UMEM Educational Pearls - By Ellen Lemkin

Toxic Holiday Plants

Of the three plants listed, which is NOT poisonous?

1.     Holly plant

2.     Poinsettia

3.     Mistletoe

 

Poinsettia plants were once thought to be very poisonous. Contrary to popular belief, poinsettias are safe to have in the home during the holidays.

Although there are reported cases of death with ingestion of Holly plants in older literature, recent experience shows gastrointestinal effects in small doses, and serious toxicity such as CNS depression in large ingestions.

Mistletoe ingestion of few of the berries would, at most, produce mild gastroenteritis; however, ingesting concentrated extracts of the plant, including the berries, may produce serious effects such as seizures, mental confusion, drowsiness, and hallucinations.

Happy holidays!

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Dabigatran

• the first new ORAL anticoagulant in over 50 years
• is a direct thrombin inhibitor
• Indicated for reducing strokes and systemic embolism in patients with a fib
• DOES NOT need monitoring and frequent dose adjustments
• Has fewer drug and food interactions than warfarin
• Costs about $8/day (more than the cost of warfarin PLUS monitoring)
• Both warfarin and dabigatran have a similar OVERALL bleeding risk, but warfarin causes more intracranial bleeding and dabigatran more GI bleeding

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EMS in Maryland has REMOVED endotracheal medication administration from its ADULT protocols

This is due to:

• Unclear efficacy and need for a much higher dosage
• Ability to administer drugs via IO route
• Decrease reliance on intubation
  • chest compressions only CPR
  • BiPAP use
• Note this does not pertain to PEDIATRICS, where it is still included in its protocols

A recent study examined the effects of accidental digital epinephrine injection from auto-injectors. 127 cases with complete follow-up had the following effects:

• no effects were reported in 10%
• minor effects in 77%
• moderate effects in 13%
• major effects in 1 case

Pharmacologic vasodilators were used in 23%. Four patients had possible digital ischemia. All patients had complete resolution of symptoms, most within 2 hours. No patient was admitted, received hand surgery consultation, or had surgical care. 

Although this speaks for the safety of digital anesthesia using epinephrine, it underscores the importance of providing education to patients who are prescribed epinephrine auto-injectors.

 

 

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The number of rabies vaccines recommended by the ACIP (Advisory Committee on Immunization Practices) has been reduced from 5 to 4 doses for unvaccinated patients.

This was based on evidence from multiple source, including pathogenesis data, animal trials, clinical studies, and epidemiological surveillance. The first dose of the 4-dose regimen should be administered as soon as possible after exposure (day 0). Additional doses are then given on day 3, 7, and 14. The first dose of rabies vaccine should be administered with HRIG, infiltrating as much as possible into the wound, with the remainder given IM at a distant site from the vaccine.

This recommendation is not applicable to immunocompromised patients, who should continue to receive the full five doses.

http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-rabies.pdf

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There are a several classes of medications that can kill a toddler with a single dose. Toddlers are particularly susceptible due to their low weights and propensity to place everything in their mouths.

1. Calcium channel blockers
2. Camphor-containing rubs
3. Opioids/opiates
4. Oil of wintergreen/ aspirin
5. Cyclic antidepressants
6. Topical blood pressure patches (clonidine)
7. Eye drops and nasal sprays (oxymetazoline)
8. Sulfonylureas
9. Antimalarial drugs (cloroquine)

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It is likely that you will be asked questions about the huge recall by McNeil..

It stems from complaints received of black particles found in the pediatric liquid formulation, which are manufactured at one facility in Fort Washington, PA.  The FDA inspected the plant and found inadequate quality standard testing and facilities. Either there were potential bacteria in one of the raw products (which did not make it to the final product), or the final concentrations were stronger than specified.

McNeil recalled forty-three formulations of pediatric liquid tylenol, zyrtec, motrin and benadryl. Generic versions are unaffected.

Complete recall information:

www.mcneilproductrecall.com

For more information and links:

http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm210442.htm

 

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Cutting Edge	Old School
	Gastric Lavage
Hyperinsulinemia and Euglycemia	Supportive care, glucagon for beta blocker overdoses
Intralipid administration	Supportive care for anesthetic overdoses, TCAs, and other lipid soluble agents
Low dose or NO narcan	High dose narcan for opoid overdoses
Checking salicylates and tylenol levels for overdose	Tox screens for everyone

CARBAPENENEMS

• Broadest spectrum of activity of all classes
• Imipenem has slightly better gm + activity; lowers seizure threshold
• Meropenem has slightly better gm - activity
• Ertapenem does not cover Pseudomonas
• Doripenem has the most activity against Pseudomonas
• May use in PCN allergic patients (cross reactivity lower than previously thought)

TIGECYCLINE

• Has broad coverage, but does not cover Pseudomonas
• Bacteriostatic; derivative of tetracycline
• Does NOT require renal dosing
• Higher mortality in VAP than other agents; do not use for intra-abdominal infections (poss higher risk of perforation)

AMIKACIN

• Has antipseudomonal activity
• Used in combination with other agents for MDR (multi-drug resistant) bacteria
• Causes nephrotoxicity and ototoxicity

COLISTIN

• Bacteriocidal against many MDR gram - bacteria
• Not active against Proteus, Provincia, Burkholderia, Neisseria, or Serratia
• Nephrotoxicity and ototoxicity reported

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SUCCIMER (DMSA)

• An oral agent used for the chelation of heavy metals, such as LEAD, ARSENIC and MERCURY
• Forms a water soluble agent that chelates the heavy metal, which are renally excreted
• Most common side effects are rashes, urticaria and GI
• A serious adverse effect is neutropenia, which is rare

NEW TREATMENT in diabetes

It was discovered that glucose given ORALLY caused more insulin release than glucose administered INTRAVENOUSLY. This led to the discovery of the incretin hormones, which are secreted by the gut (INtestinal SECRETion of INsulin), GIP and GLP-1.

