms of monitoring and observation, this is important, ALL patients with suspected pit viper envenomations should be observed for 8-12 hours with the leading edge marked every 15-30 minutes. Jeff:  In addition, serial diagnostic testing may also be needed as such changes will be used to guide treatment.  In those with systemic symptoms, lab testing will be required every 4-6 hours prior to discharge. Nachi:  Before we move onto treatment – let me quickly mention grading.  There is no universal grading system.  The snakebite severity score, the minimum-moderate-severe score, and grade 1-4 score which consider symptoms, exam findings, and lab abnormalities have all been studied.  None have been validated and none track changes, so the authors recommend relying on severity of symptoms and progression of symptoms to guide treatment. Jeff:  The crux of treatment for pit viper envenomations is with supportive care and anti-venom. Nachi:  FabAV or CroFab is the antivenom of choice for pit viper envenomations.  This antivenom is made from extracting the Fab portion of anti-venom antibodies from envenomated sheep and processing them with papain. Jeff:  Since the sheep are injected with venom from the western diamondback, eastern diamondback and Mojave rattlesnake as well as the cottonmouth, the FabAV is most effective against venom from these snakes, however it does have cross reactivity to other immunologically similar venoms. Nachi:  Indications for FabAV include a more than minimal local swelling, rapid progression of swelling, swelling crossing a major joint, evidence of hemotoxicity, signs of systemic toxicity including hemodynamic compromise, neuromuscular toxicity, and late or recurrent new-onset coagulopathy. Jeff:  Initially, dose FabAV as a bolus of 4-6 vials, IV.  With life threatening envenomations or those with cardiovascular collapse, double the starting dose to 8-12 vials.  The goal is arresting progression, improvement in coagulation abnormalities, and resolution of systemic symptoms. Nachi: Although FabAV will reduce the duration and severity of symptoms and lab abnormalities, it will not reverse tissue necrosis and may not reverse neurologic effects. Jeff:  Once the symptoms have been controlled after the bolus dose or a second bolus dose, maintenance dosing of 2 vials every 6 hours for 3 doses is recommended to prevent recurrence. Nachi:  So to reiterate.  4-6 vial bolus to start, doubled in severe cases and then 2 vials every 6 hours for 18 hours after that. Jeff:  You got it. Nachi:  And like most, maybe all medicines, there are side effects and contraindications to be aware of.  Hypersensitivity reactions and serum sickness to FabAV have been reported as 8% and 13% respectively.   Most are mild and can be treated with your standard bundle of steroids, antihistamines, fluids and epi. Jeff:  Risk factors for developing allergic reactions to FabAV include  a known allergy to papaya, papain, chymopapin, pineapple enzyme bromelain, and previous allergic reaction to FabAV. Nachi:  Although FabAV isn’t produced using copperhead venom, it may be effective in severe envenomations and in one study, FabAV reduced limb disability compared to placebo. Jeff:  Therefore, the authors very reasonably advise that you should use the patient’s clinical picture and individual factors rather than the snake species to guide your treatment. Nachi:  Interestingly, compartment syndrome should be treated with the initial 4-6 vial dose of antivenom and not necessarily a fasciotomy.  Fasciotomies have not been shown to improve outcomes and are reserved only for those failing anti-venom treatment. Jeff:  The reason for this is that antivenom may reduce tissue pressures obviating the need for fasciotomy.  In addition, fasciotomy wouldn’t affect muscle necrosis that is occurring so fascia removal really doesn’t solve anything. Nachi:  And just as anti-venom can be used to treat elevated compartment pressures, it can also be used to treat coagulopathy. Jeff:  Blood products should be used for those who are actively bleeding or severely anemic as venom does not discriminate and will destroy whatever blood it comes across. Nachi:  Recurrent and late onset coagulopathy after FabAV treatment has also been well described.   Although not exactly clear why, some speculate that it occurs for one of 4 reasons. 1) because the half life of FabAV is shorter than that of the venom, or 2) because the venom is initially stored in the soft tissues and then slowly released over time or 3) because the venom has a late onset component, or lastly, 4) there is delayed dissociation of the venom-antivenom complexes.  