Name that poison!

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Name that poison!

• Kent R. Olson, MD
• Medical Director, SF Division
• California Poison Control System

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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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Continued . . .

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

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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 35506 also describes a case
  w/ recurrent episodes of hypotonia, bradypnea

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Case

• Whats that?!?

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Radiopaque pills and poisons

• CHIPS
• Chloral hydrate
• Iron, lead, other metals
• Phenothiazines
• Sodium
• Also
• Potassium, Calcium
• Pepto-Bismol
• Some SR preparations

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Iron pills
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Pepto-Bismol
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Enteric-coated Potassium
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Case

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

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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!

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11-6-2000 FDAs 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

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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

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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

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...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)...
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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

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Continued . . .

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

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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

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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.
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More on dextromethorphan . . .

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

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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

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Ecstasy-induced hyponatremia

• SIADH? or
• Excessive water intake?
• a common practice in rave clubs to reduce the
  risk of dehydration and heat stroke