The Poison Lab

Dr. Joshua Trebach, MD (@jtrebach) joins the show for some toxic sleuthing of fishy poisonings and answers questions from reddit.com/r/askdrugs. Case report Ryan Feldman wrote about himselfStump the Tox casesCase #1Case #2case series from Dr Jillian TheobaldCase #3Case #4Ask drugsFanconi syndrome in expired tetracyclineSupport the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

In this episode Ryan and Toxo dive into a widely available prescription poison with a frightening ability to cause rapid neurologic and cardiovascular decline, and the best part, it looks like candy! Digoxin kineticsAmiodarone overdosePost market safety reviewReview of published exposures and severe outcomes from US poison centerCase from the showSupport the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Send in your guesses to [email protected] Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Dr. Howard Greller, MD (Sirius XM Doctor Radio Emergency Medicine Show, Dantastic Mr Tox & Howard, Tox & Hound) joins the show. A FANTASTIC episode complete with toxic sleuthing of fatal poisoning cases and answering questions from reddit.com/r/askdrugs. Music from PixabayAdditional information on toxins from fatal poisoning cases Toxin 1Toxin 2Toxin 3Toxin 4Popper article referenced by Dr. GrellerSupport the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

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 & HoundFind the article about the poison lab here Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

In this episode Ryan and Toxo dissect the fascinating underbelly of illegal cosmetic procedures and breakdown the toxicities that arise from them. IntroCase report of hemolysis after sodium deoxycholate injection HistoryEpidemiologyASPS statsFlorida Unlicensed Activity Unit Cost of surgeon fee for buttock implant 2018Recent new storiesBotox and Bubbles grifterQuick bio on cases mentioned in showCommon injection practicesFeminizing body contouring (pumping parties)Synthol musclesCapsule face cosmeticsToxicityInfectionSelf explanatoryFiller embolismReview 1, Review 2, Review 3Filler lodges in pulmonary vasculature->clotting, bleeding, inflammation95% occur within 72 hoursPrimarily respiratory symptoms (cough/hypoxemia)Chest x ray ground glass opacityTreat with supportive care (oxygen all the way through ECMO) +/- steroidsFiller BlindnessCRAO from body fillerNo effective treatment (exception, can use hyaluronidase if filler is hyaluronic acid)GranulomaInflammatory nodules from prolonged filler exposureMay occur months to year after injectionIllegal cosmetic= frequently lipogranuloma due to oil being present in many illegal cosmeticGranulomatous hypercalcemiaExcess calcitriol production from ganuloma causes hyperCACan be extremely delayed (up to 28 years)Recurrence up to 45%Treat with standard therapies (fluid, bisphosphonate) + steroids and/or ketoconazole to turn down granuloma CYP27B1 calcitriol productionCase from the showSome details changed for educational purposes Music in this episode from pixabay.comSupport the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Send in your guesses to [email protected] Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

In this episode of toxicologist vs internet guest Dr. Andrew Farkas, MD joins the show. This a great episode that covers everything from the drugs you would need in the apocalypse to what to worry about if your cats are dying. Complete with toxic sleuthing of fatal poisoning cases and answering questions from reddit.com/r/askdrugs. Research from Dr FarkasAdditional information on toxins from Fatal poisoning cases Toxin 1Toxin 2Toxin 3Toxin 4"Toxicologist vs the internet" segmentCocaethylene reviewBenzodiazepine urine drug screening - Blog postSupport the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

