Ciguatera Fish Poisoning
Agents Dinoflagellates Gambierdiscus toxi-cus worldwide , Ostreopsis lenticularis Caribbean only . Toxins Three neurotoxins ciguatoxin, gambierol, and scaritoxin one myotoxin maitotoxin. LD50 IV in mice Ciguatoxin 0.45 mcg kg maitotoxin 0.05 mcg kg. Mechanism Ciguatoxic-forced opening of Na channels with increased Na influx, prolonged depolarization, and myospastic contractures. Maitotoxic-forced opening of Ca channels with increased Ca influx and prolonged myospasticity. Vectors gt 100 reef...
Acute Marijuana Toxicity
Physiological effects Dose-related tachycardia, blood pressure remains stable, increased appetite, dry cotton mouth, conjunctival injection, reduced intra-ocular pressure, bronchodilation, weakness, muscle tremors, urinary retention, low testosterone levels impotence. Psychological effects Dose-related euphoria, relaxation, sensory alterations. Preexisting psychopathology may predispose to transient, acute psychotic reactions with paranoid delusions and hallucinations. Management of Marijuana...
triatomid Bugs triatominae
Family Triatominae Subfamily Reduviidae assassin, cone-nose, kissing, and stink bugs . Genera Triatoma, Rhodnius, and Panstrongylus spp. Adults Big 1-2-inch bugs with long snouts and dark eyes 4-segment antennae thin, straight, retractable proboscis triangular thorax, folding wings with contrasting dark brown-orange and light yellow-pink colors. Powerful flyers. Diseases Chagas disease Trypanosoma cruzi a wild-animal zoonosis, especially among armadillos, opossums, squirrels, and rodents....
Platinoid Mechanism and toxicityPlatinoid Overdose Management
Representatives Platinum-containing cisplatin and carboplatin. Mechanism Platinoids form intra- and interstrand crosslinks with DNA molecules when hydrolytically activated upon entering low chloride intracellular environments. Toxicities CNS gt renal gt bone marrow CNS Seizures, encephalopathy, heavy-metal induced sensory peripheral neuropathy-axonopathy, retinal toxicity, reduced color vision, ototoxicity high-frequency . Renal Distal tubular necrosis with subsequent acute renal failure ARF ....
BZ Toxicity
Figure 9.3 Mydriasis, Right Eye. Pupillary dilation or mydriasis characteristic of an anticholinergic toxidrome and overdoses with alcohol and barbiturates. General Weakness, nausea, diarrhea, chest pain. CNS Headache, vertigo, blurred vision, obtun-dation, stupor, coma all potentiated by co-ingestions, especially with alcohol. Cardiovascular VS well-maintained, not arrhythmogenic. Tolerance Occurs rapidly, within 1 week. Withdrawal Headache, tremor, weight loss, paresthesias, perceptual...
Crustacean Poisoning
Agents and toxins Bioaccumulated red algal gonyautoxins and zoanthid coral palytoxin LD50 IV in mice Gonyautoxins and tetrodo- toxin TTX 9 mcg kg palytoxin 0.15 Mechanism Gonyautoxins and TTX reversibly bind to outer pore of Na channels, decreasing Na influx and depolarization palytoxin inhibits Na-K ATPase, Na and K can enter but cannot leave axon, Ca cannot enter, causing hypocalce-mic tetanic contractions. Vectors Most Indo-Pacific xanthid crabs, terrestrial coconut crab, and Asian horseshoe...
ASA Overdose
Adult overdoses present with mixed respiratory and metabolic acidosis children present only with metabolic acidosis gt 40 mg dL . Unique toxic effects include Reye's Syndrome Non-cardiogenic pulmonary edema from hypoxia and pulmonary hypertension HTN Hypoprothrombinemia and platelet dysfunction Nausea, vomiting, slow GI motility, hemor-rhagic gastritis Rhabdomyolysis from hypermetabolism, seizure activity, and increased heat production Tinnitus preceding deafness gt 20-45 mg dl
Obligatory Myiasis
Definition Fly larvae maggots must live and feed on a live human or other animal host for part of their life cycle. Examples Cordylobia anthropophaga tumbu fly , Cochliomyia hominivorax New World screwworm , Chrysomya bezziana Old World screwworm , Dermatobia hominis bot fly , Wohlfahrtia magnifica. table 18.1 Myiasis Family Calliphoridae table 18.1 Myiasis Family Calliphoridae
Chronic Marijuana Toxicity
Marijuana is an oily, dried fibrous material obtained from the Indian hemp plant, Cannabis sativa. The most commonly used illegal substance in the United States. The most commonly abused substance in the world after nicotine, alcohol, and caffeine. Considered a gateway drug by the DEA, NIDA, and the Substance Abuse and Mental Health Services Administration SAMHSA . Tolerance and dependence Resulting from repeated use. Withdrawal syndrome Irritability, restlessness, Congenital toxicity Neonatal...
