Dive into the complete episode list for The Poison Lab. Each episode is cataloged with detailed descriptions, making it easy to find and explore specific topics. Keep track of all episodes from your favorite podcast and never miss a moment of insightful content.
Rows per page:
50
1–50 of 56
Pub. Date
Title
Duration
22 Dec 2023
Episode #29 Mystery Poisoning
00:01:44
Do you think you know the cause of these symptoms? Send your guesses to toxtalk1@gmail.com to take part in episode 18
04 Oct 2024
LIVE from Denver: 2024 NACCT Research Review – Insights from the North American Congress of Clinical Toxicology
01:22:53
In this exciting live episode from the 2024 North American Congress of Clinical Toxicology (NACCT) in Denver, Ryan dives into 12 of the most impactful research abstracts presented at the conference directly with the authors themselves. Covering a wide range of toxicology topics—from the NACSTOP2 trial on acetaminophen overdose, ECG intervals, cannabis toxicity in young children, and more—each guest breaks down their study’s findings and clinical relevance. If you missed the conference or want a deeper understanding of the year's most important toxicology research, this episode is for you. Check the show notes for links to the published abstracts, the full list of studies discussed, and time stamps for where you can find those studies.
07:48-Abstract #1. The NACSTOP2 trial: a multi-center randomized controlled trial investigating the early cessation of n-acetylcysteine in acetaminophen overdose
Guest- Dr. Anslem Wong, MD, PhD
21:33- Abstract #36. ECG intervals: does one size really fit all?
Guest- Dr. Caitlin Roake, MD, PhD
25:41- Abstract #85. Do abnormal electrocardiographic intervals predict death in poisoned patients older than 65 years?
Guest- Dr. Michael Chary, MD
30:06- Abstract #61. Minimum tetrahydrocannabinol dose that produces severe symptoms in children <6 years old with
cannabis edible ingestions
Guest- Dr. Keahi Horowitz, MD
36:25- Abstract #114. Frequency and severity of cannabis toxicity before and after legislative change to increase cannabis edible package size
Guest- Dr. Robert Hendrickson, MD
38:24- Abstract #101. Quantification of acetaminophen line-crossers in the setting o f overdose with delayed gastric absorption
Guest- Dr. Jamie Sterr, PharmD
41:41- Abstract #175. Cause for pause: bradycardia induced by transdermal rivastigmine in anticholinergic delirium
Guest- Dr. Santiago Batista Minaya, MD
46:21- Abstract #199. Cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) Syndrome with poor neurological outcome in the setting of suspected opioid use
Guest- Jack Yang and Dr. Avery Michienzi, DO
49:49- 191. Severity scores for caustic injury: Zargar they even used?
Guest- Dr. Amar Chakrabortya, MD
53:!2- Abstract #9. Disparity in immune-mediated reactions to Crotalidae polyvalent immune fab (ovine) and Crotalidae immune F(ab’)2 [equine] in alpha-gal endemic regions and alpha-gal sensitized adults
Guest- Dr. Ari Filip, MD
59:10- Abstract # 26. Acute propranolol overdose and dose thresholds of severe toxicity
Guest- Dr. Katherine Isoardi, MBBS
1:06:05- 28. Risk of serotonin toxicity following acute lamotrigine overdose
Guest- Dr. Angela Chiew, MBBS, PhD (Introduction at 1:00:00)
1:12:36- Interview with AACT President Elect
Guest- Dr. Jillian Theobald, MD, PhD
16 Dec 2020
Mini Episode: Managing Crashing Hydroxychloroquine/Chloroquine OD
00:09:51
Quick review
Toxic dose
Chloroquine >5g severe toxicity is expected (toxicity may develop below this)
HCQ less well defind
Clinical effects
Seizures (sodium channel blockade)
Arrhythmia (sodium channel blockade)
Hypotension (Alpha blockade)
Hypokalemia
Management
Activated Charcoal if awake and alert and no risk of emesis
Early invasive supportive care based on the following retrospective case control series https://www.nejm.org/doi/full/10.1056/NEJM198801073180101
High dose epinephrine (0.25 mcg/kg/min)
Diazepam 1-2 mg/kg over 30 minutes followed by 1-2 mg/kg over 24 hours (seizure prevention)
Evidence supports this may be cardio protective as well
Early intubation
Consultation with poison center recommended 1-800-222-1222
14 Jun 2024
Episode #31 Mystery Case
00:01:53
Do you think you know the cause of these symptoms? Send your guesses to toxtalk1@gmail.com to take part in the next episode
06 Jun 2024
Where is Episode #31 and Bonus Episodes- Ryan Joins "The Larry Meiller Radio Show" and The "EMS2020" Podcast
00:16:53
A quick update to share some other shows Ryan has been on in the last few weeks! Check the show notes for links to each episode!
