CASES IN MEDICAL TOXICOLOGY

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CASES IN MEDICAL TOXICOLOGY

• Steven R. Offerman, MD
• Department of Emergency Medicine
• Kaiser Permanente Northern California
• South Sacramento Medical Center
• Sacramento, CA

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(800) 411 - 8080
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KAISER TOXICOLOGY
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CASE 1

• A 32yo alcoholic male presents to the ED
  complaining of severe migraine HA
• He reports taking two vicodin every 2 hours
  without relief, last dose about 3 hrs
• HA is similar to past migraines though severe, no
  numbness or weakness, denies abdominal pain or
  vomiting

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CASE 1

• Awake and alert. Appropriate/lucid. Wearing
  sunglasses. Pupils are midrange and reactive.
  Some photophobia. Lungs are clear. Abdomen soft
  with mild epigastric TTP. Neuro exam is normal.
• CBC normal. Electrolytes normal.

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CASE 1

• Acetaminophen level of 71mg/dL, AST64, ALT55, T
  bili1.1
• Serum ethanol level of 95 mg/dL
• No scleral icterus, no stigmata of liver disease

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CASE 1

• Acetaminophen level of 71mg/dL, AST64, ALT55, T
  bili1.1
• Serum ethanol level of 95 mg/dL
• No scleral icterus, no stigmata of liver disease

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POTENTIAL TOXICITY

• Acute 7g (10g)
• Chronic 4g per day (7g)
• Susceptible patients (alcoholics, ACs, INH)
• Similar risk for acute ingestion
• Potential higher risk in chronic ingestions (4g)

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RISK ASSESSMENT

• Only two types of toxic ingestions!
• Acute ingestion known TOI (lt24 hr)
• Place on nomogram
• Unknown TOI / Chronic ingestion
• Check APAP AST/ALT
• No NAC if lt5 and normal AST/ALT

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N-ACETYLCYSTEINE

• Very effective 100 within 8 hours
• Oral in U.S. IV in Europe
• Dose 140mg/kg load, 70mg/kg Q 4hrs
• Traditional 72 hours
• Short course reassess at 20 hours

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INTRAVENOUS NAC

• Oral preparation vs Acetadote
• Concern is anaphylactoid reactions
• Indications
• Cant tolerate oral NAC
• Contraindication to oral therapy
• Ongoing GI decon (coingestant)
• Fulminant hepatic failure?
• Pregnant patient?

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CASE 2

• 25 month old male brought into the ED by parents
  after he was found eating D-con rat poison.
• He was found 30 minutes ago with pellets in his
  mouth and in the front of his diaper.
• He has been behaving normally and has not
  vomited.
• He appears normal in the ED.

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BRODIFACOUM

• Warfarin derivative Superwarfarin
• Highly potent
• Long half-life
• Dehydration

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BRODIFACOUM
Ann Emerg Med 2002 40 73-5
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CASE 3

• 13 yo male is brought into clinic by his mother.
• She states I think my son is on drugs. He has
  been behaving strangely and hanging out with the
  wrong crowd.
• The patient denies any drug use.
• The mother insists that you test for drugs.

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DRUG TESTING?
Arch Pediatr Adolesc Med 2006 160 146-50
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URINE IMMUNOASSAY
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URINE IMMUNOASSAY

• Opiates
• Cocaine metabolite
• Amphetamine
• Benzodiazepines
• Barbiturates
• No urine screen can confirm intoxication, only
  exposure

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THE GOOD

• Cocaine metabolite Benzylecogonine
• Benzylecogonine longer lived
• No false positives
• Marijuana cannibinoids (THC)
• No false positives except Efavirenz
• Barbiturates
• Detects most class members reliably

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THE BAD

• Opiates
• Opiates screen, not opioids
• Benzodiazepines
• Test for oxazepam metabolite
• PCP
• Cross reacts with DXM ketamine

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OPIATES VS OPIOIDS

• Opiates from the poppy
• Morphine, codeine, thebaine
• Opioids synthetic or semi-synthetic

TARGET (300 ng/mL)
20,000 ng/mL
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BENZOS

• Urine immunoassay detects Oxazepam

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THE UGLY

• Amphetamines
• Many false positives
• Poor cross-reactivity with sympathomimetic amines
• TCA screen
• So many false positives that a positive test is
  more likely false than true

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AMPHETAMINE ANALOGSChemistry of Getting High
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AMPHETAMINE POSITIVE

• Legal amphetamines
• Vicks inhaler (l-methamphetamine)
• Dexamphetamine (Dexadrine, Adderall)
• Methylphenidate (Ritalin, Concerta)
• Drugs metabolized to amphetamines
• Benzaphetamine, clobenzorex, famprofazone,
  fenoproporex, selegiline (D-methamphetamine)

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AMPHETAMINE POSITIVE

• Cross reactive stimulants
• Ephedrine, fenfluramine, MDA, MDMA, PMA,
  phenteramine, phenmetrazine, pseudophedrine,
  phenylpropanolamine, and other amphetamine
  analogs
• Cross reactive nonstimulants
• Buproprion (Wellbutrin), chlorpromazine,
  labetalol, ranitidine, sertraline (Zoloft),
  trazadone, trimethbenzamide (Tigan)

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GC - MS
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CASE 4

• 44 yo male presents to a London hospital with
  severe abdominal pain, vomiting, and diarrhea.
• Upon presntation he is found to have
  pancytopenia. He was previously healthy.
• Over the first 5 days of his hospitalization he
  develops alopecia.

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ALEXANDER LITVINENKO
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THALLIUM POISONING
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POLONIUM 210

• Intense alpha emitter
• Dangerous when incorporated into body
• 5 million times more toxic than hydrogen cyanide
  by weight (LD50 50ng vs 250mg)

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VIKTOR YUSHCHENKO
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OPERATION RANCH HANDAgent Orange
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DIOXIN
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GEORGI MARKOV
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RICINUS COMMUNIS
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CASE 5

• A 74 year-old man is brought in by his son for
  dizziness that is worse with standing
• Pt has a history of mild dementia and
  hypertension
• He lives alone and doesnt remember his meds
• Initial vitals are 90/55 75 18 37.4
• He seems mildly confused

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CASE 5

• In the ED, he becomes progressively more
  bradycardic, hypotensive, and disoriented
• His vitals now are BP72/34 and HR30

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CASE 5
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CCBs / BBs
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CALCIUM CHANNEL BLOCKERS
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All substances are poisons there is none which
is not a poison. The right dose differentiates
poison from remedy. - Paracelsus (1493-1541)
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CALCIUM CHANNEL BLOCKERS

• Most commonly Rxed CV drug class
• 5 of toxic deaths in 2004 (TESS)

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CCBs
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CCB MANAGEMENT

• Initial / Supportive
• ABCs
• Fluids
• Atropine?
• Decontamination

• Pharmacotherapy
• Calcium
• Catecholamines
• Glucagon
• Insulin/Glucose (HIE)
• PDE inhibitors
• Cardiac pacing
• IA Balloon Pump

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CCB MANAGEMENT

• Initial / Supportive
• ABCs
• Fluids
• Atropine?
• Decontamination

• Pharmacotherapy
• Calcium
• Catecholamines
• Glucagon
• Insulin/Glucose (HIE)
• PDE inhibitors
• Cardiac pacing
• IA Balloon Pump

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CCB DECON

• BE AGGRESSIVE!!
• Gastric Lavage (early presentations)
• SD Activated Charcoal (all)
• MD Activated Charcoal (SR preps)
• Whole Bowel Irrigation (SR preps)
• Hemodialysis No role for CCBs

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CALCIUM THERAPY

• Calcium Chloride (Inotropic agent)
• 1g bolus (10 mL of 10 soln)
• Drip at 1-3g per hour in Normal Saline
• Central Line
• Monitor ionized Ca
• (Goal 2.5-3 mEq/L)
• Calcium gluconate can be used but 1/3 calcium
  load per mg

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Glucagon Mechanism
G
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GLUCAGON

• Dose
• 5-10 mg over 1-2 minutes
• Infusion Response dose / hour
• Adverse effects
• Nausea / vomiting
• Hyperglycemia
• Rare allergy (recombinant)

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HIE THERAPY
Boyer et al. Ped Emerg Care 2002 18 36
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HIE THERAPY

• Insulin / Glucose
• Animal data
• Human case series and reports
• Exact mech unknown carbo utilization
• High Dose !!
• Insulin 1 U/kg bolus
• Insulin infusion 0.5 1 U/kg/hour

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CCB/BB Poisoning - Insulin
Boyer et al. Ped Emerg Care 2002 18 36
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CASE 6

• A 14 month-old female was brought in after
  snakebite to the face when she encountered a
  snake while playing in her backyard.

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FACIAL STRIKE
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DEADLY ENVENOMATION

• Death is rare! (5 deaths per year)
• Local effects usually most prominent
• (Limb threat gtgt Life threat)
• Life-threatening envenomations
• Intravascular strikes
• Anaphylactoid
• Facial / neck strikes

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CROTALINE FAB ANTIVENOM

• Fab-antibody based antidote (digibind)
• Ovine (sheep) serum
• 4 North American snakes
• (Western Eastern DB, Mojave, cottonmouth)
• More potent
• Fewer allergic reactions
• No serum sickness

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THE END