By Alicia Minns, MD
Introduction
Gamma-hydroxybutyric acid (GHB) and its precursors, gamma-butyrolactone (GBL) and 1,4-butanediol (1,4-BD) are popular drugs of abuse and primarily cause CNS depression. There are numerous common names for GBH such as “Liquid ecstasy,” “Georgia Home Boy,” and “Liquid G.” In the 1960s, GHB was being considered for use as a general anesthetic however it is devoid of analgesic properties and due to the number of adverse effects, it was never used in clinical practice. However, early research suggested that GHB was associated with an increased release of growth hormone and an increase in REM sleep. Subsequently in the 1980s and 1990s, GHB become a popular supplement in the body building community. Its euphoric effects were realized at that time as well and GHB became a popular “club drug.” Because GHB can cause rapid coma and amnesia, there was growing concern about its use in drug-facilitated sexual assault. In 1990, the FDA banned all nonprescription use of GHB due to this concern. Sodium oxybate is the sodium salt of GHB and is used as a treatment for narcolepsy. GHB is classified as a Schedule I drug due to its popularity as a drug of abuse and the concern for its use in drug facilitated sexual assault, and also as…
By Alicia Minns, MD
Introduction
The use of antipsychotics began in the 1950’s after it was realized that chlorpromazine, an antihistamine, had a potent calming effect on mentation. The original antipsychotics such as chlorpromazine and fluphenazine revolutionized the treatment of psychiatric disorders. Prior to these medications, patients were mainly treated with sedatives such as barbiturates and housed in institutions for indefinite periods of time. Second-generation antipsychotics, or “atypical antipsychotics” were introduced in the late 1980s are now first-line therapy in the treatment of schizophrenia and are also being used for other conditions such as bipolar disorder, tic disorders and others. Atypical antipsychotics are advertised to have fewer extrapyramidal side effects such as dystonias compared to the original first-generation antipsychotics and are thought to be equally effective.
Case presentation
A 30-year old male presented to the Emergency Department with altered mental status. He was found by his family members with an empty bottle of quetiapine, which had been filled the day prior. On exam, his temperature was 100.3F; heart rate 120 beats per minute; blood pressure 100/55 mmHg; respiratory rate of 16 breaths per minute; and…
By Janna Villano, MD
Introduction
Inhalant abuse describes the practice of inhaling vapors for the purpose of intoxication. Inhalant abuse is a growing practice, particularly among adolescents. Inhalants are particularly attractive to this age group because they are easily accessible, legal to purchase, and inexpensive. Inhalant abuse comprises the practice of huffing, sniffing, bagging, and dusting. Huffing entails holding a chemically soaked rag to the face and then inhaling. Sniffing describes inhaling the volatile substance directly from the container. Bagging is the practice of spraying or depositing a substance directly into a plastic or paper bag and subsequently inhaling the vapors, creating the potential for suffocation. Dusting, a more recent practice, describes inhaling the components of compressed air used to clean computer keyboards and electronic equipment.
Multiple common household and commercially available products, such as glues, paints and paint thinners, and aerosols are abused as inhalants. The majority of substances used are classified as volatile hydrocarbons (aliphatic, aromatic, or halogenated), nitrites, and nitrous oxide (NO). Volatile hydrocarbons include toluene, trichloroethane, butane, and tricholoethylene found in glues, spray…
By Landen Rentmeester, MD, and Binh Ly, MD
Introduction
Strychnine is an odorless, colorless crystalline powder that is found in both naturally occurring alkaloid forms as well as commercially produced salts. It has been used as a rodenticide since the 1500’s as well as for various antiquated medical treatments. Contemporary use of strychnine is mainly limited to the eradication of unwanted gophers, moles, and other rodents. However, unintentional toxicity has occurred from exposure to certain Chinese and Cambodian herbal medicines, as well as from adulterated illicit drugs. Exposures and mortality from strychnine have significantly declined in the U.S. since the 1920’s, with only nine reported deaths in the past decade.
Case presentation
A 40-year old female business executive presents with recurrent convulsive episodes that have developed over the past hour. She does not have a history of seizures or any other medical issues, but is currently in the midst of a divorce with her husband. As you enter the room, your pager goes off and the patient subsequently has another convulsive episode, where her back arches off the table, her arms flex and she seems to grimace, but is awake and alert throughout the event. After about a minute, the convulsions…
By Stephen Thornton, MD
Introduction
The use of synthetic cathinones has risen dramatically in the last several years. These drugs are analogs of the naturally occurring stimulant cathinone which is found in Khat (Catha edulis). Synthetic cathinones are skillfully marketed as “legal highs” over the internet and in smoke and convenience shops where they are often sold as “plant food” or “bath salts” and frequently labeled as “Not For Human Consumption.” When consumed, their clinical effects are very similar to the amphetamines to which they are structurally related. Sympathomimetic excess with substantial agitation and psychosis are frequently described. There is no specific antidote and treatment is focused on good supportive care with aggressive use of chemical sedation for behavioral control.
Case presentation
An emergency physician calls the Poison Control Center because he has a severely agitated patient who ingested an unknown substance which friends are calling a “bath salt.” The patient is very tachycardic, hypertensive, and diaphoretic. The treating physician is calling asking for identification of the intoxicating substance and recommendations for treatment and disposition of this patient.