Gyromitrin MMH Toxicity
Representative genus Gyromitra species. Toxin Gyromitrin, a monomethylhydrazine B6 GABA inhibitor. Antidote B6 or pyridoxine, 25 mg kg IV. Representative genus Coprinus species. Toxin Coprine. Antidote None specific. Diagnosis Onset 0.5-2 hours disulfiram reaction following ingestion of alcohol with facial flushing, nausea and vomiting, tachycardia, hypertension. Treatment Supportive, IV fluids. Representative genus Amanita muscaria, A. pantherina, A. gemmata. Toxins Ibotenic acid and its...
Latrine Fly Fanniidae
Family Muscidae. Genus Stomoxys calcitrans. Adults Resemble houseflies, but frequent stables and barns distinctly unique forward-projecting proboscis. Diseases Same as houseflies. Mechanism Same as houseflies. Eggs 50-200 creamy white eggs oviposited in horse manure. Larvae Cream-colored maggots resembling housefly maggots, but with widely separated posterior spiracular slits. Pupae Brown and barrel-shaped pupae resembling housefly pupae, but with characteristic posterior spiracular slits....
C
FIGURE 1.6 Michaelis-Menten Kinetics. The rate of a drug's elimination is initially by first-order kinetics, and then switches to zero-order kinetics when the drug's hepatic metabolizing enzyme system becomes saturated to capacity. Area under the curve AUC of concentration C x time t FIGURE 1.7 Plasma clearance. Plasma clearance is reflected by the area under the curve of a drug's plasma concentration over time, or clearance the rate of elimination plasma concentration x time. Area under the...
Convulsants
Representative plants Water hemlock, also resembles the edible herb Queen Anne's lace wild carrot . Toxin Cicutoxin. Antidote None. Diagnosis Diaphoresis, nausea, vomiting, and abdominal cramps within 1 hour then severe convulsions status epilepticus, case fatality rate CFR 30 . Treatment Gastrointestinal decontamination lavage and AC , anticonvulsants barbiturates, benzodiazepines . Figure 15.10 Commercial Landscaping with Angel's Trumpet Brugmasia sauveolens , San Diego, CA. The angel's...
Hydrocarbon Epidemiology
There are 65,000 hydrocarbon HC exposures per year 95 are unintentional 60 involve children 90 of deaths are in children under age 5 years 50 demonstrate minimal toxic effects and 20 require treatment. There are 20 deaths per year from HC poisoning 90 of these deaths occur in children under age 5 years 33 of these deaths involve gasoline motor oils 11 involve Freon and other spray can propellants usually in adolescent HC inhalation abusers , and 57 involve kerosene.
Clinical Manifestations Vbg
Adult botulism Nausea and vomiting, diarrhea, then blurred vision, diplopia, dyspha-gia, descending paralysis, respiratory failure, CFR 50 , pathognomonic manifestations descending paralysis and normal mental status. Infant botulism lt 12 months, lethargic weak, poor feeding, poor gag and suck, hypotonia floppy baby floppy head. Warning Honey in bottled milk. Primary prevention Avoid high-risk foods. Secondary prevention Food and stool cultures, identification of botulinum toxin in food,...
Scorpaenids Stonefish
Figure 17.6 Lionfish Pterosis volitans . The lionfish Pterosis volitans has dorsal fins tipped with sharp spines attached to separate venom glands, which can inflict painful envenoming injuries in divers and saltwater aquaria enthusiasts. A polyvalent Scorpaenid anti-venom is available for the management of moderate to severe envenomings caused by lionfish, scorpionfish, and stonefish. Courtesy of Charles P. Sea, Department of Emergency Medicine, Ochsner Clinic Foundation Hospital, New Orleans,...
