CASES IN MEDICAL TOXICOLOGY

1. CASES IN MEDICAL TOXICOLOGY Steven R. Offerman, MD Department of Emergency Medicine Kaiser Permanente Northern California South Sacramento Medical Center Sacramento, CA

2. (800) 411 - 8080

3. KAISER TOXICOLOGY

4. 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

5. 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.

6. CASE #1 • Acetaminophen level of 71mg/dL, AST=64, ALT=55, T bili=1.1 • Serum ethanol level of 95 mg/dL • No scleral icterus, no stigmata of liver disease

7. CASE #1 • Acetaminophen level of 71mg/dL, AST=64, ALT=55, T bili=1.1 • Serum ethanol level of 95 mg/dL • No scleral icterus, no stigmata of liver disease

11. 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)

12. RISK ASSESSMENT • Only two types of toxic ingestions! • Acute ingestion + known TOI (<24 hr) • Place on nomogram • Unknown TOI / Chronic ingestion • Check APAP + AST/ALT • No NAC if <5 and normal AST/ALT

14. 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

16. INTRAVENOUS NAC • Oral preparation vs Acetadote® • Concern is anaphylactoid reactions • Indications: • Can’t tolerate oral NAC • Contraindication to oral therapy • Ongoing GI decon (coingestant) • Fulminant hepatic failure? • Pregnant patient?

18. 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.

19. BRODIFACOUM • Warfarin derivative – “Superwarfarin” • Highly potent • Long half-life • Dehydration

20. BRODIFACOUM Ann Emerg Med 2002; 40: 73-5

21. 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.”

22. DRUG TESTING? Arch Pediatr Adolesc Med 2006; 160: 146-50

23. URINE IMMUNOASSAY

24. URINE IMMUNOASSAY • Opiates • Cocaine metabolite • Amphetamine • Benzodiazepines • Barbiturates * No urine screen can confirm intoxication, only exposure

26. 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

27. THE BAD • Opiates • Opiates screen, not opioids • Benzodiazepines • Test for oxazepam metabolite • PCP • Cross reacts with DXM & ketamine

28. OPIATES VS OPIOIDS • Opiates = from the poppy • Morphine, codeine, thebaine • Opioids = synthetic or semi-synthetic TARGET (300 ng/mL) 20,000 ng/mL

29. BENZOS • Urine immunoassay detects Oxazepam

30. 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

31. AMPHETAMINE ANALOGSChemistry of Getting High

32. 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)

33. 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)

34. GC - MS

36. 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.

37. ALEXANDER LITVINENKO

38. THALLIUM POISONING

39. POLONIUM 210 • Intense alpha emitter • Dangerous when incorporated into body • 5 million times more toxic than hydrogen cyanide by weight (LD50 50ng vs 250mg)

40. VIKTOR YUSHCHENKO

41. OPERATION RANCH HANDAgent Orange

42. DIOXIN

43. GEORGI MARKOV

45. RICINUS COMMUNIS

46. 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 doesn’t remember his meds • Initial vitals are: 90/55 75 18 37.4 • He seems mildly confused

47. CASE #5 • In the ED, he becomes progressively more bradycardic, hypotensive, and disoriented • His vitals now are BP=72/34 and HR=30

48. CASE #5

49. CCBs / BBs

50. CALCIUM CHANNEL BLOCKERS