Questions
- What are “bath…
By Mike Darracq, MD MPH
Introduction
Arsenic is a naturally occurring and ubiquitous metalloid that can result in poisoning from a variety of sources including environmental and occupational exposures as well as more nefarious intent including homicide and suicide. Historically, arsenic has been referred to as the “Poison of the Kings” and “King of Poisons” secondary to the potency and discreteness of action and historical use in the murder of political opponents. More recently, arsenic trioxide, has been increasingly used as treatment for promyelocytic leukemia (PML). Contaminated food, water, and soil are the primary sources of arsenic for the general population. Groundwater contamination by arsenic has severely impacted the health of various populations in certain regions of the world such as Bangladesh and West Bengal. There are considerable challenges associated with arsenic exposure, as many forms exist with varying degrees of toxicity. Clinical manifestations demonstrate multiple organ system involvement and depend on the acuity of exposure and individual variability in metabolism.
Case presentation
A 49 year-old Central California woman has been experiencing a several month history of non-healing vesicles and bulla covering her hands and has…
By Stephen Thornton, MD
Introduction
Mercury remains a common heavy metal exposure as it can be found in both the home and industrial setting. The toxicology of mercury (Hg) is complex due to the presences of different states (elemental, inorganic, and organic), different routes of exposure (inhalation vs. ingestion), and distinctly different pathological effects (acute vs. chronic). Further complicating the picture is that mercury has deleterious effects on many organic systems, ranging from the brain to the kidney to the skin. The evaluation of mercury exposure and toxicity is equally confusing as the limitations of laboratory testing must be appreciated. The treatment of mercury toxicity relies on cessation of the exposure and good supportive care. Chelation can be considered but its indications and benefits are not clear.
Case presentation
An emergency physician calls the Poison Control Center because a patient has been referred to the emergency department for the complaint of “mercury poisoning” and has a laboratory print out detailing a whole blood mercury level of 1208 mcg/L (normal 0-10 mcg/L). The patient states she was exposed to mercury via a broken thermostat. The patient complains of rash to her face and arms, generalized fatigue, and a…
By Cyrus Rangan, MD
Winter 2010
Introduction
Millions of cases of food poisoning are reported to poison centers, public health departments, and other health agencies every year. Food poisoning represents a crossover between infectious diseases and toxin-mediated illness, as many bacteria elaborate toxins to produce symptoms. Some cases of food poisoning involve colonization and reproduction of bacteria in the gastrointestinal tract, while others arise from pre-formed toxins in food. Food poisoning may also result from viral, fungal, or chemical contamination; this newsletter will focus on food poisoning from bacterial etiologies. Bacterial food poisoning may be short-lived and self-limited (e.g. Bacillus cereus, Staphylococcus aureus); or prolonged, with severe symptoms, complications, and sequelae (e.g. Campylobacter spp., Escherichia coli, Shigella spp.).
Case 1 presentation
A 30-year-old female had abdominal cramping and 2 episodes of vomiting after reheated fried rice that was taken home from a restaurant the night before. Onset was approximately one hour after eating the food. There was no fever and no diarrhea. By the morning she felt fine and did not seek medical attention.
Questions
- …
By Alicia Minns, MD
Introduction
The differential diagnosis of the hyperthermic patient in the emergency department is broad. It includes sepsis, heat stroke, trauma, neuroleptic malignant syndrome (NMS), malignant hyperthermia, serotonin syndrome, thyroid storm, psychostimulant overdose, anticholinergic delirium, salicylism, and withdrawal states such as baclofen withdrawal. Establishing the correct diagnosis is challenging in the setting of an obtunded patient with limited history. Although sepsis or infection is the most likely diagnosis in a patient with hyperthermia, as the temperature rises, the differential diagnosis expands to include less common conditions such as NMS. Health care providers should consider these rare conditions when evaluating a patient. However, regardless of the cause the initial management is the same, with the focus being on resuscitation and aggressive cooling. This newsletter with briefly discuss the non-infectious causes of hyperthermia related to drug and medication use.
The definition of a fever is a body temperature of greater than100.4 °F or 38 °C. The hypothalamic thermal set point rises and intact thermal control mechanisms cause body temperature to increase. Hyperthermia occurs when thermal control mechanisms fail so…
By Rais Vohra, MD
Introduction
Organochlorine compounds were introduced in the 1940’s as potent insecticides and pesticides. They offered the advantages of low cost of manufacture, nonvolatile properties, persistent environmental effects, and less toxicity compared to previous pesticides. Their use in the United States has been curtailed in recent decades because of environmental and human health concerns, and lindane was banned in California in 2002 for agricultural and pharmaceutical use. Although less commonly utilized than the organophosphorus compounds, these agents continue to be popular worldwide.
Case presentation
A 3 year old child was brought in to the emergency department (ED) because of a single, self-limited, tonic-clonic seizure. She is an otherwise healthy toddler who accidentally ingested an unknown amount of lindane topical cream in her home. The lindane had been prescribed several years ago to a relative for use as a pediculocide (medication to treat lice infestation). The patient found the old tube of topical lindane under the kitchen sink and decided to “explore” the product by ingesting an unknown amount.
On arrival to the ED the child was post-ictal, but had stable vital signs: pulse 120 bpm, respirations 25 per minute…