In this episode Ryan and Toxo take a closer look at ketamine induced irreversible bladder damage. HistoryDiscovery of KetamineMelamine outbreaksClinical EffectsIndex casesSurvey of Ketamine use prior to symptomsMechanism/TreatmentMechanism/Treatment systematic reviewRat modelsSupport the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

What substance could cause these symptoms? Send your guesses to [email protected] to participate in episode 10!Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

In this episode of toxicologist vs the internet Ryan Is joined by special guest Dr. Justin Corcoran, MD an emergency medicine physician and medical toxicologist. They take turns answering questions from reddit.com/r/askdrugs (the internet, really, really needs a toxicologist) and challenge each others toxic sleuthing by presenting cases of poisoning and allowing the other to determine the toxin responsible. "Toxicologist vs the internet" segmentEverythingisosm.com (Blog post)Biased Mu Receptor ligandsOliceridine mouse studiesOpioid hearing loss (Blog post)Opioid hearing loss reviewTox pupils  (Blog post)Why tramadol is awful (Blog post)Additional information on toxins from Fatal poisoning cases Toxin 1Toxin 2Toxin 3Toxin 4Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Ryan and Toxo dive in to Delta 8 THC, a new (maybe?) legal drug sweeping the U.S. Delta-8 THC: Key Resources and StudiesNew York Times CoverageComprehensive article on Delta-8 THC, its growing popularity, and concerns: https://www.nytimes.com/2021/02/27/health/marijuana-hemp-delta-8-thc.htmlStudies of Delta-8 THC in HumansSystematic Review:Summarizes findings from a single key study on Delta-8 THC. https://pubmed.ncbi.nlm.nih.gov/29385080/Original Study (may not be accessible):Investigates Delta-8 THC effects in humans.https://www.karger.com/Article/Abstract/136375Testing Strategies for Delta-8 THCHPLC-MS/MS Strategies:Analytical methods for testing Delta-8 THC.https://academic.oup.com/jat/advance-article-abstract/doi/10.1093/jat/bkaa184/6018445?redirectedFrom=fulltextCannabinoid Receptor BindingMechanism of Action:Study exploring how Delta-8 THC binds to cannabinoid receptors.https://pubmed.ncbi.nlm.nih.gov/27398024/If you’re interested in learning more or exploring the impact of Delta-8 THC, these resources provide a great starting point. Thank you for listening!Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Case from the showhttps://pubmed.ncbi.nlm.nih.gov/22163140/Mithradateshttps://www.wemjournal.org/article/S1080-6032(11)00043-3/pdfCase series on mad honey effectshttps://pubmed.ncbi.nlm.nih.gov/20575670/Blog post on sodium channel openershttps://emcrit.org/toxhound/ff-plant-sodium-channel-openers/Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

In this second rendition of toxicologist vs the internet Ryan Is joined by special guest Dr. Jillian Theobald, MD, PHD an emergency medicine physician and medical toxicologist. They take turns answering questions from reddit.com/r/askdrugs (the internet, really, really needs a toxicologist) and challenge each others toxic sleuthing by presenting cases of poisoning and allowing the other to determine the toxin responsible. Listen in to hear about the clinical effects of benzodiazepine on TV watching, the patient side of ketamine, cocaine chest pain, heavy metals, flower petals and much much more! Things from the Show!Ketamine for DepressionPatient Experience Blog:"30 Years of Depression Gone"https://humanparts.medium.com/30-years-of-depression-gone-3dffafabc7cf?fbclid=IwAR1gh08Kn3uSczlKbvMH54yjkWILzyA_6O3Y82q4hVqcAr3shozxwegCnmgFasoracetamStudy on Cognitive Enhancers:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5770454/#CR14KavaHepatic Injury Risk:https://pubmed.ncbi.nlm.nih.gov/15114493/Anti-Anxiety Effects:https://pubmed.ncbi.nlm.nih.gov/33207379/Cocaine Chest PainPropranolol 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 ToxicityClinical guidance for toxicity management:https://pubmed.ncbi.nlm.nih.gov/25724076/Heavy Metals in