Several drugs and compounds may be radiopaque on an abdominal radiograph. This may be helpful in an overdose to determine ingestion or amount ingested. Attached is a pic a patient that ingested potassium sustained release tables.
The mneumonic CHIPES will help you remember which are:
C - Calcium Carbonate, chloral hydrate
H - Heavy metal - like Mercury, lead
I - Iron and Iodine
P - Phenothiazines (compound that has S(C6H4)2NH in it), drugs that include: antipsychotics like chlorpromazine (thorazine) and antiemetics like prochlorperazine (compazine)
E - Enteric coated pills
S - Solvents [halogenated ones like chloroform] and Sustained Release preparations [Lithobid and K-Dur]
Many drugs/toxins cause nystagmus, particularly in overdose. Vertical, horizontal, or rotary nystagmus may be noted.
The most common drug/toxin overdoses that cause nystagmus are the following:
When you draw a urine toxicology screen it can mislead more often than help you. Here is a quick list of the test followed by some medications that cause false positives - when in doubt, call your lab to find out specifics since results will vary lab to lab:
TCA - diphenhydramine, carbamazepine, cyclobenzaprine (side note: TCA screen should never be used to determine TCA toxicity, your ECG and physical exam should be enough to determine if the patient is toxic from TCA
Cocaine - the most accurate test on the screen, positive for up to 5 days
PCP - dextromethorphan and ketamine can turn it positive
Amphetamines - pseudoephedrine, ephedrine, phenylephrine and many other OTC cough decongestants can as well, the worst screening test with the largest number of false positives
According to the Food Allergy and Anaphylaxis Network, the eight most common food allergies, which account for 90% of the food allergies in the U.S., are: dairy, soy, wheat, shellfish, fish, peanut, tree nut, and egg.
Several medications are formulated with these ingredients and should be avoided in patients with reported allergies.
| 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 |
When a child is reported to be exposed to a rat poison it is commonly a long acting coumarin like brodifacoum. The rat usually eats the poison then during its traumatic little life will cause its own death by jumping and squeezing through a crack. When a human is exposed, this is the typical sequence of events:
Treatment is the same as for coumadin, vitamin K. However, do not start empirically since the patient will be committed to high doses of vitamin K for several months. Let the patient prove they have been poisoned which means they will require recheck of their INR 2-3 days later though they can be sent home with specific warning signs of anticoagulation.
With all of the post-transplant patients we see in the ED, a refresher on the toxicities associated with the most common immunosuppressant medications is warranted.
Cyclosporine (Sandimmune® and Neoral®/Gengraf®) and tacrolimus (Prograf®) are both calcineurin inhibitors that inhibit activation and proliferation of T-lymphocytes and IL-2.
- Major concerns: Nephrotoxicity, drug interactions (CYP3A4)
- Adverse Effects:
o Electrolyte abnormalities: K+, ¯Mg+, glucose
o CNS: HA, tremor (statistically higher with tacrolimus)
o CV: HTN, lipids (increased with cyclosporine)
o End organ: hepatotoxicity, nephrotoxicity
o Cosmetic (cyclosporine specific): hirsutism, gingival hyperplasia, acne
Sirolimus/Rapamycin (Rapamune®) is an M-tor inhibitor that inhibits T-lymphocyte activation and proliferation.
- Major concerns: Drug interactions (CYP3A4)
- Adverse Effects:
o Delayed wound healing
o Leucopenia, thrombocytopenia
o Hypercholesterolemia
CARBAPENENEMS
TIGECYCLINE
AMIKACIN
COLISTIN
Radiocontrast Induced Nephropathy (RCIN)
Quinolone Induced Deliurim
Just to give you another reason NOT to give a quinolone - aside from the C. diff. This adverse effect occurs with quinolones unlike many other antibiotics. It can prolong hospital stay, cause falls and further medical work ups. Some risk factors are:
As we are now into the winter months, exposures to ethylene glycol (antifreeze) and methanol (windshield washer fluid) increase. Here is a good mnemonic for sorting through an anion gap metabolic acidosis:
C – cyanide, carbon monoxide
A – alcoholic ketoacidosis, acetaminophen (massive OD)
T – toluene (chronic from glue sniffing)
M – methanol, metformin
U – uremia
D – diabetic ketoacidosis
P – propofol infusion syndrome, propylene glycol, paraldehyde
I – iron, isoniazid, ibuprofen (massive OD)
L – lactic acidosis
E – ethylene glycol
S – salicylates, starvation ketoacidosis
A quick christmas one:
The Christmas Rose (Helleborus niger)
Actually containes cardioactive steroids - eating it will help your A fib with RVR as it will act like digoxin, as well as kill like it.
Here is a table adapted from Goldfrank's Textbook of Toxicologic Emergencies 8th Edition - Drugs that May Induce Parkinsonism. MPTP is the story that everyone hears about and actually has links to Maryland. In 1976, Barry Kidston, a 23-year-old chemistry Maryland graduate student, synthesized MPPP (Meperidine or Demerol) incorrectly and injected the result. It was contaminated with MPTP, and within three days he began exhibiting symptoms of Parkinson's disease. Ooops - permanent.
Reversible
Irreversible
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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:
Causing:
STAY TUNED FOR DOSING AND ADVERSE EVENTS!
The newest antidote for cyanide poisoning, hydroxocobalamin, has several advantages over the older Cyanide Antidote Kit (amyl nitrite, sodium nitrite, sodium thiosulfate). Hydroxocobalamin works rapidly, does not induce methemoglobinemia, and does not cause vasodilation/hypotension.
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Toxicology Expert: Poisoning Of Harvard University Scientists "No Accident"