Ryan on "The Larry Meiller Show" discussing delta cannabanoids
AHA 2023 Management of Poisoning Cardiac Arrest or Life-Threatening Toxicity Guidelines with Co-Author Dr. Eric Lavonas MD
00:50:38
In this episode, Ryan sits down with Dr. Eric Lavonas MD, a seasoned EM resuscitation guideline writer, emergency medicine physician, medical toxicologist, and lead author of the latest update to the American Heart Association's guidelines for the management of cardiac arrest and life-threatening toxicity due to poisoning. They have an in-depth discussion as they explore the key aspects of the 2023 AHA treatment recommendations and the rationale behind each decision point. A great review to discover how to effectively apply these guidelines in real-world scenarios and find out what knowledge gaps exist in the realm of toxin resuscitation. Be sure to also check out the accompanying mini-episode for a high-yield review of the major treatment recommendations.
In this Ryan sits down with Dr. Richard Dart MD, PhD. He is the lead author of the recently released "Management of Acetaminophen Poisoning in the US and Canada Consensus Statement" from the American Academy of Clinical Toxicology, American College of Medical Toxicology, Americans Poisons Centers, and the Canadian Association of Poison Centers. Listen to be informed on the most recent treatment recommendations. They dive in to the definitions established by the guideline and notable treatment recommendations, dissecting the ratinonale for each desiscion point and how to apply the guidelines. A mini episode was released along side this episode that is a high yield review of major treatment recommendations and definitions estabilished by the consensus statement.
>7.5 g in 24 h was criteria for Rumack Matthew nomogram
Consensus statement
Adult overdose at 10g/d or 200 mg/kg/d in <24 hours= potentially toxic
Pediatric <6 year at 150 mg/kg/d in <24 h = potentially toxic
Repeated Supra Therapeutic Ingestion (RSTI)
Overdose "dose"
Repeated dosing totaling
6g/d or 150 mg/kg/day x 24-48 h = potential toxic
4g/d or 100 mg/kg/day x >48 h = potential toxic (Recognize this means some people could be toxic at therapeutic dosing, but if they do not have symptoms not likely)
High risk ingestion
Reported dose >30 grams OR
[APAP] 2 x Rummack-Matthew nomogram treatment line
NAC stopping criteria
APAP<10
INR<2
AST/ALT Normal for patient or decreased by 25-50%
Patient clinically well
Notable treatment recommendations
RSTI
If patient has history of RSTI (>6 g x 24-48 h, >4 g x >48 hours) AND signs of APAP toxicity (vomiting, RUQ abd pain, AMS)
Treat if APAP >20 ug/ml OR AST/ALT elevated
Acute
Non-detectable [APAP] between 2 and 4 hours excludes ingestion
Start treatment with NAC if unable to plot on nomogram by 8 hours
NAC dose
“Higher dose” NAC (undefined) for high risk ingestion
Minimum NAC regimen should include 300 mg/kg orally or within 20-24 hours
CAP NAC dose at 100 kg (this was known with PO, but IV there was always some question since it delivers less overall)
Unique scenarios
Line crossers
APAP with anticholinergic or opioid
If 1st concentration below treatment line repeat in 4-6 hours
APAP Extended release
If 1st concentration below treatment line @ 4-12 hours, repeat in 4-6 hours
Dialysis-
Dialyze If APAP >900 w/ AMS or acidosis.
NAC IV rate during HD 12.5 mg/kg/hr minimum. No dose change for PO (not new but good reminders)
Consult liver transplant for rapid AST/ALT inc w/ coagulopathy, AMS, or mulistytem organ failure
The addition of fomepizole to acetylcysteine in the treatment of serious acetaminophen ingestions has been proposed. The panel concluded that the data available did not support a standard recommendation. As for any complicated or serious acetaminophen poisoning, a PC or clinical toxicologist should be consulted.
26 Aug 2020
Mini episode: Early After Depolarizations and Experimental Mechanisms of Torsades
Toxicologists vs the Internet (#5) With Guest Dr Howard Greller MD (Sirius XM Doctor Radio Emergency Medicine Show, Dantastic Mr Tox & Howard, Tox & Hound)
01:21:49
Music from Pixabay
Additional information on toxins from fatal poisoning cases
APAPalooza. A North American Congress of Clinical Toxicology 2023 Acetaminophen Research Highlight
00:51:31
In this episode, Ryan dives into cutting-edge research on the treatment of acetaminophen (APAP) overdose, featuring interviews with authors of several key abstracts from the North American Congress of Clinical Toxicology (NACCT) in Montreal Canada (Abstracts and posters available in the show notes). We get first looks insights into research evaluating the impact of fomepizole high risk acetaminophen overdose, as well as who gets fomepizole for acetaminophen overdose and dies. Then we evaluate the effectiveness of standard N-acetylcysteine (NAC) treatment in high risk patients and high dose NAC in high risk patients. Join us for an insightful discussion on these advancements that are reshaping the management of APAP toxicity. Guests include Dr. Masha Yemets PharmD, Dr. Molly Stott PharmD, Dr. Alexandru Ulici PharmD, and Dr. Michael Moss MD.