Regardless of the mechanism, late onset coagulopathy can be treated with FabAV. Jeff:  Luckily, bleeding associated with coagulopathy and bleeding associated with late onset coagulopathy are both extremely rare.   Nachi:  Moving on to coral snakes.  Coral snake bites should be treated with NACSA or North American Coral Snake anti-venom.  This antivenom halts or at least limits the progression of muscle paralysis and shortens the clinical course. Jeff:  Most experts recommend NACSA treatment with the first signs of systemic toxicity and not for all comers.  This recommendation is backed by the literature as in one observational study those treated with prophylactic NACSA did less favorably as compared to those who got it only after symptoms onset.  This is probably because NACSA doesn’t reverse neuromuscular weakness and only limits progression. Nachi:  And it’s not like you are just sitting by and watching while doing nothing – focus your initial treatment on wound care, pain control, and then observation for the development of systemic symptoms.  The exact length of observation will depend on the snake, but should be somewhere between 8 and 24h. Jeff:  As for dosing – the initial NACSA dose is 3-5 vials IV for both peds and adults with a repeat dose if the initial symptoms don’t improve. Nachi: Side effects and adverse reactions occur somewhere between 8-11% of the time with dermal reactions being most common and anaphylaxis being the most severe. Jeff: There is also one last anti-venom to be aware of – Coralmyn, for coral snake envenomations.  Coralmyn is a polyclonal antivenom F(ab’)2 coral snake antivenom, developed because the current lot of NACSA has technically expired although the date has been extended numerous times.  It’s currently in a phase 3 trial, so keep your eyes out. Nachi:  Other non-antivenom treatments that have been tested include acetylcholinesterase inhibitors and trypsin at the bite site – both should be considered experimental at this point. Jeff:  To wrap up the treatment section, let’s talk exotic snakes.  You may recall from the intro that these have a higher morbidity and mortality compared to native species. Nachi:  You will have to rely on your local poison control center or toxicologist for advice and you may even need to turn to the zoo or aquarium for antivenom, if it exists at all.  Patients with bites from exotic snakes should be monitored, likely in the ICU, for up to 24 hours as toxicity from some venom may have a delayed onset of up to 20 hours. Jeff:  Scary stuff, hopefully the patient knows which type of exotic snake they own and you don’t have to sort through a million google images to try to get to the bottom of this.  Anyway, there are 3 special populations to discuss.  First are pregnant patients. Nachi:  The authors cite a 1.4% incidence of snake bites in pregnant patients.  They note that this is low, but from my perspective, this seems shockingly high – why would a pregnant person ever get anywhere near a snake, seems just ill advised… Jeff:  haha, true.   But regardless, treatment is the same with antivenom as needed for all the same indications.  With fetal demise rates as high as 30%, in addition to maternal monitoring, the fetus should also be monitored. Nachi:  That number may seem high, but keep in mind that that’s from studies in other countries with more venomous snakes, so it’s likely to be lower in the US.  But the point remains, that antivenom is generally recommended to be given if the mother has indications for treatment, as poor fetal outcome is tied directly to the severity of envenomation in the mother. Jeff: Continuing right along, the next special population to discuss are pediatric patients.  Because dosing is based on the amount of venom delivered and not on patient specific factors, dosing is the same for peds and adults. Nachi:  How rare – so few meds seem to be the same for peds and adults.  The last population to discuss are anticoagulated patients.  Patients on antiplatelet or anti-coagulants are at increased risk of bleeding after pit viper envenomations and therefore should have their coags checked every 2 days following the last dose of FabAV. Jeff:  I think we’ve at least mentioned most of this months controversies, but it’s probably worth quickly reviewing them since they mostly dispel common myths. Nachi:  Good idea.  Incision and suction of snake bites is nearly universally not recommended. Jeff:  In the absence of ischemia, fasciotomy for snake bites is not recommended, even with elevated compartment pressures.  