Lessons Learned from Poison Control M A R C H 1 0 T H , 2 0 1 6 - PDF document

3/10/16 ¡ Lessons Learned from Poison Control M A R C H 1 0 T H , 2 0 1 6 HALLAM GUGELMANN, MD MPH M E D I C A L T O X I C O L O G I S T U N I V E R S I T Y O F C A L I F O R N I A A T S A N F R A N C I S C O A S S I S T A N T M E D I C A L D I R E C T O R C A L I F O R N I A P O I S O N C O N T R O L S Y S T E M , S A N F R A N C I S C O D I V I S I O N E M E R G E N C Y M E D I C I N E A T T E N D I N G C P M C S T L U K E ’ S H O S P I T A L S A N F R A N C I S C O , C A L I F O R N I A Disclosures — I have nothing to disclose 1 ¡

3/10/16 ¡ — Poison Control Centers: The critical role in chemical and drug exposures California ¡ 24/7 reliable information Poison ¡ Disaster surveillance Control ¡ Passive data mining ¡ Alert, experienced professionals System Poison Control Staff — Highly trained, licensed, certified experts ¡ PharmDs and nurses with extensive training ¡ Non-licensed information providers ÷ Handle simpler calls ÷ Use approved protocols ÷ Supervised by licensed specialists — Back-up by board-certified MD toxicologists 2 ¡

3/10/16 ¡ CPCS Public Health Surveillance… Case 1. The Pet Shop Employee — A healthy 32 year old — Clinical course: male ¡ Numbness and pain spreading up affected arm ¡ Cleaning an aquarium ¡ EKG showing sodium ¡ Superficial abrasions to 3 channel disturbance fingers of right hand The Culprit: — Goes home ¡ 2 hours later: ÷ Diffuse weakness ÷ Shivering & Myalgias — 16 hours after exposure: ÷ Collapses at work ÷ Dizzy, slurred speech ¡ Rhabdomyolysis ÷ Glassy eyes wikipedia.org ¡ 48 hours of paresthesias, weakness, muscle pains — 4 weeks later: ¡ Full resolution of symptoms Toxicon. 2008 Jun 15;51(8):1535-7. 3 ¡

3/10/16 ¡ Poison Control and the Esoteric Case — Palytoxin, from zoanthid anemones, some predatory fish ¡ Goldspot herring, boxfish, filefish, parrotfish, some crabs — Mechanism: ¡ Deranges cell membrane proteins ¡ Sodium and potassium flow into cells — Broad range of clinical findings: ¡ Dizziness, perioral and limb paresthesias, weakness wikipedia.org ¡ Nausea, vomiting, diarrhea, abdominal pain ¡ Hypertension, bradycardia, dysrhythmias ¡ Rhabdomyolysis, acute renal failure, anuria ¡ Myalgias, muscle spasms, respiratory distress, arthralgia, acute hyperkalemia, acute hyperphosphatemia For more information: thepoisonreview.com Toxicology Esoterica: La fée verte — What is absinthism? ¡ Seizures, impaired speech, hallucinations, coma — What’s to blame? ¡ Thujone? ÷ Seizures at high concentrations… ÷ Absinthe contains less than 35 mg/L of thujone ¡ Cheap absinthe: ÷ Copper sulfate & antimony chloride: additives to obtain the green color and milky opalescent effect Pablo Picasso • HUTTON I (2002) CURR DRUG The Absinthe Drinker DISCOV 9:62–64 (1902) Dalmatian sage—common flavoring herb—contains more than 50 % thujone in its oil http://www.picassoandmatisse.com/ 4 ¡

3/10/16 ¡ Case 2. An Irritated Eye… — Healthy 45 year old plant nursery employee: ¡ Right eye irritation while at work ¡ Vital signs from triage: ÷ BP 125/87 HR 83 Temp 37.4C RR 12 ¡ First thing you see: Pupils… Mydriasis Miosis Musculature and Innervation Constrictor (sphincter) Inhibition Stimulation opioids, pilocarpine, organophophates cholinergic stimulation via CN III anticholinergics Dilator (radial) Stimulation Inhibition catecholamines, sympathetic innervation cocaine, meth… clonidine Images: Wikipedia 5 ¡

3/10/16 ¡ Relevant: What is cornpicker's eye? Answer: — Mechanized combines are used to harvest corn and cornstalks. — Dried Datura plants in the field are pulverized into a dust containing belladona alkaloids. — This dust can become airborne; contact with the eyes cause mydriasis, and inhalation can cause systemic anticholinergic symptoms as well. KRENZELOK E. DATURA • POISONING. 48(2): 104-110 Images: Wikipedia The Diligent Occupational Medicine Doctor asks: — What plants were you working with? Brugmansia Images: Wikipedia 6 ¡