(First guest) Abstract #126 Characterizing fomepizole use in acetaminophen deaths reported to US poison centers- Dr. Yemets
(Second guest) Abstract #125 Clinical impact of fomepizole as an adjunct therapy in massive acetaminophen overdose- Dr. Stott
(Third guest) Abstract #131 Comparison of low-risk and high risk acetaminophen ingestions using the standard prescott protocol of intravenous N-acetylcysteine- Dr. Ulici
(Fourth guest) Abstract #130 High-risk acetaminophen overdose outcomes after treatment with standard dose vs. increased dose N-acetylcysteine- Dr. Moss
High yield highlight- Managing a Bupropion overdose
00:07:07
Ready for a high-octane dose of knowledge? 🔥🧠 Ryan's got you covered with this electrifying mini-episode on managing a bupropion overdose! 💊💥 Beware - there are plenty of pitfalls you'll want to avoid. Check out the full episode and other mini-episodes for even more tips and tricks! 🎧👀
Bupropion is the #1 antidepressant cause of major (life threatening) reported to U.S. Poison Centers
Aggressive whole bowel irrigation or charcoal may be indicated if large ingestion
Supportive care
Intubation if airway compromised
Benzodiazepine for agitation
Benzodiazepines and GABA-ergic AED's for status epileptics
Tachycardia, tremor, and agitation are risk factor for seizures
Tachycardia may be masked by alpha 2 agonist co ingestions
Seizures may occur 24 hour out
Sodium bicarbonate for wide QRS (it may be refractory)
Inodilators and vasopressors for cardiogenic shock
ECMO for refractory shock or arrhythmia
Awareness that severe bupropion toxicity can mimic brain death
send analytical confirmation of bupropion if possible to rule out confounding
Enhanced elimination
limited options due to protein binding, not routine
Focused antidote
Consider IV fat emulsion if the patient is peri arrest
Observation times
Talk to a toxicolleague about observation times, decontamination, and use of invasive therapies to avoid falling into a trap
15 Feb 2023
A Prescription for Heartache (& Seizures) (Bupropion)
01:30:40
What do bath salts, face eating zombies, and antidepressants have in common? In this episode Ryan has a number of guests (Dr Filip, Dr Olives, Dr Reyes) join to discuss a unique heart breaking poisoning that is now the number one cause of major life threatening effects in antidepressant overdose in the United States. Check out the mini episodes for more!
This antidepressant is the #1 cause of major (life threatening) effects in overdose reported to U.S. Poison Centers
Toxicologists vs the Internet (#9) With Guest Dr Frank Paloucek PharmD DABAT FAACT
01:28:32
Dr. Frank Paloucek, PharmD, DABAT (@itsalltox) joins the show. He was one of the very first emergency medicine pharmacists and one of the original board-certified clinical toxicologists (DABAT). He is now a proudly retired professor emeritus at The Univeristy of Illinois at Chicago. In his tenure there he spent nearly 20 years as the program director for their clinical pharmacy residency, was an integral part of the Toxikon Consortium toxicology fellowship, and coauthored the text book "Poisoning and Toxicology Handbook (Poisoning and Toxicology Handbook (Leiken & Paloucek's)) 4th Edition. Frank and Ryan kick off the show hearing about Frank's fledgling years working in an emergency department without EM attendings. Then they bust some toxicology myths (do you REALLY need BAL before Calcium disodium edetate in severe lead poisoning? Frank thinks no...) before jumping into solving some toxic cases. Finally, the episode ends with Frank and Ryan solving a case of poisoned AI. They ask GPT to take on the role of a poisoned patient and work together to identify the culprit. Enjoy and don't forget to leave a review.
A very NACCT Holiday-2023 North American Congress of Clinical Toxicology High Yield Abstract Review
01:34:00
In this episode Ryan is joined by a guest panel (Dr. Grant Comstock MD, Dr. Joshua Trebach MD, Dr. Emily Kiernan DO, and Dr Frank Paloucek PharmD, DABAT) to review nine of the most interesting or clinically impactful research abstracts that were presented at the 2023 North American Congress of Clinical Toxicology (NACCT) in Montreal Canada. If you didn't get a chance to read all 363 research abstracts from some of Toxicology's best and brightest this year, tune in for a high yield review as well as clinical a break down of the studies and their relevance from the expert panel.
Check the show notes for a link to the published abstracts and the list of all studies discussed in the show
10:40- Abstract 1 (PDF #225) Methotrexate toxicity in the setting of therapeutic error, a multicenter retrospective review
Lead author: Andrew Chambers
24:12- Abstract #2 (PDF #251) Oleander seeds in candlenut weight loss product strike again
Lead author: Masha Yemets
31:16- Abstract #3 (PDF #2) Efficacy of sodium tetrathionate when administered intramuscularly for the treatment of acute oral cyanide toxicity in a swine model (Sus scrofa)
Lead author: Brooke Lajeunesse
39:45- Abstract #4 (PDF #10) Is HOUR enough after out-of hospital naloxone for opioid overdose? Prospective preliminary data from real-world implementation of the modified St. Paul’s early discharge rule
Lead author: Stephen Douglas
49:05- Abstract #5- Poster titles at NACCT 2013–2022: is NACCT experiencing a pun-demic?
