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TOX UPDATE
KENT EMS ROUNDS
Kevin O'Connell MD
STUPID THINGS PEOPLE DO
BATH SALTS
BATH SALTS
Similar to amphetamines
Synthetic drugs sold in gas stations as “not for human consumption
Started in Europe few years ago
Now in US and a cause for frequent ER visits
BATH SALTS
Crystal or powder that is smoked, ingested, snorted, or injected
Frequently overdosing
Legal status of drugs
BATH SALTS
Cathinones:
MDPV – methylenedioxypyrovalerone
Methylone
Mephedrone
Keeps changing to ingredients to avoid legal issues
BATH SALTS
Increases catecholamines at synapses
Hallucinations, paranoia, violence
Tachycardia, MI
Renal or Liver failure
Trend toward increased use in mental health patients
BATH SALTS
Supportive care, IV fluids
Sedation: Ativan/Haldol
Social Service issues
May show up on Tox screen as PCP
SYNTHETIC CANABIS
SYNTHETIC CANNABIS
Initially marketed as mixture of legal herbs with cannabis-like affect
Is actually a bunch of herbs sprayed with synthetic cannabinoids
“K2”
“SPICE”
NATURAL CANABIS
SYNTHETIC CANABIS
SYNTHETIC CANABIS
John W. Huffman from Clemson University invented most synthetic canabinoids
“It bothers me that people are so stupid as to use this stuff”
SYNTHETIC CANNIBIS
Similar affect as cannabis, except less predictable
Increased psychotic features - ? If natural cannabis has “antipsychotic chemical”
Increased agitation and vomiting
More addictive behavior
Possible cardiac and seizure increase
BEFORE COCAINE
AFTER COCAINE
COCAINE
From Coca leaves in South America
1884 – Dr Halstead first used cocaine medically for nerve block
1885 - Dr Halstead became first cocaine impaired physician
Sigmond Freud recommended cocaine for various ailments
1885 – Coca Cola contained 60 mg cocaine/8oz
COCAINE
Benzoylmethylecgonine
Powder form – topically absorbed
“Crack” - freebase form, vaporizes with heat
Can be smoked – eliminates vasoconstriction associated with topical cocaine
COCAINE
BILL COSBY
“They say that cocaine intensifies your personality”
“Well, what if your an asshole?”
COCAINE
Causes euphoria, increased energy
BUT, also puts strain on every organ system
Can cause stroke, MI, arrythmias, death
Does have high addiction potential
METHAMPHETAMINE
Produce euphoria and stimulant effect similar to cocaine
Very addictive
Effects last longer than cocaine
Easily synthesized
“Ice” form can be smoked – similar to crack
METHAMPHETAMINE
“METH MOUTH”
METHANOL
Organic solvent Industrial uses Common problem in developing world
Methanol
Metabolized in liver – ADH to formadehyde Aldehyde dehydrogenase to to formic acid Tetrahydrofolate to CO2 and H2O (slow)
resulting in formic acid buildup Causes metabolic acidosis
METHANOL SYMPTOMS
Initially similar to alcohol 12 – 24 hours until toxic effects – depends on
competitive inhibition with alcohol Somnolence, vomiting, headache, abdominal
pain, seizures, vision loss, neuropathies, cardiac failure, death
OSMOLAL GAP
Calc osm= 2(NA) + (glucose/18) + (BUN/2.8) +ETOH/4.6 + Isopropol/6.0 + Meth/3.2 + Ethy
Glycol/6.2 Difference between measured serum osm and
calculated osm = osmolar gap Osmolar Gap > 10 is definitely abnormal Caution with normal gap with early presentation
METHANOL TREATMENT
IV Fluids, Bicarb, supportive care Delay methanol metabolism – ethanol or
fomepizole Dialysis if serum methanol > 20mg/dl, if > 30ml
ingested, visual complications or acidosis not responsive to bicarb
ANTIDOTES
ETHANOL – competitive inhibition, >10 times affinity for ADH than methanol
7.5ml/kg IV load over 1 hour, then 1.4ml/kg/hour drip
FOMEPIZOLE – same mech, but fewer complications than ethanol (expensive)
15mg/kg IV loading dose, then 10mg/kg IV q12 hours times 4 doses
ETHYLENE GLYCOL
Found in most radiator fluid Suicide attempts Alcoholics Accidental - children
ETHYLENE GLYCOL
Metabolized by ADH to glycoaldehyde Aldehyde dehydrogenase to glycolic acid
(profound acidosis), then to oxalate or glutamate
Oxalate can cause kidney problems and hypocalcemia
ETHYLENE GLYCOL SYMPTOMS
Somnolence , vomiting , severe metabolic acidosis, neurological problems, death
More rapid toxicity than methanol After 12 – 24 hours problems result from
oxalate crystal deposition in lung, heart, kidney and brain
Leads to multiorgan failure
OSMOLAL GAP
Calc osm= 2(NA) + (glucose/18) + (BUN/2.8) +ETOH/4.6 + Isopropol/6.0 + Meth/3.2 + Ethy
Glycol/6.2 Difference between measured serum osm and
calculated osm = osmolar gap Osmolar Gap > 10 is definitely abnormal Caution with normal gap with early presentation
ETHYLENE GLYCOL TREATMENT
IV Fluids, bicarb, supportive treatment Ethanol or Fomepizole Thiamine and Pyridoxine – to encourage less
toxic metabolic pathways than oxalate Dialysis if persistent acidosis, Ethylene glycol
level > 50, or worsening renal function
ANTIDOTES
ETHANOL – competitive inhibition, >15 times affinity for ADH than ethylene glycol
7.5ml/kg IV load over 1 hour, then 1.4ml/kg/hour drip
FOMEPIZOLE – same mech, but fewer complications than ethanol (expensive)
15mg/kg IV loading dose, then 10mg/kg IV q12 hours times 4 doses
ISOPROPOL
Rubbing alcohol Readily available Suicide Abuse in alcoholics
ISOPROPOL
Effect similar to ethanol, but more GI symptoms and more ketones, but does not usually cause significant metabolic acidosis
ISOPROPOL
Metabolized by ADH to acetone Peak acetone at 4 hours after ingestion Significant toxicity only in massive ingestions
ISOPROPOL TREATMENT
IV FLUIDS GI meds – H2/PPI Supportive care
Case #1
48 y/o male alcoholic presents intoxicated
Vomited, mild epigastric pain, somnolent
P=120 RR=26 T=37 BP= 180/80 sat= 99%
Charge nurse asks if he can go to CT2
CASE #1 LABS
NA = 147 K= 3.4 BUN= 42 Creat= 1.8
Glucose= 78 anion gap= 38
Venous pH = 7.16
ETOH = 80
CASE #1
Measured serum osm = 426
WHAT BEDSIDE TEST SHOULD YOU DO?
OSMOLAL GAP
Calc osm= 2(NA) + (glucose/18) + (BUN/2.8) +ETOH/4.6 + Isopropol/6.0 + Meth/3.2 + Ethy
Glycol/6.2 Difference between measured serum osm and
calculated osm = osmolar gap Osmolar Gap > 10 is definitely abnormal Caution with normal gap with early presentation
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