Instead treat compartment syndrome with anti-venom and save the fasciotomy for true cases of ischemia refractory to antivenom. Nachi:  With a known or suspected coral snake envenomation, due to shortages of NACSA, wait until the patient develops symptoms instead of empirically treating all bite victims. Jeff:  Maintenance dosing of FabAV continues to be debated.  The manufacturer recommends 2 doses every 6 hours for 3 doses while some experts recommend only maintenance dosing as needed.  It’s therefore probably safest to punt this to whatever poison control center or toxicologist you speak with. Nachi:  I feel like we are plugging the poison center a lot, but it’s such a good free, and usually very nice consult to have on your team. Jeff: Nice consultant – what a win!  Moving on to the cutting edge.  There is a new Crotalidae antivenom called Crotalidae Immune F(ab’)2 or, more simply, Anavip.  It should be available in the next few months.  The dosing will be 10 vials up front over 60 minutes followed by an additional 10 vials if the symptoms having been controlled.  4 more vials may be given for symptom recurrence.  Patients must be observed for a minimum of 18 hours after initial control of symptoms. Nachi: This would be a really nice development as Anavip has a longer half life and therefore should reduce the rates of late coagulopathy and decrease the need for maintenance dosing, follow up, and repeating coags. Jeff:  And finally, like we mentioned before, injection of the trypsin has been tried as a bridge to antivenom, as has carbon monoxide, which may mediate degradation of fibrinogen dependent coagulation. Nachi:  Alright, so let’s talk about the disposition next. Victims of pit viper envenomations should be monitored for 8-12 hours from the time of the bite.  They will need baseline labs and repeat testing ever 4-6 hours.  IF there is no progression of the symptoms and repeat testing is normal, the patient can be discharged. Jeff: Victims of coral snake bites should be admitted and observed for 12-24 hours regardless of symptoms. Nachi: Victims of rattle snake envenomations who initially develop hematologic abnormalities and are treated with FabAV should have repeat testing done in 2-4 days and 5-7 days. Jeff:  Wounds should also be closely followed to avoid complications and long term disfigurement and disability.  PT/OT may be necessary as well. Nachi:  Perfect, let’s round this episodes out with a review of the key points and clinical pearls from this month’s issue. There are about 10,000 ED visits in the US for snake bites each year, and 1/3 of these involve venomous species. Pit vipers produce a predominantly hemotoxic venom. Both local and systemic effects can occur. Systemic effects include tachycardia, tachypnea, hypotension, nausea, vomiting, weakness, and diaphoresis. In general, venomous snakes have a triangular or spade-like head, elliptical pupils, and hollow retractable fangs. In contrast, non-venomous snakes have a rounded head, round pupils, lack fangs, and can have a double row of vertical scales on the tail. Venomous North American coral snakes often have adjacent red and yellow bands, whereas their nonvenomous counterparts usually have a characteristic black band between the red and yellow bands. For prehospital care in the US, the following strategies are not recommended: incision or excision, use of venom extraction devices, tourniquets, chill methods, and electroshock therapy -- and they can all actually worsen outcomes.  Prehospital providers should focus on rapid transport. Be cognizant of compartment syndrome, but measure compartments when possible, as some envenomations present similarly but have only subcutaneous hypertension. Neurologic effects can be delayed up to 12 hours after coral snake envenomations. Symptoms can include a descending paralysis. For diagnostic testing, consider a CBC, coags, fibrinogen level, electrolytes, cpk, creatine, glucose, and urine studies.  All patients with envenomation should be observed for at least 8 hours. Mark the site of envenomation circumferentially to monitor for changes. Management of patients with snake bites should be treated with supportive care, pain control, and specific antivenom when indicated. FabAV or CroFab is the antivenom of choice for pit viper envenomations. Although FabAV will reduce the duration and severity of symptoms and lab abnormalities, it will not reverse tissue necrosis and may not reverse neurologic effects. Be aware of the possibility for a hypersensitivity reaction or serum sickness to FabAV. Treat with steroids, antihistamine, IV fluids, and epinephrine as appropriate. Coral snake envenomations can be treated with NACSA, which halts or at least limits the progression of muscle paralysis and shortens the clinical course.  