Lead author: Dayne Laskey
52:40- Rivastigmine discussion
Lead author: none
58:40- Abstract #6 (PDF #5) Randomized controlled trial of ANEB-001 as an antidote for acute cannabinoid intoxication in healthy adults
Lead author: Andrew Monte
1:08:00- Abstract #7 (PDF#216) Successful use of expired physostigmine to treat anticholinergic delirium in a pediatric patient
Lead author: Bryan Hayes
01:20:00- Abstract #8 (PDF #202) Enough negativity? Clinically significant salicylism with first detectable concentration twelve hours )post-ingestion
Lead author: Stacey Bangh
01:25:24 - Abstract #9 (PDF #267) High sensitivity troponin is frequently elevated after carbon monoxide exposure
Lead author: Abdullatif Aloumi
18 Apr 2021
Mini Episode: Setting The Record Straight on Delta 8 (THC)
Bromazolam, Etonitazene, and Carfentanil Walk into a Bar – Trends in Novel Illicit Drugs with Dr. Alex Krotulski
01:41:48
In this episode Ryan interviews Dr. Alex Krotulski PhD from the Center for Forensic Science Research and Education. Together take a look at trends in novel opioids, benzodiazepines, stimulants, hallucinogens, synthetic cannabinoids, and "hemp products" that are showing up in your patients, drug products, and fatal overdoses. The conversation takes places around the Center for Forensic Science Research and Education quarterly report on Novel Psychoactive Substances found in patients and drug products.
The episode starts with a discussion of the novel benzodiazepines market, highlighting bromazolam and how long it may remain in the market. Then they discuss the opioids highlighting where we are seeing carfentanil, what is happening with Para Fluorofentanyl, and other super potent opioids emergening (such as N -pyrrolidino etonitazene). After a quick discussion of synthetic cathinone's and PCP/ketamine derivatives they jump to synthetic cannabinoids, examining the history of brodifacoum contamination and how regulation has led to market changes.
Abstract 1: Vasodilation in patients with calcium channel blocker poisoning treated with high dose insulin: a comparison of amlodipine versus non-dihydropyridines
Abstract 4: “Tranq dope” opioid overdose: clinical outcomes for emergency department patients with illicit opioid overdose adulterated with xylazine
Category 3: Case Reports with Terrifying Clinical Implications
Abstract 5: Recovery after poly-drug overdose despite blood flow imaging demonstrating no brain perfusion
Abstract 6: Challenges in diagnosing an environmental cause of recurrent methemoglobinemia
Abstract 7: Acute thiamine deficiency as a complication of insulin euglycemic therapy for an amlodipine overdose
Category 4: Comparative evidence, Prognostication, and Triage
Abstract 8: Utility of pre four-hour iron concentration in predicting toxicology
Abstract 9: Andexanet alfa vs 4-factor prothrombin complex concentrate for intracranial hemorrhage at a level I trauma hospital
Category 5: Rapid Review
Abstract 10: Fentanyl and fentanyl analogue exposure among emergency personnel and first responders: a systematic review
Abstract 11: Significance of falsely low creatinine values in diagnosing massive acetaminophen ingestion
Abstract 12: Large dose intentional ciprofloxacin ingestion associated with false-positive urine immunoassay for oxycodone and fentanyl
Abstract 13: Don’t make it a double?: a 20- year review of supratherapeutic amlodipine ingestions while on chronic therapy
Abstract 14: Evaluation of pediatric lisdexamfetamine exposures reported to a statewide poison control system
Abstract 15: An assessment of the reliability of stated quantity in acute acetaminophen overdoses reported to a regional poison center
28 Aug 2024
The Poison Letter To The Editor: Listener Critiques and Author Responses for The AHA 2023 Life Threatening Poisoning Guidelines with Dr. Michael Mullins, Dr. Donna Seger, Dr. Leon Gussow, and Dr. Eric Lavonas
00:23:47
In this episode the poison lab hosts scientific discourse . Three listeners (Dr. Michael Mullins, Dr. Donna Seger, and Dr. Leon Gussow) write in their critiques surrounding specific recommendations and language used with the AHA 2023 Management of Poisoning Cardiac Arrest or Life-Threatening Toxicity guidelines. Lead author of the guidelines Dr. Eric Lavonas then responds to and addresses their points with counterpoints or appraisals. Tune in and draw your own conclusions!
High Yield Highlight- 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning
00:15:30
In this episode Ryan does a high yield "just the facts" break down of the recently released "2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Tune in to learn about the most recent treatment recommendations made by AHA via a panel of toxicology experts. This was released alongside a full interview with the lead author Dr. Eric Lavonas MD. Be sure to check out the full interview to hear it straight from the source! (link in show notes).
