Must-read post: Why dialyze patients with chronic, asymptomatic hyperlithemia?
About a month ago I discussed a new state-of-the-art review of lithium poisoning, which I rated “four skulls” and called a near must-read. Now comes a superb post entitled “Why dialyze patients with chronic, asymptomatic hyperlithemia” from Josh Farkas from PulmCrit.org and emcrit.org. It is essential reading for all clinicians who deal with lithium poisoned patients. Dr. Farkas makes the following important points: A single lithium level, not correlated with the patient’s clinical condition or history, does not provide much useful information. The serum lithium level does not correlate wel...
Source: The Poison Review - September 20, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical chronic extrip hemodialysis lithium poisoning Source Type: news

Must-read: ayahuasca in America
Ecuadorian ayahuasca shaman (Ammit Jack/shutterstock.com) In the current (Sept 12) issue of The New Yorker. Ariel Levy writes about the drug-fueled South American shamanistic ritual ayahuasca (or yagé,) and how its plants and practices are being imported to “hip” American areas such as Brooklyn and Silicon Valley. As TPR has explained before: Pharmacologically, ayahuasca is quite interesting. It is commonly made by macerating and boiling together parts of the plants Banisteriopsis caapi and Psychotria viridis. Neither of these plants, taken alone, has psychedelic properties. P. viridis does contain DMT, a p...
Source: The Poison Review - September 9, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical ariel levy ayahuasca Banisteriopsis caapi dmt New Yorker psychotria viridis Source Type: news

Case series: 8 patients exposed to phony alprazolam (Xanax) containing fentanyl and/or etizolam
3 out of 5 stars Adverse Effects From Counterfeit Alprazolam Tablets. Arens AM et al. Ann Emerg Med 2016 Aug 8 [Epub ahead of print] Reference In March of this year,there were 9 deaths reported in Pinellas County, Florida (the Tampa/St. Petersburg area) associated with fake alprazolam (Xanax) tablets containing fentanyl. Earlier, similar counterfeit pills had been seen around San Francisco and in Monroe County Southern Illinois. This letter, from the University of California-San Francisco and the California Poison Control System describes 8 cases — including 1 cardiac arrest — from that region. An additional victim ...
Source: The Poison Review - August 25, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical alprazolam counterfeit etizolam fake phony xanax Source Type: news

State-of-the-art review of lithium poisoning: almost a must-read
4 out of 5 stars Lithium Poisoning: State of the Art.  Baird-Gunning J et al. J Intensive Care Med 2016 Aug 11 [Epub ahead of print] Abstract This is a very good paper, the best comprehensive review I can remember reading on lithium. It is up to date, with 78 references as recent as 2015. A major reason I liked it so much is that the authors are quire frank about how much we don’t know, and resist giving, for instance, mandates about when to start hemodialysis based on lithium levels. This is a temptation that the authors of the recent ExTRIP review  succumbed to. Interestingly, the two papers share an author (So...
Source: The Poison Review - August 20, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical lithium poisoning Review TUSH ultrasound Source Type: news

Elephant-tranquilizer (carfentanil)-tainted heroin showing up in Ohio
4 out of 5 stars Human Health Hazards of Veterinary Medications: Information for Emergency Departments. Lust EB et al. J Emerg Med 2011 Feb;40:198-207 Abstract Yesterday, Canadian police announced that, earlier in the summer, they had seized one kilogram of carfentanil contained in a package labelled “Printer Parts” shipped from China and addressed to a man in Calgary. Carfentanil is frequently, and accurately, referred to as an “elephant tranquilizer.” It is a fentanyl analog with a potency 10,000 times that of morphine (or 100 times that of fentanyl.) It is not approved for any medical indicatio...
Source: The Poison Review - August 10, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical animal tranquilizer carfentanil opiate opioid tainted heroin Source Type: news

