1. TOX UPDATE
KENT EMS ROUNDS
Kevin O'Connell MD

2. STUPID THINGS PEOPLE DO

3. BATH SALTS

4. 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

5. BATH SALTS
Crystal or powder that is smoked, ingested,
snorted, or injected
Frequently overdosing
Legal status of drugs

6. BATH SALTS
Cathinones:
MDPV – methylenedioxypyrovalerone
Methylone
Mephedrone
Keeps changing to ingredients to avoid legal
issues

7. BATH SALTS
Increases catecholamines at synapses
Hallucinations, paranoia, violence
Tachycardia, MI
Renal or Liver failure
Trend toward increased use in mental health
patients

8. BATH SALTS
Supportive care, IV fluids
Sedation: Ativan/Haldol
Social Service issues
May show up on Tox screen as PCP

10. SYNTHETIC CANABIS

11. 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”

12. NATURAL CANABIS

13. SYNTHETIC CANABIS

14. 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”

16. 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

17. BEFORE COCAINE

18. AFTER COCAINE

19. 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

20. COCAINE
Benzoylmethylecgonine
Powder form – topically absorbed
“Crack” - freebase form, vaporizes with heat
Can be smoked – eliminates vasoconstriction
associated with topical cocaine

21. COCAINE

22. BILL COSBY
“They say that cocaine intensifies your
personality”
“Well, what if your an asshole?”

23. COCAINE
Causes euphoria, increased energy
BUT, also puts strain on every organ system
Can cause stroke, MI, arrythmias, death
Does have high addiction potential

24. 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

25. METHAMPHETAMINE

26. “METH MOUTH”

27. METHANOL

Organic solvent

Industrial uses

Common problem in developing world

28. 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

29. 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

30. 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

31. 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

32. 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

33. ETHYLENE GLYCOL

Found in most radiator fluid

Suicide attempts

Alcoholics

Accidental - children

34. 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

35. 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

36. 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

37. 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

38. 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

39. ISOPROPOL

Rubbing alcohol

Readily available

Suicide

Abuse in alcoholics

40. ISOPROPOL

Effect similar to ethanol, but more GI symptoms
and more ketones, but does not usually cause
significant metabolic acidosis

41. ISOPROPOL

Metabolized by ADH to acetone

Peak acetone at 4 hours after ingestion

Significant toxicity only in massive ingestions

42. ISOPROPOL TREATMENT

IV FLUIDS

GI meds – H2/PPI

Supportive care

43. 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

44. CASE #1 LABS
NA = 147 K= 3.4 BUN= 42 Creat= 1.8
Glucose= 78 anion gap= 38
Venous pH = 7.16
ETOH = 80

45. CASE #1
Measured serum osm = 426
WHAT BEDSIDE TEST SHOULD YOU DO?

46. 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