Crotalid Antivenins
Chemistry A polyvalent pit viper IgG antivenin prepared in horses hyperimmunized to venoms of the eastern and western diamondback rattlesnakes Crotalus spp. and the tropical fer-de-lance Bothrops spp. . Mechanism Direct Ag Ab antagonism. Contraindications Horse serum allergy, prior antivenin allergy relative contraindication is a positive skin test. Soon to be replaced by less antigenic polyvalent Crotalid Fab CroFab . Use All proven eastern and western coral snake bites. Dose 3-5 vials, up to...
Descriptive Epidemiology
Incidence rate United States 5 mushroom poisonings per 100,000 persons per year. 95 of toxic mushrooms ingested cannot be identified. 50 of patients are asymptomatic, 25 require treatment, 15 of these have minor toxicity, 5 moderate toxicity, and 0.2 major toxicity. 1-2 patients die of mushroom poisoning each year United States . 95 of deaths are due to Amanita species ingestions case fatality rates CFRs for Amanita ingestions are 25-50 . Ring or annulus remains of partial veil Ring or annulus...
Applications Hve
Use 1 All acetaminophen overdoses, especially in patients with preexisting glutathi-one depletion alcoholics malnourished, HIV-AIDS, P450 inducing drugs 2 free radical scavenging in poisonings with carbon tetrachloride, chloroform, dichloropropane, and cyclophosphamide. Dose Rule of 7s administer 140 mg kg orally within 8 hours, then 70 mg kg every 4 hours over 3 days for 17 doses in 72 hours. Side effects Oral administration PO anticipate vomiting co-administer an antiemetic , IV...
Tsetse flies Glossinidae
Family Glossinidae. Genus Glossina. Adults Both sexes are daytime biters, especially through dark clothing, large yellow-brown to black with rigid, forward projecting proboscis and characteristic upside-down hatchet wing venation, wings rest over abdomen like scissors. Diseases Human Trypanosoma brucei gam-biense chronic sleeping sickness, T. brucei rhodesiense virulent sleeping sickness and animal T. brucei brucei African trypanosomiasis. Mechanism Amastigotes sucked up on blood-feed migrate...
Propofol Diprivan
Pharmacology GABA enhancer. Overdose Transient apnea, dose-related respiratory depression and hypotension, not arrhythmogenic. Miscellaneous Lipemic serum due to high TGs histamine and anaphylactoid reactions to soybean-egg emulsion formulation, rarely true anaphylaxis supports bacterial overgrowth. Pharmacology GABA enhancer. Overdose Same as propofol and involuntary muscle movements, rarely severe cardiovascular and respiratory depression. Miscellaneous Suppresses adrenal steroid hormone...
Basic Management
Orogastric lavage Reduced gastric motility and concretion potential. Initial AC slurry 1 g kg and cathartic. MDAC q 2-4 h, 0.5 g kg, no additional cathartic, especially for phenobarbital, meprobamate, and glutethimide. WBI-PEG ELS For gastrointestinal concretions on x-ray meprobamate and overdoses with sustained-release SHs diazepam CR . Use Old nerve-headache tonics and sedatives Bromo-Seltzer gas fumigant for soil, fruits and vegetables vehicle for some drugs bromo-pheniramine and...
Isopropanol 70
Toxicity Gastrointestinal gt dermal gt CNS Gastrointestinal Caustic hemorrhagic gastroenteritis, necrotic mucosal ulcerations, late esophageal stricture. Dermal Caustic burns, contact dermatitis iodophor , ioderma acne iodide . CNS Metabolic acidosis, delirium, vasomotor collapse. Treatment No emesis careful aspiration lavage with starch, milk, or sodium thiosulfate to reduce most toxic elemental iodine I2 to the least toxic iodide I- activated charcoal AC and early endoscopy. Chemical name...
Loperamide Immodium
An OTC insoluble meperidine analog, like diphenoxylate, that immobilizes gastrointestinal tract also used as an antidiarrheal. Safer than diphenoxylate because loperamide does not contain atropine or delay gastric emptying, does not have a prolonged half-life, and is not associated with prolonged retention of pills in stomach from anticholinergic effects. Overdose management may also require continuous naloxone infusion 1 wake-up dose 0.4 mg IV boluses every 2 minutes until arousal 2 infusion...