The incretin-based therapies increase levels of GLP-1, either by providing an incretin mimetic (exenatide and liraglutide), or by inhibiting their breakdown by DPP-4 (sitagliptin, saxagliptin, vilagliptin)

Their administration results in:

• Stimulation of glucose dependent insulin secretion
• Suppression of glucagon secretion
• Slowing of gastric emptying
• Improvement if b-cell functioning

Causing:

• Improved glycemic control
• Decrease in A1C
• Mild weight loss
• Mild decrease in BP

                 STAY TUNED FOR DOSING AND ADVERSE EVENTS!

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Iron Toxicity Treatment

Out	In
Checking TIBC to determine if treatment is necessary	Checking iron levels...If peak is > 500 mcg/dl, or the patient shows signs of systemic toxicity, treat with deferoxamine
Deferoxamine challenge... no longer recommended!	Using WBI for ingestion of 20 mg/kg iron, if visible iron pills on x-ray, or symptoms of mild toxicity (for treatment of severe toxicity see above)
Platform shoes	Strappy sandals

WBI: whole bowel irrigation

Reminder from Poisondex:

OVERDOSE: SEVERE: Stupor, shock, acidosis, GI bleed, coagulopathy, hepatotoxicity, and coma. MILD/MODERATE: Nausea, vomiting, diarrhea, lethargy, leukocytosis, and hyperglycemia. Clinical phases: (1) 0-2 hours: Nausea, vomiting, diarrhea, and abdominal pain. Lethargy, shock, GI bleeding, and acidosis if severe; (2) Apparent recovery; (3) 2-12 hours: Acidosis, hypotension; (4) 2-4 days: Hepatotoxicity; (5) days-weeks: GI strictures.

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Vicks VapoRub Toxicity

With the removal of OTC product indications for children under the age of 2 for cough and colds, more parents are turning to other agents such as Vicks VapoRub for the relief of cough and cold symptoms. Unfortunately these agents are also associated with toxicities and the potential exists for an increased number of poisonings. The primary components of these agents are:

• Camphor
• Eucalyptus Oil
• Menthol

Menthol is used to relieve symptoms of chest congestion. There is NO data to support efficacy, and paradoxically, studies have indicated increased airflow resistance with application. There is a case report of an 18 month old who developed respiratory distress after application. Symptoms associated with overdose, or inappropriate route (mucosal, oral) are:

• Aspiration
• Apnea
• Laryngoconstriction
• Nausea
• Ataxia
• Cardiac and CNS toxicity (confusion, euphoria)

Camphor in products with higher concentrations such as Campho-phenique can cause additional toxicity with effects:

• GI symptoms
• CNS: confusion, hallucinations, excitation, coma, seizures
• Apnea
• Asystole

Treatment for both is supportive.
 

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Oseltamivir (Tamiflu)

• Has low protein binding and does not inhibit CYP450 (resulting in a low incidence of drug interactions)
• Requires dosage adjustment with creatinine clearance of < 30 ml/min
• Does not require dosage adjustment in patients with liver failure or the elderly
• Most common adverse effects are nausea and vomiting
• Serious effects include anaphylaxis and skin reactions. Neuropsychiatric effects reported include hallucinations, delerium and abnormal behavior
• It may be administered to infants and children due to the high potential morbidity associated with influenza

 

For complete indications and dosing: www.cdc.gov/h1n1flu/recommendations.htm

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• Recently, a study was published which compared adverse drug events in patients who had received either fomepizole or ethanol for ethylene glycol or methanol poisoning.
• Importantly, this is the first trial which has compared these events head to head.
• Retrospectively, 172 charts over a 9 year period were reviewed. Toxicologists identified at least 1 ADR in 74 of 130 ethanol treated cases (57%) versus 5 of 42 fomepizole treated cases (12%).
• Severe ADRs occurred in 20% of ethanol treated patients vs 5% fomepizole treated patients.
• This adds further data to support the use of choosing fomepizole over alcohol for treatment of toxic alcohol poisonings

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Clevidipine

• A new intravenous antihypertensive agent
• Has a very rapid onset (2-4 min) and offset (5-15 min), in contrast to the available IV calcium channel blocker nicardipine, which has a duration of action of 3-6 hours
• Contraindicated in patients with soy or egg allergies, and in those with defective lipid metabolism
• Most common ADR's reported were headache, nausea, and vomiting
• Initiate at 1-2 mg/hr, most respond at doses between 4-6 mg/hr
• Maximum recommended dose is 16 mg/hr
• Costs between $86 to $140 per 50 mg vial

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There have been multiple case reports of patients who have had coronary stents who have been on clopidogrel for > 1 year who have developed coronary thrombosis after clopidogrel cessation. There are also reports of patients who have developed DVTs likewise after clopidogrel cessation. In vivo studies in diabetics have demonstrated increased platelet and inflammatory markers after clopidogrel withdrawal. It appears that abrupt discontinuation of clopidogrel may lead to a thrombotic state in susceptible patients.

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Although we tend to think of ACS with cocaine use, there are many other serious complications, including:

• Agitation, psychosis, and anxiety
• Hyperthermia
• Vascular headache of withdrawal
• Seizures
• Hemorrhagic stroke (many of these patients have an underlying vascular abnormality)
• Ischemic stroke
• Acute Renal Failure
• Crack Lung: acute pulmonary syndrome that occurs after inhaling freebase cocaine presents as fever, dyspnea, hypoxemia, diffuse alveolar infiltrates, and respiratory failure
• Intestinal perforations

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