Cakeshttps://pubmed.ncbi.nlm.nih.gov/18802411/Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Quick Review: Chloroquine and Hydroxychloroquine ToxicityToxic DoseChloroquine: >5 g is associated with severe toxicity (though toxicity can occur at lower doses).Hydroxychloroquine (HCQ): Toxic dose is less well-defined.Clinical EffectsSeizures: Due to sodium channel blockade.Arrhythmias: Resulting from sodium channel blockade.Hypotension: Caused by alpha-adrenergic blockade.Hypokalemia: Often a notable feature.ManagementDecontamination:Administer activated charcoal if the patient is awake, alert, and has no risk of emesis.Supportive Care:High-dose epinephrine:Recommended dose: 0.25 mcg/kg/min.Based on retrospective case-control series: https://www.nejm.org/doi/full/10.1056/NEJM198801073180101Diazepam:Administer 1–2 mg/kg over 30 minutes, followed by 1–2 mg/kg over 24 hours.Prevents seizures and may provide cardioprotective effects.Airway Management:Consider early intubation to secure the airway in deteriorating cases.Expert Consultation:Contact a poison center for guidance: 1-800-222-1222.Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

In this episode Ryan and Toxo discuss some potential toxic spices and break down the toxicity and treatment of a once well known medicine Cinchona Bark, Quinine, and Associated ToxicitiesHistorical PerspectiveUse of Cinchona Bark Powder for Malaria:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4973170/Evolutionary Pressure of Malaria on Sickle Cell Traits:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3499995/CinchonismDefinition: Classic toxicities caused by ingestion of quinoline derivatives from cinchona bark.Brief Review:https://pubmed.ncbi.nlm.nih.gov/32644745/EtiologySources:Powdered cinchona bark: Used in tonic water, to treat restless legs, or as a remedy for certain viruses.Prescription quinoline derivatives:QuinineQuinidineHydroxychloroquineChloroquineClinical EffectsSymptoms:Dizziness, flushing, headache, tinnitus.Potential for vision loss.Laboratory Abnormalities:Hypoglycemia, hypokalemia, long QRS.TreatmentSupportive Care:Manage airway, breathing, and circulation (ABCs).Early use of epinephrine as a preferred pressor based on animal and chloroquine data.Correct Endocrine/Metabolic Abnormalities:Hypertonic Sodium: For wide QRS (use cautiously to avoid worsening hypokalemia).Decontamination:Consider multi-dose activated charcoal for significant ingestions.Ocular ToxicityKey Findings:Ocular toxicity is often delayed but can become permanent.Quinine levels >15 are associated with increased ocular toxicity.Quinine-induced blindness: https://pubmed.ncbi.nlm.nih.gov/3983356/Hall AP, et al. Quinine-induced blindness. Br J Ophthalmol. 1997. doi:10.1136/bjo.81.12.1029Recovery:Vision may recover centrally first, then peripherally.Hyperbaric oxygen therapy (HBO) is often used but remains debated.OtotoxicityMechanism:Tinnitus caused by microstructural changes in the outer hair cells of the cochlea and organ of Corti.Vasoconstriction and prostaglandin inhibition contribute to decreased hearing.Studies:Jastreboff PJ, et al. Quinine-induced tinnitus in rats. Arch Otolaryngol Head Neck Surg. 1991. doi:10.1001/archotol.1991.01870220110020Roche RJ, et al. Quinine induces reversible high-tone hearing loss. Br J Clin Pharmacol. 1990. doi:10.1111/j.1365-2125.1990.tb03704.xMore on Toxicity from StudiesCardiac Arrhythmias in Patients Taking Quinine Alone:Padmaja UK, Adhikari P, Periera P. Experience with quinine in falciparum malaria. Indian J Med Sci. 1999. PMID: 10695226.Negative Inotropic Effects of Quinidine:Hoffmeister HM, et al. Negative inotropic effect of class-I antiarrhythmic drugs. Eur Heart J. 1987. doi:10.1093/oxfordjournals.eurheartj.a062178.Tinnitus and Hearing Effects: Jarboe JK, Hallworth R. The effect of quinine on outer hair cell shape, compliance and force. Hear Res. 1999. doi:10.1016/s0378-5955(99)00031-3.Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