Have a burning question you have always wanted to ask a toxicologist? What are tips for managing an anticholinergic overdose? What is the deadliest poison? Why are they called lead pencils if there is no lead?! Send your questions in to toxtalk1@gmail.com to take part in a future episode! (If you would like to be anonymous simply state it in the email)
10 Jun 2020
Mini Episode: Fundamentals: Testings Tests, Addictions vs Dependence, How Do We Alter Drug Absorption, What Do Drugs Do?
00:27:03
Concepts in this episode
testing our tests
Sensitivity: Rate of Positive test in those who have the disease
Specificity: Rate of negative test in those without the disease
Anti anxiety effects- https://pubmed.ncbi.nlm.nih.gov/33207379/
Cocaine chest pain
Propranolol effects on coronary constriction- https://pubmed.ncbi.nlm.nih.gov/1971166/
Labetalol effects on coronary constriction- https://pubmed.ncbi.nlm.nih.gov/8506886/
Management of amphetamine compound toxicity-> https://pubmed.ncbi.nlm.nih.gov/25724076/
Heavy metals in cakes
https://pubmed.ncbi.nlm.nih.gov/18802411/
30 Mar 2022
Case Teaser Episode 14- Fast and Fatalurious
00:01:05
Send in your guesses to toxtalk1@gmail.com
01 Jul 2024
The Poison Lab - Stump The Toxicologist Reel 2023
01:38:55
In this bonus episode Ryan highlights some of the great episodes done in 2023 and compiles ALL of the stump the toxicologist segments from 2023 into one easy to consume episode. Test your toxicology differential skills with more than six poisoning cases. Check out the actual episodes for more information in the show notes on each of the poisonings.
Where is Episode 13 ? Bonus Episodes AND Next Episode Guest Dr. Howard Greller MD (Sirius XM Doctor Radio Emergency Medicine Show, Dantastic Mr Tox & Howard, Tox & Hound),
00:09:04
No episode today. Head here for the live radio show!
Join us next show for Dr. Howard Greller of Sirius XM Doctor Radio, Dantastic Mr Tox & Howard, and Tox & Hound
Used by people to make tonic water, treat restless legs, or viruses
Prescription quinoline derivatives may cause cause similar effects
Quinine
Quinidine
Hydroxychloroquine
Chloroquine
Clinical effects
Dizzy
Flushed
Head ache
Tinnitus
Potential for vision loss
Laboratory assessment
Hypoglycemia
Hypokalemia
Long QRS
Treatment
Supportive care for ABCs
Potential role for epinephrine as preferred pressor from animal data and chloroquine data
Correct endocrine/metabolic abnormalities
Hypertonic sodium for wide QRS (be careful of worsening hypokalemia)
Consider multi dose activated charcoal
More on toxicity/studies from the episodes
Incidence of caridac arryhmias in patients taking quinine alone
Padmaja UK, Adhikari P, Periera P. Experience with quinine in falciparum malaria. Indian J Med Sci. 1999 Apr;53(4):153-7. PMID: 10695226.
Negative inotropic effects of quinidine
Hoffmeister HM, Hepp A, Seipel L. Negative inotropic effect of class-I-antiarrhythmic drugs: comparison of flecainide with disopyramide and quinidine. Eur Heart J. 1987 Oct;8(10):1126-32. doi: 10.1093/oxfordjournals.eurheartj.a062178. PMID: 3119341
Occular toxicity, can be permanent
Treatment is debated, not clear what is preferred , HBO used often
Vision may recover centrally first, than peripheral
Jarboe JK, Hallworth R. The effect of quinine on outer hair cell shape, compliance and force. Hear Res. 1999 Jun;132(1-2):43-50. doi: 10.1016/s0378-5955(99)00031-3. PMID: 10392546.
31 Mar 2021
More Bitter than Sweet (Mad Honey and Grayanotoxin)
Toxicologists vs the Internet (#8) With Guest Dr Adam Blumenberg MD
01:30:25
Dr. Adam Blumenberg, MD (@ABlumenbergMD) Join's the show. He is an emergency medicine physician, medical toxicologist, and Assistant Professor at Columbia University Medical Center in New York City. He hosts his own toxicology youtube series (www.ToxicHistory.com) and has developed multiple free medical education software programs in toxicology (www.toxicrunner.net) and medical simulation (www.medsimstudio.com). Most impressively, he has produced his own free base lidocaine crystals on a stove top, if you ask nicely he might just loan you one. He joins the show to sleuth the cause of fatal poisoning cases and tackle internet questions from reddit.com/r/askdrugs
The Undead Patient: The Complexity of Brain Death Determination in Drug Overdose
01:17:04
In this episode Ryan explores the concept of brain death and the implications of drug overdoses causing false positive diagnosis of brain death. He is joined by an author of the ACMT Position statement on brain death in overdose (Dr. Andrew Stolbach MD) as well as authors of two case reports (neuro critical care physician Dr. Ranier Reyes and emergency physician Dr. Doug Stranges) involving bupropion where patients had absent brain stem reflexes after overdose but made a full neurologic recovery. We delve into the criteria used to determine brain death and the challenges faced by families and healthcare professionals when dealing with this sensitive topic.