Side effects to NACSA include dermal reaction as the most common -- and anaphylaxis as the most severe. Patients with bites from exotic snakes should be monitored, likely in the ICU, for up to 24 hours as toxicity from some venom may have a delayed onset of up to 20 hours. You may have to turn to your local zoo for help with anti-venoms here. Management of pregnant patients is the same as nonpregnant patients with regards to snake envenomations. Dosing of antivenom is based on the amount of venom. Dosing is the same regardless of the age of the patient. All patients requiring antivenom or with suspected envenomation should be admitted.  Seek consultation with your regional poison center and local toxicologist Jeff: So that wraps up the September 2018 episode of Emplify. Nachi: As always - the address for this month’s credit is ebmedicine.net/E0918, so head over there right away to get your credit.  Remember that the  you heard throughout the episode corresponds to the answers to the CME questions. Jeff: And don’t forget to grab your free issue of Synthetic Drug Intoxication in Children at ebmedicine.net/drugs specifically for emplify listeners. Feel free to share the link with your colleagues or through social media too. Next month we are talking sepsis and the ever frequently changing guidelines so it’s not something you want to miss.  Talk to you soon   Most Important References 4. *Lavonas EJ, Ruha AM, Banner W, et al. Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop. BMC Emerg Med. 2011;11:2-227X-11-2. (Consensus panel) 6. *Bush SP, Ruha AM, Seifert SA, et al. Comparison of F(ab’)2 versus Fab antivenom for pit viper envenomation: a prospec­tive, blinded, multicenter, randomized clinical trial. Clin Toxicol (Phila). 2015;53(1):37-45. (Randomized controlled trial; 121 patients) 7. *Gerardo CJ, Vissoci JR, Brown MW, et al. Coagulation parameters in copperhead compared to other Crotalinae envenomation: secondary analysis of the F(ab’)2 versus Fab antivenom trial. Clin Toxicol (Phila). 2017;55(2):109-114. (Ran­domized controlled trial; 121 patients) 8. *American College of Medical Toxicology, American Acad­emy of Clinical Toxicology, American Association of Poison Control Centers, European Association of Poison Control Centres and Clinical Toxicologists, International Society on Toxinology, Asia Pacific Association of Medical Toxicology. Pressure immobilization after North American Crotalinae snake envenomation. Clin Toxicol (Phila). 2011;49(10):881-882. (Position statement) 10. *Wood A, Schauben J, Thundiyil J, et al. Review of eastern coral snake (Micrurus fulvius fulvius) exposures managed by the Florida Poison Information Center Network: 1998-2010. Clin Toxicol (Phila). 2013;51(8):783-788. (Retrospective; 387 patients) 48. *Cumpston KL. Is there a role for fasciotomy in Crotalinae envenomations in North America? Clin Toxicol (Phila). 2011;49(5):351-365. (Review) 75. *Walker JP, Morrison RL. Current management of copper­head snakebite. J Am Coll Surg. 2011;212(4):470-474. (Retro­spective; 142 patients) 81. *Kitchens C, Eskin T. Fatality in a case of envenomation by Crotalus adamanteus initially successfully treated with polyvalent ovine antivenom followed by recurrence of defibrinogenation syndrome. J Med Toxicol. 2008;4(3):180-183. (Case report) 118. *Hwang CW, Flach FE. Recurrent coagulopathy after rattle­snake bite requiring continuous intravenous dosing of anti­venom. Case Rep Emerg Med. 2015;2015:719302. (Case report)

In light of recent international negotiations over nuclear disarmament and efforts to respond to the use of chemical and poisonous weapons, we sit down with Dr. Erickson to discuss the health and environmental impacts of conflict and emergencies. Dr. Timothy B. Erickson is an emergency medicine physician at the Brigham and Women’s Hospital in Boston where he serves as the Chief of Medical Toxicology in the Department of Emergency Medicine, and a faculty member at the Harvard Humanitarian Initiative. He is an expert in environmental toxicology and crisis in climate change, and has active humanitarian health projects in conflict regions of Ukraine and Syria, as well as ongoing health projects in Nepal and India. Dr. Erickson earned his M.D. degree from The Chicago Medical School in 1986, and is a Fellow of the American College of Emergency Physicians, the American College of Medical Toxicology, the American Academy of Clinical Toxicology, and the National Geographic Explorers Club.