3/10/16 ¡ Pupils… Mydriasis Miosis Musculature and Innervation Constrictor (sphincter) Inhibition Stimulation anticholinergics opioids, pilocarpine, organophophates cholinergic stimulation via CN III Dilator (radial) Stimulation Inhibition catecholamines, sympathetic innervation cocaine, meth… clonidine Images: Wikipedia Case 2 – continued… — Datura sap had gotten in the patient’s eye — She was sent home, and her symptoms resolved over then next 24 hours 7 ¡

3/10/16 ¡ Case 3. On the subject of eyes... — 30 year old male veteran ¡ 3 deployments to Afghanistan — Ocular complaints: ¡ Persistent image in his visual field after staring then looking away ¡ Also: ÷ Field of points of light throughout his vision ÷ Junctions of high contrast seen as through a prism — Toxic exposures: Medical ¡ Depleted uranium Toxicologist Consultation ¡ Single IED exposure resulting in loss of consciousness and persistent tinnitus ¡ Remote LSD use What is the patient exhibiting? Palinopsia Visual Snow — Staring at an object, — Constant field of then shifting his gaze multiple points of light to a blank screen results in a persistent image of the object 8 ¡

3/10/16 ¡ Ocular Toxins — Disconjugate gaze ¡ Botulism ¡ Elapids ¡ Paralytic shellfish poisoning ¡ Tetrodotoxin — Funduscopic changes ¡ Carbon monoxide ¡ Cyanide ¡ Ergot alkaloids ¡ Methanol — Nystagmus ¡ Carbamazepine ¡ Ethanol ¡ Phencyclidine — Papilledema ¡ Amiodarone, lead, vitamin A Image: Goldfrank’s Toxicologic Emergencies, 9 th Ed. What is the patient actually exhibiting? Palinopsia Visual Snow — Staring at an object, — Constant field of then shifting his gaze multiple points of light to a blank screen results in a persistent image of the object 9 ¡

3/10/16 ¡ Xenobiotics and Palinopsia? — Trazodone, nefazodone, risperidone ¡ 5HT2a modulators — Clomiphene, topiramate ¡ GABA disruption-mediated? ¡ Clomiphene has been associated with permanent palinopsia — Mirtazapine ¡ Visual trails predominantly, meets Naranjo Criteria — Zosuquidar ¡ Antineoplastic — Maprotiline, Interleukin 2 ¡ Links are somewhat questionable… Could this be toxicologic? — Palinopsia: ¡ Broad range of illicits and pharmaceuticals that could have caused the problem. ¡ No clear intervention available. — What about depleted uranium? 10 ¡

3/10/16 ¡ Depleted Uranium Bullets — Used in armor-piercing bullets and defensive plating ¡ Medical radiation shielding — Byproduct of enriched uranium production ¡ Both nuclear reactor and nuclear weapons byproduct Uranium ore à uranium oxide (U 3 OX) — 68.4% denser than lead à UF 6 (gas) — Natural uranium is ~0.70% 235 U Separate 234 U 235 U 238 U — Depleted uranium has 0.2% 235 U via gas chromatography Images: Wikipedia Clinical Effects of Depleted Uranium — Various forms in nature and after absorption — Dermal exposure: ¡ Animal studies: 7g/kg à dermal damage, renal failure — Respiratory exposure: ¡ Inhalation: ÷ 85% deposited in bones, 15% in renal proximal tubules — Embedded fragments: ¡ Friendly fire and shrapnel exposure ¡ Generally removed to decrease risk of absorption 11 ¡

3/10/16 ¡ Case 3. Could this be toxicologic? Maybe. — Palinopsia: ¡ Caused by a broad range of drugs ¡ Depleted uranium-induced? Unlikely. — Visual snow: ¡ May be linked to a history of LSD use ¡ Commonly migraine-related — No known treatments for either Toxicology Esoterica: The Cost of Being Callipygian — 27 year old female — Gluteal enhancement: — Shortness of breath and ¡ Silicone implants wheezing 18 hours after ¡ Polyacrylamide hydrogel undergoing a buttock ¡ Liposuction contouring enhancement procedure via autologous fat transfer ¡ Polymethyl-methacrylate — Could her presentation (PMMA) and the procedure be — Possible complications of related? PMMA: ¡ Anaphylactoid reactions 2009: ¡ Inflammation, infections Former Miss Argentina dies after a PMMA buttock injection ¡ Emboli embolizes to her lungs, and possibly brain. 12 ¡

3/10/16 ¡ Case 4. Out cold — An occupational medicine nurse at a chicken waste rendering plant is called to help. Rendering: reclaiming fats and protein from animal waste tissue. Associated with bovine spongiform encephalopathy. — A blocked condenser connected to a storage vessel had been cleared, and the resulting gas emission knocked three workers unconscious — EMS crews call Poison Control en route to the hospital What are “knockdown gases”? — Cyanide — Hydrogen sulfide 13 ¡