Nothing to Disclose Craig Smollin MD Medical Director California - - PDF document

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Nothing to Disclose Craig Smollin MD Medical Director California - - PDF document

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3/8/18 Novel Toxicants in the Environment Cases from Poison Control Nothing to Disclose Craig Smollin MD Medical Director California Poison Control System, SF Division Associate Professor of Emergency Medicine University of California, San

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3/8/18 1 Novel Toxicants in the Environment Cases from Poison Control

Craig Smollin MD

Medical Director California Poison Control System, SF Division Associate Professor of Emergency Medicine University of California, San Francisco

Nothing to Disclose

United States Poisoning Data

  • In 2015, U.S Poison Control Centers managed 2.2

million human exposures.

  • 28.3% managed in a health care facility.
  • 4.7% admitted to a critical care unit.
  • Poisoning is the leading cause of death in United

Sates.

Poisoning is the leading cause of death from injuries in the U.S.

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3/8/18 2

55 Poison Control Centers The California Poison Control System (CPCS) The California Poison Control System (CPCS)

San Diego San Francisco Fresno Sacramento

  • California Population ~40 million
  • Poison Control System
  • Four Divisions
  • ~ 250,000 human exposures/year
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3/8/18 3 Case #1 – Leg pain and rash

  • A previously healthy 5 year-old male presents

with intermittent bilateral lower extremity pain.

  • Pain wakes him from sleep and improves with

massage.

  • Seen in clinic and diagnosed with “growing

pains”

Case #1 – Leg pain and rash

  • Pain worsens:

– Continuous “pins and needles” – Prefers to sit with knees drawn to chest – Associated with intermittent profuse sweating

Case #1 – Leg pain and rash

  • Pertinent Exam findings

– Blood pressure 150/100 mmHg – Mild diaphoresis – Stomatitis – Rash on bilateral hands

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3/8/18 4

Desquamation Erythema Stomatitis

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3/8/18 5 Case #1 – Leg pain and rash

  • Laboratory tests:

– CBC, electrolytes, glucose, renal function normal – Urinalysis + protein – Serum catecholamines:

  • Norepinephrine 598 umol/mol (nl 0-80)
  • Epinephrine 61 umol/mol (nl 0-35)
  • Dopamine 1041 umol/mol (nl 0-1130)

Pink’s Disease

  • Characteristics:

– Pink palms and soles +/- desquamation – Red cheeks and nose – Loss of hair, teeth and nails – Salivation and marked diaphoresis – Transient rashes – Painful extremities – Neuropsychiatric symptoms

Case #1 – Leg pain and rash

  • Laboratory tests:

– Spot urine mercury 26.7 mcg/L (nl <10 mcg/L) – 24 hour urine mercury 512 mcg/L (nl <50 mcg/L)

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3/8/18 6

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3/8/18 7 Case #2 Deadly Pesticide

  • A family of ten used an unknown pesticide

under their mobile home.

  • Family members complained of an odor.
  • Four days later, family members complained
  • f abdominal pain and vomiting.
  • Seen in an Emergency Department and

discharged with the “flu”.

Case #2 Deadly Pesticide

  • The father attempted to wash away the

pellets using a water hose.

  • The following morning, 911 was called due to

multiple family members will dyspnea and depressed level of consciousness.

  • No carbon monoxide detected.
  • One child in cardiac arrest. Multiple family

members required transport to the hospital.

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3/8/18 8 Aluminum Phosphide

  • AlP + 3 H2O à Al(OH)3 + PH3 (Phosphine gas)
  • Phosphine Gas:

– Garlic or fishy odor – Highly toxic (lungs, brain, kidneys, heart, liver) – ACGIH TLVTWA = 0.3 ppm (0.42 mg/m3) – IDLH = 50 ppm

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3/8/18 9 Aluminum Phosphide

  • Clinical Presentation:

– Cough dyspnea, headache, dizziness and vomiting – ARDS – Acute renal failure – Hepatitis – Seizures and coma – Myocardial manifestations

Pesticides

  • Commonly reported to poison control centers.
  • Exposures occur through production, transportation

and application.

  • California with largest number of individuals

employed in occupations using pesticides.

  • Most commonly reported classes:

– insecticides, herbicides, repellants, fumigants, fungicides.

  • Most common routes:

– Inhaled and dermal.

Case #3 An Unusual Opioid

  • A 36 year-old male brought to the emergency

department by EMS after ingesting hydrocodone/acetaminophen.

  • Obtunded (grumbles/withdraws to pain).
  • Pin point pupils.
  • Respiratory rate is 8/min.
  • Improved after 2 mg of naloxone.
  • 1.5 hrs later the patient developed recurrent

symptoms with respiratory depression, and a decline in oxygen saturation to 90%.

  • Sxs improved after repeat dose of 6 mg

naloxone.

Case #3 An Unusual Opioid

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3/8/18 10

Case #3 An Unusual Opioid

  • 1.5 hrs later the patient developed recurrent

symptoms with respiratory depression, and a decline in oxygen saturation to 90%.