Narcan and Synthetic Opioids: vive la résistance? Probably not. Read this absolutely brilliant piece from The Tox & The Hound here. (They did all the hard work and we stole their sources.) Opioid "resistance" to naloxone is most likely not a thing, per se. The reported effect from synthetic and novel opioids are unlikely to be due to the agent's binding affinity for receptors within the brain, but rather from an ability to rapidly permeate the blood brain barrier much faster than "traditional" opioids such as heroin. Even in cases where a synthetic opioid agent was identified, the vast majority of cases did not need more than 4mg of naloxone to achieve reversal. Synthetic opioids don't bind any more "tightly" to receptors than naloxone. Synthetic opioids will usually cross the blood brain barrier faster than traditionally encountered agents. Most available evidence shows that synthetic opioid toxicity does not require significantly more naloxone to achieve clinically significant effect. Ergo, the traditional serial naloxone dosing algorithm does not need much modification. 0.04mg -> 0.4mg -> 2mg -> 4mg -> 8mg -> 10mg Not all that "overdoses" is an opioid. Consider all other causes of altered mental status or coma. Namely: hypothermia, hypoxia, and hypercarbia. Acidosis may potentiate the effect of opioids, highlighting the demand for timely and effective ventilation. Polypharmacy or adulteration is increasingly common. Consider intoxication by additional agents. Anchoring bias is a dangerous phenomenon: don't get burned! The Nose Knows. Or does it? Intranasal (IN) naloxone is popular among many EMS agencies as well as law enforcement, fire departments, and bystanders. IN naloxone has been shown to be effective in several randomized controlled trials for successful reversal of opioid intoxication. However... There are important pitfalls to be cognizant of when choosing this option for delivering naloxone.  Intranasal naloxone has poor bioavailability when compared to IV or IM dosing, so higher doses may be required to achieve clinical effect. This is further potentiated by the maximum volume able to be absorbed by the nasal mucosa (around 0.5mL). Patients administered intranasal naloxone may have a variable or delayed response in achieving reversal. Protect Ya Neck Standard isolation precautions are adequate protection against the overwhelming majority of overdose scenes. In the rare instance where respiratory or splash exposure is a concern, a properly fitted N95 mask and goggles will be sufficient. To date, there has yet to be a laboratory confirmed case where a first responder or emergency healthcare provider has suffered a clinically significant opioid intoxication (bradypnea, hypoxia ) as the result of an occupational exposure to fentanyl or its analogues. TotalEM Podcast: https://www.totalem.org/emergency-professionals/podcast-73-ppe-in-opiate-overdoses References 1) Wax, P. M., Becker, C. E., & Curry, S. C. (2003). Unexpected “gas” casualties in Moscow: A medical toxicology perspective. Annals of Emergency Medicine, 41(5), 700–705. https://doi.org/10.1067/mem.2003.148 2) Stolbach, A. (2018). Is This Anything? Naloxone-resistant opioids. Retrieved from https://emcrit.org/toxhound/is-this-anything/ 3) Sutter, M. E., Gerona, R. R., Davis, M. T., Roche, B. M., Colby, D. K., Chenoweth, J. A., … Albertson, T. E. (2017). Fatal Fentanyl: One Pill Can Kill. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine, 24(1), 106–113. https://doi.org/10.1111/acem.13034 4) Klar, S. A., Brodkin, E., Gibson, E., Padhi, S., Predy, C., Green, C., & Lee, V. (2016). Furanyl-Fentanyl Overdose Events Caused by Smoking Contaminated Crack Cocaine — British Columbia, Canada, July 15–18, 2016. MMWR. Morbidity and Mortality Weekly Report, 65(37), 1015–1016. https://doi.org/10.15585/mmwr.mm6537a6 5) Uddayasankar, U., Lee, C., Oleschuk, C., Eschun, G., & Ariano, R. E. (2018). The Pharmacokinetics and Pharmacodynamics of Carfentanil After Recreational Exposure: A Case Report. Pharmacotherapy. https://doi.org/10.1002/phar.2117 