UMEM Educational Pearls

 Melamine

• In case you thought the chinese only sent their toxin filled products to the USA, a massive scandal has been occurring with their milk.
• Adding melamine to their milk, companies were able to get falsely elevated readings of protein which is measured by the government to make sure the milk was not watered down.
• 53,000 illnesses, over 12,000 hospitilizations and at least 4 infant deaths have been attributed to their milk supply - 20% of China's milk supply is thought to be contaminated
• Melamine or melamine resin is used to make plastics and involved in other polymeric reactions.
• Toxicity involves the creation of kidney stones - imagine the pain in these poor children
• These children died from renal failure from multiple kidney stones.
• Check the link below to the news article

Show References

 Cheese Heroin: a slang term for the combination of heroin with an over-the-counter antihistamine

• The two are combined and forms a cheesy like powder that is different from pure heroin
• A string of deaths were reported between 2005-2007 in Texas, many adolscents
• This concoction is more often insufflated than smoked or injected
• Combines opioid effect with the anticholinergic confusion and hallucinations
• Scorpion was a heroin that was combined with scopolamine that had similiar effect

Treatment

• Find the anticholinergic toxidrome, place the foley and supportive care are mainstays
• Consider administration of physostigmine 1mg IV slowly over 2-5 minutes (call toxicologist)
• The anticholinergic effects will linger much longer than the heroin effects ( <1hr)

 Latrodectus sp (Black Widow Spider)

• The only indigenous neurotoxic insect  in the state of Maryland and found through many states in the US
• The "bite" often not visible and does not cause a necrotic lesion like the brown recluse
• Causes Acetycholine release from post-synaptic motor and sensory nerves
• This leads to intense muscle contraction and pain. There have been reports of a black widow spider on the leg and the patient undergoes ex lap surgery for suspected acute abdomen only to find out the abdominal muscles were fasciculating due to envenomation
• Treat with aggresive analgesia and benzodiazepines.
• Not often lethal with approximately 60-70 deaths in the US over 30 years

Take a look at a picture of the black widow on the following attachment

Attachments

• 0809112343_black-widow-spider-1.jpg (14 Kb)

Topical Lidocaine for local anesthesia

Disclosure: I have no financial or invested interest in the product or the company.

Show References

Buprenorphine (Suboxone)

• Use in opioid maintenance therapy programs, doesn't have QT prolongation and less respiratory depression than methandone
• Patients must been maintained on <40mg of methadone for successful conversion to buprenorphine to take place
• Primary caregivers can prescribe after taking a course
• Partial agonist can actual precipitate withdrawal if patient takes a full opioid (say sneaking a little heroin before appointment)
• Suboxone is buprenorphine+naloxone, since naloxone has poor bioavailability when taken appropriately there is no effect but if the tablet is crushed and injected the patient will go into florid withdrawal.
• Use and abuse has been steadily increasing and death can still occur from overdose.
• Pain is difficult to manage in patient on buprenorphine since opioid effect will be blunted, buprenorphine is potent partial agonist.

 A recent landmark article has cited a connection between non-insulin dependent diabetes and low-level arsenic in our drinking water.

• Approximately 13 million in the USA are drinking water that contains Arsenic levels higher than EPA allowable standards
• This study controlled for organic arsenic (found in seafood) and was looking for the effect of inorganic arsenic which is the more toxic compound - don't have to stop eating sushi
• This study essentially found a dose response curve with people with lower arsenic levels having lower incidence of non-insulin dependent diabetes, those with higher levels, higher risk.

Show References

 Navas-Acien A, Silbergeld EK, Pastor-Barriuso R, Guallar E.

 

Arsenic exposure and prevalence of type 2 diabetes in US adults.

JAMA. 2008 Aug 20;300(7):814-22.

Alcohol-Drug Interactions

• There are a number of medications that produce the disulfiram-like reaction when ingested with alcohol.
• The disulfiram reaction is a very uncomfortable reaction characterized by severe flushing, and may be accompanied by tachycardia and hypotension.
• Although we always think of metronidazole, there have been well described cases of bactrim causing this reaction.
• Tinidazole, a new antiprotozoal used in the treatment of trichomonas, causes this as well.
• Patients should be advised to avoid alcohol for 24 hours after metronidazole, and 72 hours after bactrim and tinidazole.

Other common medications that produce this reaction:

1. Sulfonylureas: chlorpropamide, tolbutamide, glyburide

2. Cardiovascular medications: Isosorbide dinitrate, nitroglycerin

Show References

• Elemental Mercury is found in manometers, some mercury switches and thermometers.
• Elemental Mercury is also in the CFLs (Compact Fluoroscent Lightbulbs) that are popular now due to rising energy cost (approx 4 mg)
• Organic mercury found in seafood is only toxic in high consistent doses - though has been catastrophic. See attached picture which was the award winning Time magazine cover of the year showing a mother holding her child who had congenital disfigurement due to mercury being dumped into Minamata Bay
• Elemental Mercury is mostly a neurotoxin causing personality changes, nervousness, shyness and depression.
• Acrodynia is pain and pink discoloration of hands and feet due to mercury poisoning in children.