00:00-19:00 Introduction to brain death guidelines
19:00-28:00 Introduction to limitations in guidelines regarding overdose
28:30-38:00 Interview with ACMT Position statement author
39:00- End- Interview with Bupropion brain death mimic authors and summary
High Yield Highlight-Consensus Statement on Management of Acetaminophen Poisoning in the US and Canada
00:13:11
This episode is a a high yield "just the facts" break down of the recently released "Management of Acetaminophen Poisoning in the US and Canada Consensus Statement" from the American Academy of Clinical Toxicology, American College of Medical Toxicology, Americans Poisons Centers, and the Canadian Association of Poison Centers. Listen to be informed on the most recent treatment recommendations. This was released alongside a full interview with the consensus statement corresponding author Dr. Richard Dart MD, PhD. Be sure to check out the full interview to hear it straight from the source! (link in show notes).
Start treatment with NAC if unable to plot on nomogram by 8 hours
NAC dose
“Higher dose” NAC (undefined) for high risk ingestion
Minimum NAC regimen should include 300 mg/kg orally or within 20-24 hours
CAP NAC dose at 100 kg (this was known with PO, but IV there was always some question since it delivers less overall)
Unique scenarios
Line crossers
APAP with anticholinergic or opioid
If 1st concentration below treatment line repeat in 4-6 hours
APAP Extended release
If 1st concentration below treatment line @ 4-12 hours, repeat in 4-6 hours
Dialysis-
Dialyze If APAP >900 w/ AMS or acidosis.
NAC IV rate during HD 12.5 mg/kg/hr minimum. No dose change for PO (not new but good reminders)
Consult liver transplant for rapid AST/ALT inc w/ coagulopathy, AMS, or mulistytem organ failure
The addition of fomepizole to acetylcysteine in the treatment of serious acetaminophen ingestions has been proposed. The panel concluded that the data available did not support a standard recommendation. As for any complicated or serious acetaminophen poisoning, a PC or clinical toxicologist should be consulted.
27 May 2020
Cleaning with War Gas and Drinking Javel Water (Chlorine Gas and Bleach)
00:32:57
Ryan and Toxo talk about the the history of a commonly used disinfectant. They break down the many ways it can cause harm if not used appropriately, including creating chemical weapons and turning you...
Key points
Bleach mixed with various chemicals can make many toxic substances
Bleach + acid= chlorine gas
Bartholette original Cl2 + H2O ⇄ HCl + HClO
To drive the reaction to the right, a base was added, to neutralize HCl and reduce the amount of product
Chlorine gas is a high solubility irritant, it dissolves quickly in the mucous membranes and causes severe irritation of upper airway, eyes and nose (moist mucous membranes), effects are noticed quickly
Treatment for most chemical inhalation injuries involves removal from ongoing exposure, maintenance of a patent airway, and supportive care
Oxygen for hypoxemia
Bronchodilators (albuterol)
Intubation if needed
If the exposure is to chlorine gas there may be a role for nebulized sodium bicarbonate.
Due to initial irritation, exposure may present looking vary severe, but may turn around with good supportive care
If you accidentally make chlorine gas, get to fresh air, open windows if you can and call your local poison center or 911
Bleach ingestion are basic and can cause a liquefactive necrosis
Some may result in oral irritation
Treatment involves assessing the injury to determine risk of stricture and possible esophageal stenting
Brief summary of steroid use with irritant gases: Reproduced with permission from : Pape KO, Feldman R. Smoke inhalation and Toxic Exposure. Chapter In: Erstad B, ed. Critical Care Pharmacotherapy. Lenexa: American College of Clinical Pharmacy. January 2020.
Steroid use in pulmonary irritant induced pneumonitis is not well evaluated in randomized controlled trials. Reviews of animal data suggest no significant benefit for poorly water soluble or high doses of water-soluble irritants. They may also have a negative effect on the recovery phase (deLange 2011).Numerous case reports exist detailing positive outcomes from use of steroids in patients exposed to pulmonary irritants (deLange 2011).However, without an appropriate comparator it is not known if symptom resolution is related to the intervention or the natural progression of the disease. Small human crossover trials evaluating the effects of mild ozone exposure found a reduction in bronchiolar lavage inflammatory markers with inhaled fluticasone or budesonide but no difference in clinical effects (deLange 2011, Nightingale 2000, Alexis 2008, Vagaggini 2001). Due to the absence of well controlled trials, steroids are not routinely recommended for chemical pneumonitis. However, there is also a lack of negative data and institutional protocols or patient specific factors may govern their use.
1. De Lange DW, Meulenbelt J. Do corticosteroids have a role in preventing or reducing acute toxic lung injury caused by inhalation of chemical agents? Clin Toxicol (Phila) 2011;49:61-71. 2. Vagaggini B, Taccola M, Conti I, et al. Budesonide reduces neutrophilic but not functional airway response to ozone in mild asthmatics. Am J Respir Crit Care Med 2001;164:2172–6. 3. Alexis NE, Lay JC, Haczku A, et a. Fluticasone propionate protects against ozone-induced airway inflammation and modified immune cell activation markers in healthy volunteers. Environ Health Perspect 2008;116:799–805. 4. Nightingale JA, Rogers DF, Chung KF, et al. No effect of inhaled budesonide on the response to inhaled ozone in normal subjects. Am J Respir Crit Care Med 2000;61:479–86.
