Podcast # 464: Narcan’t?

Author: Aaron Lessen, MD

Educational Pearls:

  • A problem of take-home-naloxone is the administration of it by an able-bodied bystander
  • Australian study looked at consecutive opioid overdose deaths in a single year to identify characteristics of overdose and potential for bystander administered naloxone
  • Of the 235 fatal heroin overdoses reviewed, 83% were alone with only 17% (38 cases) having another person present
  • Half of those in the presence of others had a bystander that was not impaired
  • Take-home-naloxone needs a competent person to administer it. Make sure to review this along with other harm reduction strategies when prescribing/dispensing it to patients

References

Stam NC, Gerostamoulos D, Smith K, Pilgrim JL, Drummer OH. Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia. Clin Toxicol (Phila). 2019 May;57(5):325-330. doi: 10.1080/15563650.2018.1529319. Epub 2018 Nov 17. PubMed PMID: 30451007.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 463: Buproprion Overdose

Author: Erik Verzemnieks, MD

Educational Pearls:

  • Buproprion is used as an antidepressant and for smoking cessation
  • Severe buproprion overdoses can cause seizures and lead to cardiac dysrhythmias
  • Benzodiazepines are treatment of choice for seizures
  • Bicarbonate and Interlipid are also possible treatment options with less evidence

References

Stall N, Godwin J, Juurlink D. Bupropion abuse and overdose. CMAJ. 2014 Sep 16;186(13):1015. doi: 10.1503/cmaj.131534. Epub 2014 Apr 28. PubMed PMID: 24778361; PubMed Central PMCID: PMC4162783.

Balit CR, Lynch CN, Isbister GK. Bupropion poisoning: a case series. Med J Aust. 2003 Jan 20;178(2):61-3. PubMed PMID: 12526723.

Bruccoleri RE, Burns MM. A Literature Review of the Use of Sodium Bicarbonate for the Treatment of QRS Widening. J Med Toxicol. 2016 Mar;12(1):121-9. doi: 10.1007/s13181-015-0483-y. Review. PubMed PMID: 26159649; PubMed Central PMCID: PMC4781799.

Podcast # 462: Death after OD

Author: Don Stader, MD

Educational Pearls:

  • 10% of patients seen in the emergency department for opioid overdose patients will die within a year
  • Half of these overdoses will occur in the next month
  • This mortality rate is higher than patients with STEMI, of which 7% will die within one year
  • Take-home naloxone, as well as medication assisted treatment like buprenorphine can save lives

References

Olfson M, Crystal S, Wall M, Wang S, Liu SM, Blanco C. Causes of Death After Nonfatal Opioid Overdose. JAMA Psychiatry. 2018 Aug 1;75(8):820-827. doi: 10.1001/jamapsychiatry.2018.1471. PubMed PMID: 29926090; PubMed Central PMCID: PMC6143082.

Olfson M, Wall M, Wang S, Crystal S, Blanco C. Risks of fatal opioid overdose during the first year following nonfatal overdose.Drug Alcohol Depend. 2018 Sep 1;190:112-119. doi: 10.1016/j.drugalcdep.2018.06.004. Epub 2018 Jul 4. PubMed PMID: 30005310.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 459 Clonidine Ingestion

Author:  Julian Orenstein, MD

Educational Pearls:

 

  • Severe clonidine ingestion can present as a fluctuating mental status between typically accompanied by changes in vital signs (hypotension/bradycardia)
  • Respiratory depression requiring intubation is not uncommon

 

References

Isbister GK, Heppell SP, Page CB, Ryan NM. Adult clonidine overdose: prolonged bradycardia and central nervous system depression, but not severe toxicity. Clin Toxicol (Phila). 2017 Mar;55(3):187-192. doi: 10.1080/15563650.2016.1277234. Epub 2017 Jan 20. PubMed PMID: 28107093.

Spiller HA, Klein-Schwartz W, Colvin JM, Villalobos D, Johnson PB, Anderson DL. Toxic clonidine ingestion in children. J Pediatr. 2005 Feb;146(2):263-6. PubMed PMID: 15689921.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 455: Hunting for PeeCP

Author: Michael Hunt, MD

Educational Pearls:

 

  • Like all tests, urine toxicology (utox) screens can have false positives
  • Prescription medications such as demerol, antipsychotics, ketamine, and tramadol can all produce a false positive utox for PCP
  • Over-the-counter medication such as dextromethorphan also mimic PCP on utox

 

References

Doyon S. (January 2014). False Positive Urine Screens for Phencyclidine. ToxTidbits. Retrieved from https://www.mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2014/January%202014%20ToxTidbits.pdf

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 454: Tylenol Overdose

Educational Pearls:

 

  • Acetaminophen overdose can also present in patients taking too much over the course of days to weeks – not just intentional ingestions
  • If acute overdose is suspected, refer to the Rumak-Matthew nomogram to guide treatment based on time of ingestion and the time of level
  • In chronic overdose, Tylenol levels will not guide treatment
  • NAPQI is the toxic metabolite of acetaminophen
  • N-acetylcysteine (NAC) can be effective treatment in both acute and chronic overdoses
  • 7.5 g is the daily toxic dose of Tylenol in adults, 150mg/kg in children

 

 

References:

Smilkstein MJ. Acetaminophen. In: Goldfrank’s Toxicologic Emergencies, Goldfrank LR, Flomenbaum NE, Lewin NA, et al (Eds), Appleton & Lange, Stamford 1998. P.541.

Chiew AL, Gluud C, Brok J, Buckley NA. Interventions for paracetamol (acetaminophen) overdose. Cochrane Database Syst Rev. 2018 Feb 23;2:CD003328. doi: 10.1002/14651858.CD003328.pub3. Review. PubMed PMID: 29473717.