Attachments

• 0807242206_smith_minimata.jpg (83 Kb)

•  Therapeutic concentration considered 10-20 mg/dL
•  Some hospitals report in "mg/L" thus a level of 110 mg/L is therapeutic
•  Symptoms of Toxicity usually > 40 mg/dL
•  Consider Hemodialysis in any patient with a serum concentration >100 mg/dL

First Line Therapy:  Urine Alkalinization (pH >7.5) by administrating NaHCO3

Other Indications for Hemodialysis in Salicylate Poisoned Patient:

1. Renal Failure
2. CHF
3. Acute Lung Injury
4. Persistent CNS disturbances
5. Refractory metabolic acidosis or electrolyte abnormality
6. Hepatic insufficiency with coagulopathy

• Metformin is the most commonly prescribed oral diabetic mediction in US
• Relative contraindication is in renally impaired patients, they are susceptible to the lactic acidosis
• Lethal adverse effect is the increase production of lactate
• ED patient with an anion gap metabolic acidosis, check for metformin and check the lactate
• The lactic acidosis is often severe (>10 mmol/L) and carries a high mortality rate that has been estimated at >40%
• Correction of pH and emergent hemodialysis are essential

Show References

 ADOLESCENT DRUG ABUSE

• "Pharming" is prescription drug abuse
• Teens will take medications from their home medicine cabinets, mix them in bags together indiscriminately and make "trail mix" to pass around parties
• "Cheese" is a combination of heroin with cough and cold preparations. The heroin concentration in cheese is typically between 2-8% compared to 30% found in black tar heroin, and is considered "starter heroin"

Show References

•  Dapsone has been used to treat leprosy but more commonly to in brown recluse spider bites and to prevent PCP pneumonia and toxoplasmosis in our HIV population
• It can cause methemoglobinemia: a reduced form of iron (ferrous to ferric) in the Hb molecule that decreases your oxygen carrying capacity. 
• Due to its color, cyanosis is a predominant symptom out of proportion to symptoms.
• Treatment: Methylene Blue 1-2 mg/kg IV
• Pitfall: Dapsone's long half-life may cause reoccurrence of MetHb and require retreatment

Here is a short list of medications that will actually prevent a patient from being anticoagulated by coumadin. These medications will make it difficult for the patient to reach therapeutic levels and need to be warned about this drug-drug interaction with coumadin:

• Antacids
• Antihistamines
• Barbituates
• Carbamazepine
• Cholestyramine
• Corticosteroids
• Griseofulvin
• OCPs
• Phenytoin
• Rifampin
• Vitamin K

Reference: Goldfrank's Textbook of Toxicologic Emergencies, 6th Edition

Trandermal Delivery Systems

• Uses a gradient (high concentration drug in patch) and a matrix to facilitate transdermal absorption
• Patch often contains up to 100x the amount of drug that is on the label (ex: fentanyl 100mcg/hr actually = 10 MILLIGRAMS of fentanyl in patch)
• When prescribing the following will increase absorption: sweating, heat, swallowing the patch, trying to eat the gel in the patch
• Fentanyl and clonidine are the two most lethal patches on the market in regards to toxicity.
• Rarely needed in the ED, shouldn't be prescribed except in rare instances

"Ketofol" (Ketamine plus propofol)

• Given for conscious sedation, for all age groups
• Takes advantage of properties of both agents
• Ketamine generally produces hypertension, does NOT produce respiratory depression, has an emergence phenomena, and has analgesic properties
• Propofol causes hypotension and respiratory depression, has NO analgesic properties, and may blunt both nausea and emergence phenomena seen with ketamine
• Given as a 1:1 ratio of ketamine and propofol, both 10 mg/ml
• Dose is usually 1-3 ml aliquots; median dose in a recent study was 0.75 mg/kg
• Median recovery 15 minutes (5-45 minutes; 80% recovered in less than 20 minutes)

Show References

Pool Cleaner Toxicity - Chlorine Gas Exposure 

The "shock" treatment that is utilized in pool cleaner is often contained in a large plastic container and is calcium hypochlorite. Chlorine gas accumulates in the small amount of airspace found in the container. If a future patient opens the container either in an enclosed space or within close proximity of the face that allows for large inhalational exposure.

• Toxicity looks like CHF with hypoxia, rales and acute lung injury on CxR
• Chlorine gas will bind hydrogen ion in the aveoli forming HCl - hydrochloric acid
• Nebulized NaHCO3 would theoretically neutralize this acid but has not been found to improve clinical outcome though it has been found to improve symptoms.
• Supportive care and observation including CxR  4-6 hours after exposure are necessary since the effects of the chlorine gas may be delayed.

 Toxicology Trivia for $1000 - These are in fruits of the "rose" family and in some roots that contain cyanogenic glycosides and other cyanide containing compounds. It would actually take a fair amount of work to ingest enough to reach toxicity:

• Bitter almonds
• Apricot kernels
• Peach pits
• Plum sees
• Apple and pear seeds
• Cassava (actually have to wash the root prior to eating - skin contains the CN)
• Lima Beans

• Adolescents abuse inhalational agents due to lack of access to ETOH and illicit drugs
• Often halogenated hydrocarbon propellants like computer cleaner and paint stripper
• Sensitizes the myocardium to catecholamines
• Child is caught huffing and is frightened causing a catecholamines surge then v-fib arrest
• This was reported in a 1970 case series and "Sudden Sniffing Death" was coined (1)
• Actual treatment would be to administer B-Blocker in this instance (theoretical)

Bass. Sudden Sniffing Death. JAMA 1970.

Show References

 How to recognize a truly toxic mushroom ingestion (remember one mushroom can be lethal!):

1) Onset of GI symptoms within 3 hours from time of ingestion: USUALLY NONTOXIC

- Control nausea and  vomiting

- Look for toxidrome: hallucinations, muscarinic symptoms, lethargy

2) Onset of GI symptoms greater than 5 hrs is associated with more toxic mushrooms

- High degree of suspicion for a cyclopeptide mushroom (Amanita phylloides)

- Follow liver enzymes and consier referral to liver transplant center