In this episode Ryan Is joined by a special guest Dr. Matthew Stanton PharmD, BCPS, DABAT, an emergency medicine pharmacist and clinical toxicologist. Ryan and Matt take turns answering questions from reddit.com/r/askdrugs (the internet, really, really needs a toxicologist) and finally they challenge each others toxic sleuthing by presenting some cases of poisoning and allowing the other to try to determine the toxin responsible. Episode Show NotesArticles by the Host and CollaboratorsPotential Toxicity of Vitamin E Acetate in THC Vape CartridgesAuthored by Ryan and Matt:Study 1Study 2Related News:Article covering the arrest of a man selling vape cartridges—incident occurred one floor below our host. Co-author of the above papers is quoted.Read the full articleFalse Positives in Drug TestingFalse Positive for FentanylReview ArticleSerotonin SyndromeComprehensive ReviewUnderstanding Serotonin SyndromeLSD and 5-HT2A Partial AgonismMechanistic InsightsBinding Affinity of Psychoactive CompoundsReview ArticleCases of LSD-Related DeathsDiscussion and ReviewSerotonin Syndrome with Stimulant CompoundsRisk ReviewMethamphetamine-Induced Serotonin SyndromeCase ReportToxicity CasesCase 1: Toxicity ReviewDetailed AnalysisCase 2: MethemoglobinemiaComprehensive ReviewCase 3: Toxicity InsightsIn-depth ReviewCase 4: Poisoning Case ReportCase DiscussionSupport the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Great review of potential torsades mechanisms based off experimental data- https://www.sciencedirect.com/science/article/pii/S1880427611800050Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Action potentialSodium/Potassium ATPase pumps create more positively charged ions outside the cell than inside the cell, this creates a relative negative charge in the cellPhase 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 occursPhase 3- Potassium continues to leave the cell  allowing return to -90 mv Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Ryan and Toxo go in depth on an old substance that has begun to resurface with new toxicity due to users taking massive amounts. Loperamide. Dive into the regulatory history, mechanisms of its toxic cardiac effects, and a brief discussion of treatment in episode 4. Buying as much loperamide as you possibly can Loperamide History1969: Synthesized. (1)1976: FDA Approved as Schedule V. (2)"IMODIUM FDA Application No.(NDA) 017694". U.S. Food and Drug Administration (FDA). 1976.https://www.deadiversion.usdoj.gov/schedules/orangebook/orangebook.pdf1982: Descheduled. (3)Florey, Klaus (1991). Profiles of Drug Substances, Excipients and Related Methodology, Volume 19. Academic Press. p. 342. ISBN9780080861142.2010: Increasing poison center calls, arrhythmia cases, and hospitalizations. (4,5,6)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.http://dx.doi.org/10.15585/mmwr.mm6545a72016: DEA denies rescheduling request. (7)https://www.chpa.org/PDF/09_05_17_CommentsCitizenPetitionLoperamide.aspx2019: FDA works with manufacturers to reduce package size to 48 tablets. (8)https://www.fda.gov/drugs/drug-safety-and-availability/fda-limits-packaging-anti-diarrhea-medicine-loperamide-imodium-encourage-safe-usePharmacist Knowledge Gap: Awareness of abuse remains low.Feldman R, Everton E. National assessment of pharmacist awareness of loperamide abuse and ability to restrict sale if abuse is suspected. J Am Pharm Assoc (2003). 2020. doi:10.1016/j.japh.2020.05.021https://pubmed.ncbi.nlm.nih.gov/32641253/Toxic MechanismsInhibition of Sodium and HERG Channels:Kang J, Compton DR, Vaz RJ, Rampe D. Proarrhythmic mechanisms of the common anti-diarrheal medication loperamide. Naunyn Schmiedebergs Arch Pharmacol. 2016. doi:10.1007/s00210-016-1286-7https://pubmed.ncbi.nlm.nih.gov/10837556/IC50 for HERG Ikr ~ 40 nm/l (1908 ng/dl), inhibits as low as 10 nm/l.Klein MG, Haigney MCP, et al. Potent Inhibition of hERG Channels by Loperamide. JACC Clin Electrophysiol. 