  • Sxs improved after repeat dose of 6 mg

naloxone. Onset, Duration of Effect, and Potency of Selected Opioids

Opioid Analgesic (route) Onset of effect (min) Duration of effect (hrs) Potency Morphine (IV) 5-10 3-6 1 Oxycodone (PO) 10-15 4-6 0.5 Hydrocodone (PO) 30-60 4-6 0.33 Hydromorphone (IV) 15 4-6 6.66 Methadone (PO) 30-60 6-12 1 Fentanyl (IV) Immediate 0.5- 1 100 Buprenorphine (PO) 60 4-12 ? Meperidine (IV) 1-5 2-4 0.1 Naloxone (IV) 1-2 1-2

High Naloxone Requirements

  • Higher potency opioids may require larger

doses of naloxone

– Poklis A. Fentanyl: a review for clinical and analytical toxicologists. J Toxicol Clin Toxicol. 1995;33(5):439-47. – Schumann H, Erickson T, Thompson TM, Zautcke JL, Denton JS. Fentanyl epidemic in Chicago, Illinois and surrounding Cook County. Clin Toxicol (Phila). 2008;46(6):501-6.

  • 1.5 hrs later the patient developed recurrent

symptoms with respiratory depression, and a decline in oxygen saturation to 90%.

  • Sxs improved after repeat dose of 6 mg

naloxone.

  • Urine toxicology screen negative.

Case #3 An Unusual Opioid

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3/8/18 11

Urine Drug Screening: Opiates

USUALLY DETECTED

  • Morphine
  • Heroin
  • Codeine
  • Hydrocodone1
  • Hydromorphone1

1 Depending on the assay

USUALLY NOT DETECTED

  • Oxycodone2
  • Methadone2
  • Fentanyl
  • Meperidine
  • Buprenorphine2
  • Tramadol

2 Specific assays available

  • 1.5 hrs later the patient developed recurrent

symptoms with respiratory depression, and a decline in oxygen saturation to 90%.

  • Sxs improved after repeat dose of 6 mg

naloxone.

  • Urine toxicology screen negative.
  • Acetaminophen level negative.

Case #3 An Unusual Opioid

Laboratory Analysis: Fentanyl 3.5 mg Promethazine 2.3 mg Acetaminophen 39.2 mg

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3/8/18 12

Novel Psychoactive Substances and Opioids

  • W18
  • Furanylfentanyl
  • Acetylfentanyl
  • MT-45
  • 3-methylfentanyl (TMF)
  • 4-methoxybutyrofentanyl

What PPE for First Responders? What PPE for First Responders? What PPE for First Responders?

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3/8/18 13

ACMT Position Statement on Workplace Exposure to Fentanyl

  • Risk of significant exposures to emergency

responders is extremely low.

  • Incidental dermal contact unlikely to cause toxicity.
  • Nitrile gloves for routine handling.
  • In exceptional circumstances where there are drug

particles or droplets suspended in air use N95 respirator

  • Worker should be trained to recognize opioid

intoxication and to administer naloxone.

Case #4 Feeling blue

  • 57 year-old Chinese woman presents to the ED after

eating previously frozen oven-cooked mudfish.

  • She complains of headache, lightheadedness,

shortness of breath and paresthesias of her extremities.

  • Husband ate same fish and had dizziness which

resolved.

Case #4 Feeling blue

  • Physical Exam:

– Dusky appearing skin without respiratory distress – Vital Signs: P 84, RR 21, BP 120/80, O2 sat 85% – Lungs are clear bilateral

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3/8/18 14

Case #4 Feeling blue Case #4 Feeling blue

  • Physical Exam:

– Dusky appearing skin without respiratory distress – Vital Signs: P 84, RR 21, BP 120/80, O2 sat 85% – Lungs are clear bilateral

  • Placed on a non-rebreather oxygen mask

– ABG: 7.41, pCO2 43, pO2 452, O2 sat 100% – CXR unremarkable

Case #4 Feeling blue

  • Physical Exam:

– Dusky appearing skin without respiratory distress – Vital Signs: P 84, RR 21, BP 120/80, O2 sat 85% – Lungs are clear bilateral

  • Placed on a non-rebreather oxygen mask

– ABG: 7.41, pCO2 43, pO2 452, O2 sat 100% – CXR unremarkable – MetHb level 40.2%

Case #4

  • Treated with IV methylene blue (1 mg/kg)
  • Skin discoloration and tachypnea improved

within 1 hour.

  • Repeat MetHb level 1.3% at 3 hours.
  • Department of Public Health notified and

investigation revealed that frozen dried mudfish imported from Thailand had high levels of sodium nitrite.

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3/8/18 15

  • Fe in Hgb oxidized Fe2+ à Fe 3+
  • Reduced oxygen carrying capacity
  • Treatment

– Methylene blue 1% – 1-2 mg/kg over 5 minutes – Symptoms generally improve over 1 hour – General rule treat when Methgb level > 20%

Methemaglobinemia Selected Drugs and Toxins Causing Methgb

Drugs Toxins Local anesthetics Chloroquin Dapsone Nitrites Phenazopyridine Primaquin Sulfamethoxazole Aniline Dyes Benzene derivative Paraquat

Amyl Nitrite “Poppers”

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3/8/18 16

  • The Poison Control System is an important public

health resource.

  • Involved in cases of significance to occupation and

environmental health.

  • Case #1 à Mercury Exposure
  • Case #2 à Aluminum Phosphide Exposure
  • Case #3 à Fentanyl as an adulterant
  • Case #4 à MetHgb from nitrite exposure

Summary Poison Control System 24/7 Hotline 1-800-222-1222 - Public 1-800-411-8080 - Hospitals

— Immediate consultation by

clinical pharmacists

— Back-up by MD toxicologists