6) George, A. V., Lu, J. J., Pisano, M. V., Metz, J., & Erickson, T. B. (2010). Carfentanil--an ultra potent opioid. The American Journal of Emergency Medicine, 28(4), 530–2. https://doi.org/10.1016/j.ajem.2010.03.003 7) Melichar, J. K., Nutt, D. J., & Malizia, A. L. (2003). Naloxone displacement at opioid receptor sites measured in vivo in the human brain. Eur J Pharmacol, 459(2–3), 217–219. https://doi.org/10.1016/S0014-2999(02)02872-8 8) Cole, J. B., & Nelson, L. S. (2017). Controversies and carfentanil: We have much to learn about the present state of opioid poisoning. American Journal of Emergency Medicine. https://doi.org/10.1016/j.ajem.2017.08.045 9) Connors, N. J., & Nelson, L. S. (2016). The Evolution of Recommended Naloxone Dosing for Opioid Overdose by Medical Specialty. Journal of Medical Toxicology, 12(3), 276–281. https://doi.org/10.1007/s13181-016-0559-3 10) ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders. (2016). https://doi.org/10.1007/s13181-017-0628-2 11) Casale, J. F., Mallette, J. R., & Guest, E. M. (2017). Analysis of illicit carfentanil: Emergence of the death dragon. Forensic Chemistry, 3, 74–80. https://doi.org/10.1016/j.forc.2017.02.003 12) Zuckerman, M., Weisberg, S. N., & Boyer, E. W. (2014). Pitfalls of intranasal naloxone. In Prehospital Emergency Care (Vol. 18, pp. 550–554). https://doi.org/10.3109/10903127.2014.896961 13) Chou, R., Korthuis, P. T., McCarty, D., Coffin, P. O., Griffin, J. C., Davis-O’Reilly, C., … Daya, M. (2017). Management of Suspected Opioid Overdose With Naloxone in Out-of-Hospital Settings. Annals of Internal Medicine, 167(12), 867. https://doi.org/10.7326/M17-2224 14) Rzasa Lynn, R., & Galinkin, J. (2018). Naloxone dosage for opioid reversal: current evidence and clinical implications. Therapeutic Advances in Drug Safety, 9(1), 63–88. https://doi.org/10.1177/2042098617744161 15) Kim, S., Wagner, H. N., Villemagne, V. L., Kao, P. F., Dannals, R. F., Ravert, H. T., … Civelek, a C. (1997). Longer occupancy of opioid receptors by nalmefene compared to naloxone as measured in vivo by a dual-detector system. Journal of Nuclear Medicine : Official Publication, Society of Nuclear Medicine, 38(11), 1726–31. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9374341

In this episode we talk to Lewis Goldfrank about his early life and how he ended up in Emergency Medicine and Medical Toxicology and the creation of Goldfrank’s Toxicologic Emergencies

Taking innovative approaches and scaling them to a large healthcare setting

Did you ever wonder what it’s like to explore the Amazon LOOKING for venomous, poisonous and toxic risks? Or how about pondering what it takes to get in the prestigious National Geographic Explorers Club? Or how about summiting Mt. Aconcagua or making it to Everest Base Camp, or even to Antarctica? How about curiosities as to what makes the Harvard Humanitarian Initiative tick and the amazing projects it undertakes to make the work a better, healthier, and safer place?  Well then you will enjoy this laughter filled and inspirational episode with the remarkable Dr. Tim Erickson. Tim is a Core Faculty at the prestigious Harvard Humanitarian Initiative, with expertise in environmental toxicology and crisis in climate change. He also has active humanitarian health projects in conflict regions of Ukraine and Syria. He’s also an emergency medicine physician at the Brigham and Women’s Hospital in Boston where he serves as the Chief of Medical Toxicology in the Department of Emergency Medicine. Dr. Erickson is a Fellow of the American College of Emergency Physicians, American College of Medical Toxicology, American Academy of Clinical Toxicology, and the prestigious National Geographic Explorers Club. Previously, he served as the Director for the Center for Global Health and Professor of Emergency Medicine and Medical Toxicology at the University of Illinois at Chicago’s College of Medicine. Dr. Erickson has been a member of multiple editorial boards and has a prolific academic history including publishing over 120 original journal articles and book