Lancaster EM, Hiatt JR, Zarrinpar A. Acetaminophen hepatotoxicity: an updated review. Arch Toxicol. 2015 Feb;89(2):193-9. doi: 10.1007/s00204-014-1432-2. Epub 2014 Dec 24. Review. PubMed PMID: 25537186.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast #449:  Banana Bags

Author: Dylan Luyten, MD

Educational Pearls:

  • A “banana bag” is a bag of IV fluid that contains various vitamins and minerals including folate and thiamine
  • IV fluids do not alter intoxicated patients recovery in the emergency department
  • Folate deficiency is rare in the intoxicated patient
  • Some intoxicated patients may be thiamine deficient, and those that would benefit the most need significantly more daily thiamine supplementation than provided in a banana bag

References:

Perez SR, Keijzers G, Steele M, Byrnes J, Scuffham PA. Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol-intoxicated patients in the emergency department: a randomised controlled trial. Emerg Med Australas. 2013 Dec;25(6):527-34. doi: 10.1111/1742-6723.12151. Epub 2013 Nov 8. PubMed PMID: 24308613; PubMed Central PMCID: PMC4253317.

Li SF, Jacob J, Feng J, Kulkarni M. Vitamin deficiencies in acutely intoxicated patients in the ED. Am J Emerg Med. 2008 Sep;26(7):792-5. doi: 10.1016/j.ajem.2007.10.003. PubMed PMID: 18774045.

ay E, Bentham PW, Callaghan R, Kuruvilla T, George S. Thiamine for prevention and treatment of Wernicke-Korsakoff Syndrome in people who abuse alcohol. Cochrane Database Syst Rev. 2013 Jul 1;(7):CD004033. doi: 10.1002/14651858.CD004033.pub3. Review. PubMed PMID: 23818100.

Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast #448:  Chronic Salicylate Toxicity

Author: Ryan Circh, MD

Educational Pearls:

  • Chronic salicylate (ASA) toxicity can present in elderly patients as altered mental status
  • Consider chronic toxicity in patients with an unexplained anion gap acidosis
  • Treatment for chronic ingestion typically  includes IV fluids and urine alkalinization

References:

O’Malley GF. Emergency department management of the salicylate-poisoned patient. Emerg Med Clin North Am. 2007 May;25(2):333-46; abstract viii. Review. PubMed PMID: 17482023.

Durnas C, Cusack BJ. Salicylate intoxication in the elderly. Recognition and recommendations on how to prevent it. Drugs Aging. 1992 Jan-Feb;2(1):20-34. Review. PubMed PMID: 1554971.

Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 440 : Carbon Monoxide Poisoning

Author: Katie Sprinkle, MD

Educational Pearl:

 

  • Carbon monoxide (CO) is the leading cause of death from poison world-wide
  • CO forms from the combustion of any carbon based product
  • Patients often present with non specific symptom like headache, vomiting, and malaise
  • Consider this diagnosis with multiple people presenting with similar symptoms from a single location
  • Treatment is with high flow oxygen (i.e. non-rebreather)
  • Hyperbaric therapy is controversial and up for debate – discussion with local consultants may help guide this management/transfer
  • Tobacco smokers typically have elevated levels of carbon monoxide at baseline

 

Editor’s Note: smoking hookah for one hour may be the equivalent of smoking nearly 100 cigarettes

References:

Jacob P, Abu Raddaha AH, Dempsey D, et al. Nicotine, carbon monoxide, and carcinogen exposure after a single use of a water pipe. Cancer Epidemiol Biomarkers Prev. 2011;20(11):2345-53.

Ng PC, Long B, Koyfman A. Clinical chameleons: an emergency medicine focused review of carbon monoxide poisoning. Intern Emerg Med. 2018 Mar;13(2):223-229. doi: 10.1007/s11739-018-1798-x. Epub 2018 Feb 12. Review. Erratum in: Intern Emerg Med. 2018 Mar 22;:. PubMed PMID: 29435715.

American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Carbon Monoxide Poisoning:., Wolf SJ, Maloney GE, Shih RD, Shy BD, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning. Ann Emerg Med. 2017 Jan;69(1):98-107.e6. doi: 10.1016/j.annemergmed.2016.11.003. PubMed PMID: 27993310.

Guzman JA. Carbon monoxide poisoning. Crit Care Clin. 2012 Oct;28(4):537-48. doi: 10.1016/j.ccc.2012.07.007. Review. PubMed PMID: 22998990.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast #394: Myths of Medication Assisted Treatment

Author: Katie Sprinkle, MD

Educational Pearls:

  • Medication Assisted Treatment (MAT) is the treatment of addiction with medications, commonly used for opioid use disorders
  • A long held belief is MAT simply replaces one addiction for another, which is patently false
  • MAT is one of the most affective methods to treat a patient with opioid addiction
  • Unfortunately, outdated requirements for prescribers along further prevent its widespread use

References:

Salsitz E, Wiegand T. Pharmacotherapy of Opioid Addiction: “Putting a Real Face on a False Demon.” Journal of Medical Toxicology. 2016;12(1):58-63. doi:10.1007/s13181-015-0517-5.

Duber HC, Barata IA, Cioè-Peña E, Liang SY, Ketcham E, Macias-Konstantopoulos W, Ryan SA, Stavros M, Whiteside LK. Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):420-431. doi: 10.1016/j.annemergmed.2018.04.007. Epub 2018 Jun 5. Review. PubMed PMID: 29880438.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD