name that poison! kent r. olson, md medical director, sf division california poison control system
TRANSCRIPT
Name that poison!
Kent R. Olson, MDMedical 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
Continued . . .
No response to naloxone Treated supportively, eventually
recovered
Initial Hx: GM takes lisinopril, HCTZ Also using eye drops for glaucoma
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
Case
What’s that?!?
Radiopaque pills and poisons
“CHIPS”– Chloral hydrate– Iron, lead, other metals– Phenothiazines– Sodium
Also:– Potassium, Calcium– Pepto-Bismol– Some SR preparations
Iron pillsIron pills
Pepto-BismolPepto-Bismol
Enteric-coated Potassium
Enteric-coated Potassium
Case
Young woman with a headache BP 138/100 HR 38/min, irregular
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!
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...
“... significant concerns because of ... the inability to predict who is at risk.”
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
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
“...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)...”
“...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)...”
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
Continued . . .
CT and LP negative Blood Cx negative Special analysis for
dextromethorphan was positive
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™
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.”
More on dextromethorphan . . .
Anecdotal reports of cases of dramatic and unexpected responses
Potential mechanism: genetically-related poor liver metabolism (CYP2D6 isoform)– Swiss 10%– Swedes 6.8%– French 3.9%– Chinese 1%
Case
Young woman had a seizure Had been at a “Rave” party the night
before Na 116 mEq/L Had consumed about 5 L
water during the evening
Ecstasy-induced hyponatremia
SIADH? or Excessive water intake?– a common practice in rave clubs to
reduce the risk of dehydration and heat stroke
Gut decontamination
Current consensus:– Gut emptying of limited value– AC alone probably fine in most patients
Some twists:– SI still useful at home w/in 5-10 min?– Lavage for selected cases?– Role of Whole Bowel Irrigation?–What about home AC?
Anyonefor
charcoal?
California Poison Control System Public Hotline: 1-800-876-4766
8-POISON Health Professionals: 1-800-411-8080 300,000 exposures/year– 2/3 are kids– also: suicides, occupational, hazmat,
veterinary, consumer product recalls, ... Most kids can be managed at home– PCC can communicate with 9-1-1 or
paramedics on scene