chapters as well as editing 4 major textbooks. He has presented over 100 national and international invited lectures related to emergency medicine, toxicology, humanitarian global health, and wilderness/expedition medicine. And he has extensive international experience in Africa (Rwanda, Sudan, and Kenya), Asia (India, Vietnam, and Nepal), South America (Brazil, Peru, and Argentina), Europe (Kosovo, Ukraine, France) and Antarctica. But he’s also lobbed a snake at my daughter (it’s OK, it was rubber). His office is filled with blowgun darts that may or may not still have qari on their tips, as well as skulls and a variety of spiders and snakes, which I believe are all dead, but with Tim, you never know. So be warned…. In this episode we travel around the world to humanitarian hot spots as well as Antarctic rescues in very cold spots. We discuss his Tox-Boy beginnings and his current work at Harvard, and a great deal in-between.  Tim is the poster-boy for living a life in full—adventure, family, healing others, and training future and current physicians and healthcare providers—while have an amazing time doing it all.

Each year, poison centers manage numerous exposure cases involving Halloween-related substances, like candy, glow sticks, and special cosmetics. Hear from Dr. Christopher Holstege, director of the Division of Medical Toxicology at UVA, and the co-medical director of the Blue Ridge Poison Center, about simple precautions to take in order to prevent accidental poisoning this Halloween. Tagged under: Children's Health

Lead exposure is an ongoing issue that impacts the health of children across our nation. Exposure in children under six can damage organs, slow development, learning and behavior problems and more. Hear from Jennifer Lowry, MD, Section Chief, Medical Toxicology as she discusses the impacts lead poisoning has on young children and ongoing education needed within the medical community. During this session you will also learn the about comprehensive pediatric environmental health services provided by Children's Mercy Kansas City (supported through the Mid-America Pediatric Environmental Health Specialty Unit).

Accurate weight estimates are important because they are used to determine appropriate medication dosage, fluid volumes for resuscitation, breathing tube sizes, and more. But what do you do in situations when you are unable to weigh the child? The Mercy TAPE was developed by Children’s Mercy researchers led by Susan Abdel-Rahman, Pharm.D, Clinical Pharmacology and Medical Toxicology, (TAPE stands for TAking the guesswork out of Pediatric weight Estimation) to address that question. The unique and pragramatic Mercy Tape has been demonstrated to be more accurate than any other method currently available for children ages two months to 16 years, accurately predicting weight within 10 percent of actual weight in about 80 percent of children, and within 20 percent of actual weight in 98 percent of children; in essence, getting within 20 percent of actual weight in nearly 100 percent of children (including children that are malnourished or obese)…all at a cost of about 1/3 of a penny per device.Dr. Susan Abel-Rahman is here to explain how The Mercy TAPE allows clinicians to get an accurate idea of a child’s weight by making two measurements of the upper arm.

The September 2012 Edition of the JMT Podcast. Join Howard Greller & Dan Rusyniak as they explore writing, scorpions, pad thai, punding, nasal halos and everything else in this issue of the Journal of Medical Toxicology.

The June 2012 Edition of the JMT Podcast. Join Howard Greller & Dan Rusyniak as they explore the atropinization, snake bites, twinkies and everything else in this issue of the Journal of Medical Toxicology.

The December 2012 Edition of the JMT Podcast. Join Howard Greller & Dan Rusyniak as they explore the special Opioid Edition of the Journal of Medical Toxicology. Topics including use, misuse and abuse of opioid medications along with one sad dog.

Controversies in Medical Toxicology – Gaps Between Evidence & Practice