Seven cases of laboratory-confirmed exposures to the synthetic cannabinoid MDMB-CHMICA
3 out of 5 stars Clinical toxicity following analytically confirmed use of the synthetic cannabinoid receptor agonist MDMB-CHMICA. A report from the Identification Of Novel psychoActive substances (IONA) study. Hill SL et al. Clin Toxicol 2016 Sep;54:638-643. Abstract MDMB-CHMICA is a synthetic cannabinoid receptor agonist (SCRA) with strong affinity for the CB1 receptor. It has to date not been banned in may localities, and is available on the street under labels such as “AK47 Loaded,” “Manga Hot,” “Black Diamond,” and “Sweet Leaf Obliteration.” It use has been associated w...
Source: The Poison Review - August 8, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical MDMB-CHMICA sweet leaf synthetic cannabinoid Source Type: news

Seven cases of laboratory-confirmed exposed to the synthetic cannabinoid MDMB-CHMICA
3 out of 5 stars Clinical toxicity following analytically confirmed use of the synthetic cannabinoid receptor agonist MDMB-CHMICA. A report from the Identification Of Novel psychoActive substances (IONA) study. Hill SL et al. Clin Toxicol 2016 Sep;54:638-643. Abstract MDMB-CHMICA is a synthetic cannabinoid receptor agonist (SCRA) with strong affinity for the CB1 receptor. It has to date not been banned in may localities, and is available on the street under labels such as “AK47 Loaded,” “Manga Hot,” “Black Diamond,” and “Sweet Leaf Obliteration.” It use has been associated w...
Source: The Poison Review - August 8, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical MDMB-CHMICA sweet leaf synthetic cannabinoid Source Type: news

Counterfeit Norco containing fentanyl and the synthetic opioid U-47700
3 out of 5 stars Fentanyl and a Novel Synthetic Opioid U-47700 Masquerading as Street “Norco” in Central California: A Case Report. Armenian P et al. Ann Emerg Med 2016 [Epub ahead of print] Full Text In a recent “Toxicology Rounds” column for Emergency Medicine News, I pointed out that designer opioids such as U-47700 are being identified in street drug specimens and overdose cases with increasing frequency. Knowing this, I was not really surprised when it was announced last week that the autopsy on music superstar Prince confirmed the presence of U-47700, as well as fentanyl. U-47700 is a synt...
Source: The Poison Review - July 28, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical counterfeit Norco synthetic opioid U-47700 Source Type: news

All bleeding stops — but does idarucizumab (Praxbind) make it stop faster?
3.5 out of 5 stars Persistent life-threatening hemorrhage after administration of idarucizumab. Alhashem HM et al. Am J Emerg Med 2016 June 30 [Epub ahead of print] Reference Dabigatran (Pradaxa) is a direct thrombin inhibitor approved for stroke and embolism prophylaxis in patients with non-valve-related atrial fibrillation. When it was first released in 2008, a major disincentive to widespread use was the lack of a reliable reversal agent to treat major bleeds, or to administer before necessary invasive procedures. In October 2015, the U.S. Food and Drug Administration approved idarucizumab (Praxbind), a monoclonal ant...
Source: The Poison Review - July 27, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical anticoagulant hemorrhage idarucizumab pradaxa praxbind reversal agent Source Type: news

A normal (or negative) anion gap does NOT rule out salicylate toxicity
3 out of 5 stars Salicylate toxicity in the absence of anion gap metabolic acidosis. Bauer S, Darracq MA. Am J Emerg Med  2016 Jul;34(7):1328.e1-3 Reference Moderate-to-severe salicylate toxicity typically presents with a combined metabolic acidosis and respiratory alkalosis. Often, the arterial blood gas shows a pH quite near the normal 7.4, but with decreased pCO2 and decreased bicarbonate. However, occasional case reports have shown that in these cases the anion cap may, rarely, but normal or even negative. This seems to be related to specific electrodes that measure chloride level loosing selectivity as they age, an...
Source: The Poison Review - July 23, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical anion gap aspirin poisoning laboratory error salicylate toxicity Source Type: news

