Podcast #251: Cyanide Poisoning

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist ? Emergency Medicine

Educational Pearls

  • Cyanide poisoning is suspected in patients who present with lactic acidosis after being trapped around burning household objects. It affects our ability to metabolize and can quickly lead to CV collapse and death.  
  • Because cyanide blood levels are not quickly available, the diagnosis is made by history and lactic acidosis on ABG.
  • The cyanokit is the key treatment. It contains hydroxocobalamin, which binds to cyanide so it can be excreted.
  • One side effect to be aware of is that the cyanokit will turn everything red, including mucous membranes, saliva, urine, and skin. This will interfere with some lab values, so make sure to get labs before administration.

References: Mégarbane B, et al. Antidotal treatment of cyanide poisoning. J Chin Med Assoc. 2003

Podcast #223: Acyclovir Toxicity

Author: Nick Hatch, M.D.

Educational Pearls

  • Acyclovir toxicity can uncommonly cause altered mental status, low blood glucose, hallucinations and myoclonic jerks.
  • Toxicity often occurs in the setting of renal insufficiency, as it is cleared by the kidneys.
  • Acyclovir is often used to treat shingles, which can also cause similar symptoms as acyclovir toxicity due to encephalitis – rule this out in the setting of a concomitant shingles infection.

References: http://www.rxlist.com/zovirax-drug.htm

Podcast #217: Designer Drugs

Author: John Winkler, M.D.

Educational Pearls:

  • Designer, or “synthetic” drugs include bath salts, synthetic THC, and many others.
  • Many of these drugs are originally manufactured in China and are shipped globally.
  • Treatment usually involves airway control and sedation – ketamine may be useful.
  • Traditional tox screens do not test for these drugs.

References: https://www.drugabuse.gov/related-topics/trends-statistics/national-drug-early-warning-system-ndews

Podcast #211: E-cigarettes

Author: Michael Hunt, M.D.

Educational Pearls:

  • Children under age of 6 are at greatest risk of accidental nicotine overdose from ingestion.
  • Biphasic presentation:
    • Hyperadrenergic = nausea, vomiting, tachycardia, flushing.
    • Bradycardia and respiratory depression.



Mayer B. How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century. Archives of Toxicology. 2013;88(1):5-7. doi:10.1007/s00204-013-1127-0.

Podcast #202: Tide Pods

Author: Susan Brion M.D.

Educational Pearls:

  • Laundry and dishwasher detergent pods resemble candy and can be ingested by children.
  • These tide pods are very highly concentrated and can cause chemical burns of the lips, airway, eyes, mouth and esophagus.
  • The strong bases in detergent pods (pH>12) can cause liquefactive necrosis, which can cause immediate perforation of the esophagus.
  • Common symptoms associated with ingestion of detergent pods include pain, dysphagia, drooling, mediastinal pain, upper airway inflammation. The presence or absence of symptoms does not indicate severity – suspected ingestions should be admitted and undergo bronchoscopy.
  • Mental status should be assessed rapidly because detergent ingestion can lead to CNS depression and aspiration.

References: Bonney AG, Mazor S, Goldman RD. Laundry detergent capsules and pediatric poisoning. Canadian Family Physician. 2013;59(12):1295-1296.


Podcast #198: Imodium

Author: Aaron Lessen M.D.

Educational Pearls:

  • Imodium (loperamide) is a mu-opioid receptor agonist. Traditionally, it is used as an anti-diarrheal. It is also abused recreationally for an opioid high and to self-treat opioid withdrawal.
  • 40 or more pills are often ingested. People often co-ingest with cimetidine to potentiate the desired effects.
  • Patients will present with opioid overdose symptoms (narrow pupils, respiratory depression).
  • Narcan is effective in reversing an overdose of Imodium.
  • Imodium prolongs QT and predisposes to Torsades, so monitor rhythm and then treat like any other opioid OD.

References: http://www.tandfonline.com/doi/abs/10.3109/15563650.2016.1159310

Podcast #190: Toradol Dosing

Author: Rachel Duncan, PharmD BCPS

Educational Pearls:

  • Toradol (Ketorolac) is an NSAID used for its anti-inflammatory properties
  • In practice, the common dosages are 30mg IV or 60mg IM
  • Clinical concerns arise in patients with renal insufficiency or bleeding, but the risks are small (<1%)
  • Studies have found that doses over 7.5mg have the same efficacy in pain control as higher doses
  • Consider lower-dose Toradol (15mg) and decrease dose in the elderly and those with a CrCl<50

References: Motov S, Yasavolian M, Likourezos A, et al. “Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial”. Ann Emerg Med 2016. http://www.annemergmed.com/article/S0196-0644(16)31244-6/fulltext

Podcast #189: Caffeine

Author:  Donald Stader M.D.

Educational Pearls:

  • Coffee originates from Ethiopia. Its “active ingredient” is caffeine
  • Caffeine is a xanthine alkaloid used in medicine to control headache and as a neonatal stimulant
  • Studies have shown that coffee may increase lifespan
  • Overdose can be encountered in those using diet pills or concentrated caffeine pills and is treated with dialysis

References: Juliano, LM et al. “A critical review of caffeine withdrawal: empirical validation of symptoms and signs, incidence, severity, and associated features.” Psychopharmacology, 2004. https://www.ncbi.nlm.nih.gov/pubmed?term=15448977

Podcast #185: Neuromuscular Blocking Agents

Run Time:  4:38 minutes

Author: Peter Bakes M.D.

Educational Pearls:

  • The Neuromuscular Junction (NMJ) is a neuronal synapse in skeletal muscle mediated by nicotinic acetylcholine receptors
  • Paralytic agents, commonly used in the ED for intubation, include succinylcholine and rocuronium/vecuronium
  • Succinylcholine is a depolarizing paralytic while rocuronium is a non-depolarizing agent.
  • A newly developed reversing agent, sugammadex, can be used to counter the effects of curonium based paralytics.  This is especially helpful due to the long duration of action of rocuronium (45 minutes to 1 hour) as compared to succinylcholine (<15 minutes)


References: https://www.acep.org/Physician-Resources/Clinical/Thoracic-Respiratory/Rocuronium-vs–Succinylcholine–Which-Is-Best-/

Podcast #170: Spice

synthetic-marijuana-plagues-southwest-floridaRun Time:  2 minutes

Author: John Winkler M.D.

Educational Pearls:

  • There are multiple synthetic marijuana alternatives that causes more amphetamine reaction. Known as Spice, K2, and many other names, they are made by changing the side branches of THC.
  • An overdose can cause a spectrum of reactions from general agitation to severe excited delirium to death.
  • Patients present physiologically with tachycardia, elevated blood pressure, elevated temperature, psychosis, and severe agitation.
  • It is important to make sure that the patient is kept calm and safe with multiple doses of sedating medication, end tidal CO2, and airway protection.
  • In New York City on 7/13/16 33 people had a suspected overdose on synthetic marijuana.
  • To make a synthetic marijuana illegal the exact chemical structure needs to be presented to the legislature, and can sometimes take up to 1 year. However, the frequency of changes in the chemical structure of synthetic marijuana hard to keep illegal.

Link to Podcast: http://medicalminute.madewithopinion.com/spice/

References: https://www.drugabuse.gov/publications/drugfacts/synthetic-cannabinoids