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


Podcast #151: The Most Common Fatal Ingestions

be53de65-7db5-4265-b1e5-4d2022d56af9Run Time: 8 minutes

Author: Peter Bakes M.D.

Educational Pearls:

  • CO poisoning is one of the most common fatal accidental ingestions.
  • Two main causes of CO poisoning are 1) SI – such as a car left running in closed space, which accounts for ⅓ of CO poisoning 2) Any tool/appliance that runs on fuel and produces CO from incomplete combustion of that fuel.
  • Exposure to a CO level of 50-100 parts per million for a few hours is when patients start to feel symptomatic. Where as, a CO2 in ambient air is at 400 parts per million.
  • Pathophysiology – CO has a 120 times higher affinity to hemoglobin than O2, CO causes functional anemia, CO causes lipid peroxidation, CO binds to cytochromes which inhibits energy production, and CO binds to myoglobin which decreases cardiac function.
  • The classic clinical presentation of CO poisoning is flu-like illness with a low energy state. CO can also cause ataxia, cognitive problems, and cerebellar dysfunction due to its toxicity to the brain. It is one of the only diseases which causes headache and chest pain at the same time.
  • In the ED test a carboxyhemoglobin level – greater than 20% is when the patient is in need of immediate treatment.
  • In the ER patients are placed on an O2 non-rebreather, or in more severe cases can be placed in hyperbaric chamber.
  • CO has a half-life of 4-6 hours in normal air with an O2 concentrations of 21%. With the non-rebreather the half-life is decreased to 60-90 minutes, and in a hyperbaric chamber the half-life is again decreased to 20-30 minutes.
  • Patients are treated until they become asymptomatic. Patients further removed from the exposure may need neuro-psychiatric testing for prolonged cognitive problems caused by hypoxia and lipid peroxidation.
  • Interestingly, families who believe they lived in a haunted house may have been exposed to toxic CO and experienced delusions and delayed manifestations when in the “haunted house”, but when leaving the house the family will begin to feel better.

Link to Podcast: http://medicalminute.madewithopinion.com/the-most-common-fatal-ingestion/

References: https://medlineplus.gov/carbonmonoxidepoisoning.html

Podcast #138: Bromide Toxicity – 1966

bromo-seltzer-bottleRun Time: 3 minutes

Author: Christopher Holmes M.D.

Educational Pearls:

  • In the chapter on altered mentation in a 1966 pamphlet on handling emergency medical situations, the number one suspicion of altered mental status was toxic substance ingestion.
  • The key suspects for toxic ingestion at that time were benzodiazepines and bromide toxicity. They specifically state in the pamphlet that opiods are rarely a cause for altered mentation.
  • Bromide was commonly used in the 18th and 19th century as a headache remedy and sedative. Until the 1970s, bromo-seltzer was used for headaches before being withdrawn from the market. Bromide is currently used to treat epilepsy in dogs and in Germany.
  • Reportedly, bromide was given to the British soldiers of WW I and people with epilepsy during Victorian times to decrease their sexual drive. Epilepsy was believed to be caused by masturbation, during the Victorian age, and therefore decreasing sexual drive decreased seizure activity.
  • The half-life of bromide is 12.5 days, so chronic use leads to bromism. 5-7% of psych admissions were due to bromism caused by the chronic use of bromide. The maximum daily recommended dose of bromide is 0.5 to 1 gram per day to avoid toxicity. In the 1960s, typical doses were between 3-5 grams per day.
  • Symptoms include somnolence, psychosis, seizures, delirium, headache, fatigue, ataxia, memory loss, restlessness, irritability, and hallucinations.
  • The treatment is a fluid flush and salt load the patient.

Link to Podcast: http://medicalminute.madewithopinion.com/bromide-toxicity-1966/

References:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2385720/pdf/ulstermedj00100-0055.pdf