Fentanyl can cause serotonin syndrome
3.5 out of 5 stars Serotonin Syndrome Induced by Fentanyl in a Child: Case Report. Robles LA. Clin Neuropharmacol 2015 Sept-Oct;38:206-8. Abstract When many clinicians think of serotonin syndrome (SS), they consider the usual suspects: Selective Serotonin Uptake Inhibitors (SSRIs) Citalopram Fluoxetine Sertraline Escitalopram Paroxetine Serotonin-Norepinephrine Reuptake Inhibitors Venlafaxine Duloxetine Antidepressants Trazodone Buspirone Clomipramine Aside from these common culprits, there are other commonly used drugs whose clear association with serotonin syndrome is less-often realized: Fentanyl Methadon...
Source: The Poison Review - July 8, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical fentanyl opioid serotonin syndrome Source Type: news

Loperamide (Imodium) overdose can cause fatal cardiac toxicity
A recent paper described two fatalities associated with overdose of the anti-diarrhea drug loperamide (Imodium.) This drug, once available by prescription only, had been thought so safe that in 1988 it was approved for purchase over-the-counter. Here are some important questions regarding this medication: Why is it sometimes called the “poor man’s methadone”? Why, despite having typical opiate μ-receptor activity, does it generally not cause respiratory or mental status depression? Why is P-glycoprotein (P-gp) important for understanding the pharmacokinetics of loperamide, and what does that have to do ...
Source: The Poison Review - July 4, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical cardiotoxicity imodium loperamide opiate P-glycoprotein Source Type: news

Acetaminophen and N-acetylcysteine are removed by hemodialysis
3.5 out of 5 stars Massive acetaminophen overdose: effect of hemodialysis on acetaminophen and acetylcysteine kinetics. Ghannoum M et al. Clin Toxicol 2016 Jul;54:519-22. Abstract As we’ve discussed before, massive acetaminophen [APAP] overdose may be a somewhat different beast from the usual, run-of-the-mill case that reliably responds to N-acetylcysteine [NAC] (if administered at an early stage.)There is evidence that a very large intake of APAP (some say >500 mg/kg) can poison mitochondria, causing severe effects that manifest even before onset of hepatotoxicity. “Massive overdose” is suggested b...
Source: The Poison Review - June 30, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical acetaminophen acetylcysteine hemodialysis massive overdose Source Type: news

A can ’t miss item in the differential diagnosis of neuroleptic malignant syndrome
2 out of 5 stars Psychiatric Emergencies for Clinicians: Emergency Department Management of Neuroleptic Malignant Syndrome. Wilson MP et al. J Emerg Med 2016;51:66-69. Reference This review article about neuroleptic malignant syndrome (NMS) is brief but disappointing and misleading on some points. For example, the authors state that: The majority of cases of NMS develop symptoms within the first week [after starting the offending medication], and virtually all develop symptoms within the first 30 days. The clinician who takes this statement to the bank could easily miss late-onset NMS occurring as a result of dose change,...
Source: The Poison Review - June 22, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical anti-NMDA receptor encephalitis dantrolene neuroleptic malignant syndrome Source Type: news

A can’t miss item in the differential diagnosis of neuroleptic malignant syndrome
2 out of 5 stars Psychiatric Emergencies for Clinicians: Emergency Department Management of Neuroleptic Malignant Syndrome. Wilson MP et al. J Emerg Med 2016;51:66-69. Reference This review article about neuroleptic malignant syndrome (NMS) is brief but disappointing and misleading on some points. For example, the authors state that: The majority of cases of NMS develop symptoms within the first week [after starting the offending medication], and virtually all develop symptoms within the first 30 days. The clinician who takes this statement to the bank could easily miss late-onset NMS occurring as a result of dose change,...
Source: The Poison Review - June 22, 2016 Category: Toxicology Authors: Leon Gussow Tags: Medical anti-NMDA receptor encephalitis dantrolene neuroleptic malignant syndrome Source Type: news