Reactions of Sodium Hypochlorite wit other compounds to make nasty products -
Odabasi M. Halogenated volatile organic compounds from the use of chlorine-bleach-containing household products. Environ Sci Technol. 2008;42(5):1445‐1451. doi:10.1021/es702355u
Good review of the basics of caustic ingestions such as bleach
Hoffman RS, Burns MM, Gosselin S. Ingestion of Caustic Substances. N Engl J Med. 2020;382(18):1739‐1748. doi:10.1056/NEJMra1810769
Pulmonary irritants- Nelson LS, Odujebe OA. Simple asphyxiants and pulmonary irritants. In: Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR, eds.Goldfrank's Toxicologic Emergencies, 11e New York, NY: McGraw-Hill; 2019.
Incidence data
Gummin DD, Mowry JB, Spyker DA, et al. 2017 Annual report of the American association of poison control centers’ national poison data system (NPDS): 34th annual report. Clin Toxicol (Phila) 2017;55:1072–254.
29 Feb 2024
Inefficient Heat (Mystery Case 29) & Toxicologists vs The internet with Dr. Ann Arens
01:35:06
Dr. Ann Arens, MD an emergency medicine physician and medical toxicologist with Oschner Medical center in New Orleans, LA joins the show to educate us on some HOT toxins, solve toxic cases, and opine on the philosophical and existential reasons drugs even exist. Tune in for a fantastic discussion with Dr. Arens and to hear the answer to our mystery case.
The Poison Lab Does Psilocybin- A Deep Dive with Psilocybin Research Pharmacist Dr. Paul Hutson
01:37:38
In this enlightening episode, Ryan engages in a deep conversation with Dr. Paul Hutson, PharmD, a renowned researcher in the field of psilocybin and director of the Transdisciplinary Center for Research in Psychoactive Substances at the University of Wisconsin Madison. Dr. Hutson shares his extensive knowledge and insights into the promising role of psilocybin in the treatment of depression and substance use disorder.
Throughout the discussion, they delve into the research that supports the use of psilocybin in medical therapy, shedding light on the rigorous processes involved in conducting such studies. Dr. Hutson elucidates the efficacy and safety findings that have emerged from his and others research, offering listeners a glimpse into the potential future of psilocybin in mainstream medical practices. Listeners will gain a deeper understanding of the meticulous approach to research that ensures both safety and effectiveness. Dr. Hutson shares firsthand experiences and observations, providing a rich and detailed perspective on the current state of psilocybin research. Moreover, the conversation ventures into the practical aspects of integrating psilocybin into contemporary medical practices, discussing the potential frameworks and guidelines that would govern its use. They explore what the future might hold for patients and practitioners alike as they stand on the cusp of a revolutionary shift in mental health treatment.
Whether you're a healthcare professional keen on the latest developments in medical research or someone interested in the evolving landscape of mental health treatment, this episode promises to be a rich source of information and insight. Tune in to be informed and to foster a deeper understanding of the promising horizon that psilocybin research is unveiling in the medical community.
Weiss D, Lee D, Feldman R, Smith KE. Severe lead toxicity attributed to bullet fragments retained in soft tissue. BMJ Case Rep. 2017;2017:bcr2016217351. Published 2017 Mar 8. doi:10.1136/bcr-2016-217351
Lead has been deeply intertwined with human culture, used as currency, building material. cosmetics and innumerable other uses. It has has even been proposed to be the fall of Rome due to use in their aqueducts and wine.https://pubmed.ncbi.nlm.nih.gov/14261844
The 1986 amendment to the Safe Drinking Water Act required lead-free solder, flux, fittings, and pipes as of June 1988.
The Lead and Copper Rule originally required replacement of the public and private service pipelines; however, the rule was revised in 2000 to allow for only partial service line replacement in the publicly owned sectors
If you have an elevated blood lead level- call your toxicologist or poison center. Thanks for listening!
22 May 2020
Welcome to The Poison Lab
00:03:21
Welcome to the poison lab! Tune in to satisfy your taste for the history, science, and medical management of the infinite poisons the world has to offer!
