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  • 1. TOX UPDATEKENT EMS ROUNDSKevin OConnell MD
  • 2. STUPID THINGS PEOPLE DO
  • 3. BATH SALTS
  • 4. BATH SALTSSimilar to amphetaminesSynthetic drugs sold in gas stations as “not for human consumptionStarted in Europe few years agoNow in US and a cause for frequent ER visits
  • 5. BATH SALTSCrystal or powder that is smoked, ingested, snorted, or injectedFrequently overdosingLegal status of drugs
  • 6. BATH SALTSCathinones:MDPV – methylenedioxypyrovaleroneMethyloneMephedroneKeeps changing to ingredients to avoid legal issues
  • 7. BATH SALTSIncreases catecholamines at synapsesHallucinations, paranoia, violenceTachycardia, MIRenal or Liver failureTrend toward increased use in mental health patients
  • 8. BATH SALTSSupportive care, IV fluidsSedation: Ativan/HaldolSocial Service issuesMay show up on Tox screen as PCP
  • 9. SYNTHETIC CANABIS
  • 10. SYNTHETIC CANNABISInitially marketed as mixture of legal herbs with cannabis-like affectIs actually a bunch of herbs sprayed with synthetic cannabinoids“K2”“SPICE”
  • 11. NATURAL CANABIS
  • 12. SYNTHETIC CANABIS
  • 13. SYNTHETIC CANABISJohn W. Huffman from Clemson University invented most synthetic canabinoids“It bothers me that people are so stupid as to use this stuff”
  • 14. SYNTHETIC CANNIBISSimilar affect as cannabis, except less predictableIncreased psychotic features - ? If natural cannabis has “antipsychotic chemical”Increased agitation and vomitingMore addictive behaviorPossible cardiac and seizure increase
  • 15. BEFORE COCAINE
  • 16. AFTER COCAINE
  • 17. COCAINEFrom Coca leaves in South America1884 – Dr Halstead first used cocaine medically for nerve block1885 - Dr Halstead became first cocaine impaired physicianSigmond Freud recommended cocaine for various ailments1885 – Coca Cola contained 60 mg cocaine/8oz
  • 18. COCAINEBenzoylmethylecgoninePowder form – topically absorbed“Crack” - freebase form, vaporizes with heatCan be smoked – eliminates vasoconstriction associated with topical cocaine
  • 19. COCAINE
  • 20. BILL COSBY“They say that cocaine intensifies your personality”“Well, what if your an asshole?”
  • 21. COCAINECauses euphoria, increased energyBUT, also puts strain on every organ systemCan cause stroke, MI, arrythmias, deathDoes have high addiction potential
  • 22. METHAMPHETAMINEProduce euphoria and stimulant effect similar to cocaineVery addictiveEffects last longer than cocaineEasily synthesized“Ice” form can be smoked – similar to crack
  • 23. METHAMPHETAMINE
  • 24. “METH MOUTH”
  • 25. METHANOL Organic solvent Industrial uses Common problem in developing world
  • 26. 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
  • 27. 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
  • 28. 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
  • 29. 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
  • 30. 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
  • 31. ETHYLENE GLYCOL Found in most radiator fluid Suicide attempts Alcoholics Accidental - children
  • 32. 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
  • 33. 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
  • 34. 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
  • 35. 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
  • 36. 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
  • 37. ISOPROPOL Rubbing alcohol Readily available Suicide Abuse in alcoholics
  • 38. ISOPROPOL Effect similar to ethanol, but more GI symptoms and more ketones, but does not usually cause significant metabolic acidosis
  • 39. ISOPROPOL Metabolized by ADH to acetone Peak acetone at 4 hours after ingestion Significant toxicity only in massive ingestions
  • 40. ISOPROPOL TREATMENT IV FLUIDS GI meds – H2/PPI Supportive care
  • 41. Case #148 y/o male alcoholic presents intoxicatedVomited, mild epigastric pain, somnolentP=120 RR=26 T=37 BP= 180/80 sat= 99%Charge nurse asks if he can go to CT2
  • 42. CASE #1 LABSNA = 147 K= 3.4 BUN= 42 Creat= 1.8Glucose= 78 anion gap= 38Venous pH = 7.16ETOH = 80
  • 43. CASE #1Measured serum osm = 426WHAT BEDSIDE TEST SHOULD YOU DO?
  • 44. 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