2016. doi:10.1016/j.jacep.2016.07.008Reported Fatalities:Marraffa JM, Holland MG, et al. Cardiac conduction disturbance after loperamide abuse. Clin Toxicol (Phila). 2014. doi:10.3109/15563650.2014.969371https://pubmed.ncbi.nlm.nih.gov/29941678/TreatmentGuidelines:Eggleston W, Palmer R, Dubé PA, et al. Loperamide toxicity: recommendations for patient monitoring and management. Clin Toxicol (Phila). 2020. doi:10.1080/15563650.2019.1681443https://www.sciencedirect.com/science/article/pii/S1880427611800050Supportive Care:Arrhythmia Management:Electrical cardioversion for torsades.Magnesium to prevent early after depolarizations (target Mg >2, K >4).Lidocaine recommended for VT (does not prolong QTc).Overdrive pacing (e.g., isoproterenol) if bradycardia precedes arrhythmia.Beta-blockers for long QT syndrome.Wide QRS Tachycardia: Use hypertonic sodium (1–2 amps of 8.4% Sodium Bicarbonate IV).Where Do We Go From Here?Further research is needed to understand the incidence of loperamide-induced toxicity and the impact of FDA packaging changes.Concerned about loperamide regulation? Contact us at [email protected]://www.deadiversion.usdoj.gov/schedules/orangebook/orangebook.pdfAl-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS Guidelines for VT and Sudden Cardiac Death. J Am Coll Cardiol. 2018. doi:10.1016/j.jacc.2017.10.054Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Ryan and Toxo cover some topics off the "one pill can kill" list, try breaking down the toxic mechanism of opioid induced respiratory depression in a simplistic way (but maybe fail), and walk through the triage and management of poison center case where a child was "potentially" exposed to a lethal toxin at home. Case ReportPediatric ingestion case study discussed at the beginning of the episode: https://pediatrics.aappublications.org/content/130/6/e1700"One Pill Can Kill" ResourcesMissouri Poison Center resource guide:http://missouripoisoncenter.org/wp-content/uploads/2015/02/2011-One-Pill-Can-Kill.pdfPediatric poison prevention article:https://pubmed.ncbi.nlm.nih.gov/16419734/HealthyChildren.org guide on medication safety:https://www.healthychildren.org/English/safety-prevention/at-home/medication-safety/Pages/Poison-Prevention-One-Pill-Can-Kill.aspxRespiratory Centers and Drug EffectsDetailed overview of the impact of drugs on respiratory centers:https://www.ncbi.nlm.nih.gov/books/NBK482414Buprenorphine StudiesEpidemiologyAAPCC Annual Report on poisoning trends:https://pubmed.ncbi.nlm.nih.gov/31752545/Trends in pediatric opioid exposures:https://pubmed.ncbi.nlm.nih.gov/32178937/Trends in ED visits for unsupervised medication exposures:https://pubmed.ncbi.nlm.nih.gov/26347435/Exposure StudiesU.S. Poison Center data on buprenorphine: https://pubmed.ncbi.nlm.nih.gov/29941678/Harvard Emergency Medicine group analysis: https://pubmed.ncbi.nlm.nih.gov/27756148/Maryland Poison Center/RADARS data:https://pubmed.ncbi.nlm.nih.gov/18381506/ICU exposures in children:https://pubmed.ncbi.nlm.nih.gov/20921918/Triage Considerations for Pediatric ExposuresSymptoms: What are the current symptoms and their severity?Causative Agent & Exposure Characteristics: What substance was ingested, and in what quantity? What’s the context of the exposure?History: Includes past medical history, patient weight, and the time elapsed since exposure.Onset: When are symptoms expected to appear?Labs: Perform toxin-specific assessments where applicable.Aggravating/Remitting Factors: What interventions have already been performed, and how have they affected the patient?If you have questions about these studies or poisoning scenarios, consult your local poison center or toxicologist. Thank you for tuning in!Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Get ready for a HEAVY subject, literally. Ryan and Toxo talk about the toxic mechanisms, signs of poisoning, and treatment of one of the worlds most ubiquitous poisons. This is a long, but interesting one, consider listening in chunks. Excellent Review SourcesCalello DP, Henretig FM. "Lead." In: Goldfrank's Toxicologic Emergencies, 10th ed, Hoffman RS, Howland MA, Lewin NA, et al (Eds), McGraw Hill Education, New York, 2015. p.1219.Toxic Substances Database for Lead: https://www.atsdr.cdc.gov/toxprofiles/tp.asp?id=96&tid=22Clinical Case from Today's ShowSevere lead toxicity from retained bullet fragments:Weiss D, Lee D, Feldman R, Smith KE. "Severe lead toxicity attributed to bullet fragments retained in soft tissue." BMJ Case Rep. 2017;2017. doi:10.1136/bcr-2016-217351Full Text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5353372/History of LeadLead’s abundance has increased over time due to radioactive decay: https://iopscience.iop.org/article/10.1086/375492Its use spans currency, cosmetics, aqueducts, and even wine, contributing to societal impacts like the fall of Rome: https://pubmed.ncbi.nlm.nih.gov/14261844Lead in society overview: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6522252/Common Sources of Lead ExposureLead Paint: Up to 50% lead until 1940; still present in millions of homes.Soil: Contaminated by tetraethyl leaded gasoline (introduced by Thomas Midgley): https://interestingengineering.com/thomas-midgley-jr-the-man-who-harmed-the-world-the-mostLead Piping:EPA Lead and Copper Rule: https://www.epa.gov/sites/production/files/2016-10/documents/508_lcr_revisions_white_paper_final_10.26.16.pdfTraditional Medicines: Ayurveda: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2538609/Kohl (cosmetics): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1567936/Bullets: https://pubmed.ncbi.nlm.nih.gov/30939573/The "Lead Crime Hypothesis": https://pubmed.ncbi.nlm.nih.gov/27035924/Clinical EffectsBen Franklin’s "Dangles and Bellyaches": https://pubmed.ncbi.nlm.nih.gov/22910081Colic/constipation.Neuropathy.Neurocognitive/Behavioral Effects:IQ reduction, visual-spatial impairment, reduced processing speed, and irritability.Impacts in young children: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3909981/Chronic Conditions:Kidney and vascular disease: https://www.atsdr.cdc.gov/toxprofiles/tp13-c2.pdfHematologic effects (e.g., hemolytic anemia): https://www.atsdr.cdc.gov/toxprofiles/tp13-c2.pdfBurton lines (sulfate deposits): https://www.amjmed.com/article/S0002-9343(12)00286-0/pdfLead lines (metaphyseal calcification): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1912933/Toxic MechanismsBinds to sulfhydryl groups.Acts as a divalent cation, interfering with numerous enzymatic processes.Comprehensive overviews:Goldfrank’s Toxicologic Emergencies, 10th ed.https://www.atsdr.cdc.gov/csem/csem.asp?csem=34&po=10Treatment OverviewChelation Therapy:BAL: Painful IM injection; contraindicated in G6PD deficiency.https://www.sciencedirect.com/science/article/pii/S0041008X99987252Ca2NaEDTA: IV; used for levels >70 µg/dL or encephalopathy.https://www.sciencedirect.com/science/article/abs/pii/S0013935184710632Succimer: Oral; ensure lead has passed the small intestine before starting.https://www.sciencedirect.com/science/article/abs/pii/S0013935184710632Management Based on Blood Lead Levels:Kids: https://www.cdc.gov/nceh/lead/advisory/acclpp/actions-blls.htmAdults: https://pubmed.ncbi.nlm.nih.gov/17431500/If You Encounter Lead ExposureConfirm elevated capillary blood lead with venous testing.Call your toxicologist or poison center for guidance.Thanks for listening!Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Concepts in this episode Ryan and Toxo introduce their roles while explaining the current state of toxicology and what exactly a poison is. testing our testsSensitivity: Rate of Positive test in those who have the diseaseSpecificity: Rate of negative test in those without the diseasePositive predictive value: True positive/ True Positive + False PositiveNegative predictive value: True negative/True negative + False negativePharmacokinetics and dynamics(PK) Bioavailablity = Amount of drug available to be used by the bodyOral Bioavailablity= Dose- Fraction excreted unchanged- Fraction metabolized in gut- Fraction metabolized by liver How drugs interact with the body (PD)Agonist- stimulates receptorPartial agonist- Activation of receptor with ceiling effect, never achieves maximal activationAntagonist- Prevents receptor activationInverse agonist- induces an opposite effect as an agonist after binding receptorAddiction vs dependanceAddiction- Relationship between user and substanceA few definitions but frequently involving consequences in life from use and loss of control over use of substanceDependence- Physiologic changes in body due to chronic useDown regulation of stimulated receptorsPhysiologic basis for tolerance and withdrawalSupport the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Ryan and Toxo Discuss the History and Risks of a Common DisinfectantIn this episode, Ryan and Toxo dive into the history of a commonly used disinfectant, exploring its dangers when misused. From creating chemical weapons to causing severe injuries, they break down its toxic potential and offer critical safety tips. They break down the many ways it can cause harm if not used appropriately, including creating chemical weapons and turning your body into soap. Finally they review treatment recommendations if you accidentally are exposed, or if you are health care provider treating an exposure. Key PointsBleach Reactions with Other ChemicalsBleach + Acid → Chlorine GasReaction: Cl₂ + H₂O ⇄ HCl + HClOBase neutralizes HCl to drive reaction forward; reversed with acid addition.SourceBleach + Ammonia → Chloramine GasChloramine properties: PubChem LinkBleach + Rubbing Alcohol (Isopropyl) → ChloroformBleach + Soap → Carbon TetrachlorideToxic Effects of Chlorine GasMechanism: High solubility irritant, dissolving in mucous membranes, causing severe irritation in the eyes, nose, and upper airway.Symptoms: Effects are noticed quickly and may appear severe initially.Treatment:Remove from exposure, ensure a patent airway, and provide supportive care.Oxygen for hypoxemia.Bronchodilators (e.g., albuterol) for airway irritation.Nebulized Sodium Bicarbonate may have a role in treating chlorine gas inhalation.Systematic ReviewSafety AdviceIf exposed to chlorine gas, move to fresh air, open windows, and call 911 or your local poison center.Bleach Ingestion: Can cause liquefactive necrosis. Treatment focuses on assessing injury for risk of stricture or esophageal stenting.Steroid Use in Chemical Inhalation InjuriesResearch Summary:Corticosteroids are not routinely recommended due to limited evidence from controlled trials.Case reports suggest potential benefit but lack appropriate comparators.References: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.Historical ContextClaude Berthollet: Pioneer of chlorine disinfection.BiographyAntoine Labarraque: Innovator in bleach use for sanitation.BiographyAdditional ReferencesCaustic Ingestion Review:Hoffman RS, Burns MM, Gosselin S. NEJM 2020Pulmonary Irritants Overview:Nelson LS, Odujebe OA. Goldfrank's Toxicologic Emergencies, 11e.Reactions of Sodium Hypochlorite with Other Compounds:Odabasi M. Environ Sci Technol 2008Chlorine Gas Exposure Management:Huynh Tuong A, et al. Clin Toxicol 2019Incidence Data:Gummin DD, et al. Clin Toxicol 2017Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Ryan and Toxo introduce their roles while explaining the current state of toxicology and what exactly a poison is. Information about medical and clinical toxicology can be found at American Academy of Clinical Toxicology (AACT)- clintox.orgAmerican College of Medical Toxicology (ACMT)- acmt.netSupport the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website

Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game!The Poisonus Fungus Amongus Children's Book!Full book reading (6 minutes!)Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website