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Name that poison!

Name that poison!. Kent R. Olson, MD Medical Director, SF Division California Poison Control System. Case. 9 month old being watched by grandmother Found flaccid, grunting, with decreased level of consciousness HR 70/min, BP 105/59 Resp agonal, O2 sat 80% Pupils pinpoint.

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Name that poison!

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  1. Name that poison! Kent R. Olson, MD Medical Director, SF Division California Poison Control System

  2. Case • 9 month old being watched by grandmother • Found flaccid, grunting, with decreased level of consciousness • HR 70/min, BP 105/59 • Resp agonal, O2 sat 80% • Pupils pinpoint

  3. Continued . . . • No response to naloxone • Treated supportively, eventually recovered • Initial Hx: GM takes lisinopril, HCTZ • Also using eye drops for glaucoma

  4. Continued . . . • Alphagan™ (brimonidine 0.2%) • used for open-angle glaucoma • Stimulates -2 receptors (similar to clonidine) • CNS depression, bradycardia, HOTN • Peripheral: alpha-agonist can elev BP • J Tox Clin Tox 1997; 35:506 also describes a case w/ recurrent episodes of hypotonia, bradypnea

  5. Case • What’s that?!?

  6. Radiopaque pills and poisons • “CHIPS” • Chloral hydrate • Iron, lead, other metals • Phenothiazines • Sodium • Also: • Potassium, Calcium • Pepto-Bismol • Some SR preparations

  7. Iron pills

  8. Pepto-Bismol

  9. Enteric-coated Potassium

  10. Case • Young woman with a headache • BP 138/100 HR 38/min, irregular

  11. Phenylpropanolamine • Strong alpha agonist: •  vascular resistance • Elevated BP • Reflex bradycardia or even AV block • not due to “Cushing reflex” • Treatment: • Vasodilator (eg, phentolamine, NP) • caution if pt has already stroked • Do NOT give atropine for bradycardia!

  12. 11-6-2000: FDA’s MedWatch • “FDA is taking steps to remove phenylpropanolamine hydrochloride from all drug products due to the risk of hemorrhagic stroke... • “...FDA has significant concerns because of the seriousness of stroke and the inability to predict who is at risk… ”

  13. Case • Healthy 2 yo F became agitated • T 102.7 F • HR 163/min RR 43/min • Pupils widely dilated • Profusely diaphoretic • Bowel sounds present • Accuchek blood glucose normal

  14. Continued . . . • The parents brought in a half-empty bottle of Amp II Pro Drops™that had accidentally been left open and was found near the child • Product is a weight loss supplement containing ephedrine

  15. “...Based on thermogenesis, which increases the rate at which the body burns fat. Amp II Pro Drops is a synergistic, unique blend of ingredients. From improved metabolic system functions, more energy can be achieved and weight management maximized. It contains 5 herbal extracts, DMAE and B-12. It is an appetite controller with energizers; stimulates free breathing, enhances athletic performance, increases stamina, endurance and alertness. (Do not use if you have high blood pressure, are pregnant or lactating)...”

  16. Case • 6 yo F acting strange • Talking nonsense, ? hallucinating • Tremulous, ataxic • T 38º C, HR 160/min • Pupils a little dilated, bowel sounds present, skin dry but not flushed • Urine toxicology screen negative

  17. Continued . . . • CT and LP negative • Blood Cx negative • Special analysis for dextromethorphan was positive

  18. Dextromethorphan (“DMX”) • Common OTC cough suppressant • Odd pharmacology: • d-isomer of opioid levorphanol • antitussive but not analgesic • antagonizes NMDA receptors • inhibits serotonin reuptake • Popular drug of abuse in teens • OTC cough syrups, Coricidin

  19. What's the DXM Trip Like? “Well, that depends on how much you take. There are four different kinds of experiences, based on the dosage; these are called plateaus. The first plateau is a mild stimulant effect with a little bit of a buzz... The second plateau is more intoxicating and has been compared to being drunk and stoned at the same time. The third plateau is dissociative, like a lower dose of ketamine. The fourth plateau is fully dissociative like a higher dose of ketamine.”

  20. More on dextromethorphan . . . • Anecdotal reports of cases of dramatic and unexpected responses (esp. in Orientals) • Potential mechanism: genetically-related poor liver metabolism (CYP2D6 isoform)

  21. Case • Young woman had a seizure • Had been at a “Rave” party the night before • Na 116 mEq/L • Had consumed about 5 Lwater during the evening

  22. Ecstasy-induced hyponatremia • SIADH? or • Excessive water intake? • a common practice in rave clubs to reduce the risk of dehydration and heat stroke

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