Fun theories about co evolution of PGP and CYP https://pubmed.ncbi.nlm.nih.gov/10837556/
Inhibition of sodium channels, and to a higher affinity, Human Ether a Go-Go Related (HERG) channel leads to prolonged repolarization (9)
IC50 for HERG Ikr ~ 40 nm/l (1908 ng/dl), inhibits as low as 10 nm/l (10)
Case reports of conduction disturbance with level of 22 ng/ml (14)
Levels in fatalities vary but reported as high as 270 ng/ml in some studies (15)
Prolonged re polarization leads to torsades
Early after depolarizations may trigger, which are then propagated torsades via re entrant rhythms (11)
Treatment
ACMT loperamide guidelines (12)
Supportive care
Arrhythmia management
Torsades (13)
Electrical cardioversion (terminates re entrant rhythm)
Magnesium (prevents early after depolarization)
Target Mg >2 and K >4
Lidocaine-> Recommended in 2006 Sudden cardiac death guidlines, not mentioned in 2017, however one of the only VT recommended antiarryhtmics that do not prolong QTc (others, sotalol, amiodarone, and procainamide, do)
If preceded by bradycardia, Overdrive pacing with isoproterenol to target HR~ 100
Beta blockers are recommended in patients with LQTS
Miller H, Panahi L, Tapia D, Tran A, Bowman JD. Loperamide misuse and abuse. J Am Pharm Assoc (2003). 2017;57(2S):S45eS50.
Feldman R, Everton E. National assessment of pharmacist awareness of loperamide abuse and ability to restrict sale if abuse is suspected [published online ahead of print, 2020 Jul 5]. J Am Pharm Assoc (2003). 2020;S1544-3191(20)30264-8. doi:10.1016/j.japh.2020.05.021
Eggleston W, Marraffa JM, Stork CM, et al. Notes from the Field: Cardiac Dysrhythmias After Loperamide Abuse — New York, 2008–2016. MMWR Morb Mortal Wkly Rep 2016;65:1276–1277. DOI: http://dx.doi.org/10.15585/mmwr.mm6545a7
Kang J, Compton DR, Vaz RJ, Rampe D. Proarrhythmic mechanisms of the common anti-diarrheal medication loperamide: revelations from the opioid abuse epidemic. Naunyn Schmiedebergs Arch Pharmacol. 2016;389(10):1133-1137. doi:10.1007/s00210-016-1286-7
Klein MG, Haigney MCP, Mehler PS, Fatima N, Flagg TP, Krantz MJ. Potent Inhibition of hERG Channels by the Over-the-Counter Antidiarrheal Agent Loperamide. JACC Clin Electrophysiol. 2016;2(7):784-789. doi:10.1016/j.jacep.2016.07.008
Eggleston W, Palmer R, Dubé PA, et al. Loperamide toxicity: recommendations for patient monitoring and management. Clin Toxicol (Phila). 2020;58(5):355-359. doi:10.1080/15563650.2019.1681443
Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in J Am Coll Cardiol. 2018 Oct 2;72(14):1760]. J Am Coll Cardiol. 2018;72(14):e91-e220. doi:10.1016/j.jacc.2017.10.054
Marraffa JM, Holland MG, Sullivan RW, et al. Cardiac conduction disturbance after loperamide abuse. Clin Toxicol (Phila). 2014;52(9):952-957. doi:10.3109/15563650.2014.969371
Miller H, Panahi L, Tapia D, Tran A, Bowman JD. Loperamide misuse and abuse. J Am Pharm Assoc (2003). 2017;57(2S):S45-S50. doi:10.1016/j.japh.2016.12.079
09 Dec 2022
Episode 19 Mystery Case
00:01:44
Do you think you know the cause of these symptoms? Send your guesses to toxtalk1@gmail.com to take part in episode 18
08 Dec 2021
Lethal Buttock Injection (And Other Toxicities of Illegal Cosmetic Body Fillers)
Mini Episode: The Saga of the Cardiac Action Potential
00:15:27
Action potential
Sodium/Potassium ATPase pumps create more positively charged ions outside the cell than inside the cell, this creates a relative negative charge in the cell
Phase 4- Resting (~ -90 mv)
Phase 0- Sodium enters the cell (+10 mv)
Phase 1- Potassium efflux from cell as now there is no negative charge holding it in (0 mv)
Phase 2- Calcium channels open and allow calcium in, calcium triggers the ryandoine receptor and allows for calcium dependent calcium release from the sarcoplasmic reticulum occurs
Phase 3- Potassium continues to leave the cell allowing return to -90 mv
Open and Shut (Mystery case 31) with Guests Dr. Dan McCabe and Dr. Crissy Lawson
01:42:35
In this episode Ryan is joined by two expert guests to help read listener guesses for the cause of this poisoning murder and shed light on the toxin involved in the case, which puzzled medicolegal investigators. Ryan is joined by Dr. Dan McCabe, MD (emergency medicine physician, medical toxicologist, medical director of Iowa poison center) and Dr. Crissy Lawson PharmD (emergency medicine pharmacist).
Enhance your understanding of The Poison Lab with My Podcast Data
At My Podcast Data, we strive to provide in-depth, data-driven insights into the world of podcasts. Whether you're an avid listener, a podcast creator, or a researcher, the detailed statistics and analyses we offer can help you better understand the performance and trends of The Poison Lab. From episode frequency and shared links to RSS feed health, our goal is to empower you with the knowledge you need to stay informed and make the most of your podcasting experience. Explore more shows and discover the data that drives the podcast industry.
