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