Pharmacology Plant Oils
Volatile oils evaporate at room temperature Resins mixtures of oily plant resins Olive oil, peanut oil, canola oil, safflower oil Alkaloids belladonnas, pyrrolizidines Anticholinergic, hepatic veno-occlusion Mucous membrane irritants, steroids, anticoagulants Prunus pits apple, apricot, peach, etc.
Miscellaneous
Representative plants Pokeweed, English ivy, yew, horse chestnut. Toxin Phytolaccine phytolaccatoxin , Diagnosis Nausea, vomiting, diarrhea, abdominal cramps colic, lymphocytosis pokeweed . Figure 15.17 Euphorbia marginata Snow-on-the-Mountain . The Euphorbia species plants include a wide variety of popularly cultivated indoor and outdoor plants, specifically poinsettias, candelabra and pencil cactus, creeping spurge, and snow-on-the-mountain. The Euphorbia species plants can induce a chemical...
Dextromethorphan Robitussin
An OTC synthetic opioid agonist and analog of codeine with no analgesic activity that is used as a cough suppressant, like codeine. In overdose, causes miosis and CNS depression, with choreoathetosis and dystonia from increased presynaptic serotonin release. Also acts as a sigma agonist and can cause a PCP-like psychosis. Formulated as a hydrobromide salt bromism, CNS depression, ataxia, confusion, coma. Can also precipitate serotonin syndrome, like meperidine, by increasing presynaptic release...
Contraindicated Snake Bite Treatments United States
Tourniquets lymphatic constriction bands are also not highly recommended in the United States. Ice packs or immersion potential for frostbite. Excision of bite site. Electric shock to bite site. Cutting on bite site to extract venom negative-pressure venom extractors have been used on some exotic snake bite sites. Sucking on the bite site further contaminates wound. Figure 16.9 Gila Monster Heloderma suspectum , Desert Southwest U.S. The shy, slow-moving, and nocturnally active Gila Monster...
Toxic Alcohols
Definition Measured cations - measured anions Na - Cl- HCO3- 140 - 110 24 6. High MMUDPPIILEESS Methanol, Met-formin, Uremia, Diabetic ketoacidosis, Par-aldehyde, Phenformin, INH, Iron, Lactic acidosis, Ethanol, Ethylene glycol, Salicy-lates, and Solvents. MMETAL ACCIID GAPP Methanol, Metformin, Ethylene glycol, Toluene, Alcohol ketoacidosis, Lactic acidosis, Aspirin, Carbon monoxide, Cyanide, Isoniazid, Iron, Diabetic ketoacidosis, Generalized seizures, Aminoglycosides, Par-aldehyde,...
Glutaraldehyde
Uses Hot, dry gas sterilization. Toxicity more toxic than formaldehyde Potent mucosal irritant mutagen and carcinogen. Acute Upper airway, conjunctival, gastrointestinal, and dermal irritation with nausea. CNS Malaise, light headedness, syncope, seizures, coma, sensory and motor neuropathies, rarely parkinsonism. Chronic High spontaneous abortion rates, increased rates of leukemias and gastric cancers. Treatment Removal and supportive therapy. Uses Cold liquid sterilization of endoscopic and...
Diagnosis and General Management
Diagnosis Positive urine ferric chloride test radiopaque phenothiazine concretions on abdominal x-ray serum levels unhelpful. General management Orogastric lavage gt ipecac emesis due to CNS effects consider MDAC HP and HD useless due to increased VD cardiovascular support with a-agonists only, as P-agonists cause vasodilation NaHCO3 for conduction block and prolonged QRS complex physostigmine for central anticholinergic syndrome could exacerbate conduction blockade.
INH Metabolism
Hepatic metabolism Two pathways, 1 acety-lation gt 2 dehydrazination. Rapid acetylators of INH An autosomal dominant trait present in 50 of U.S. population and 95 of Inuits, Chinese, Japanese, and Africans who will distribute 30-50 less free INH than slow acetylators most whites with reduced half-life and less drug efficacy. Slow acetylators higher INH toxicity, especially slow acetylators on concomitant rifampin. Who are the slow acetylators 60 of Caucasian Americans, 60 of Jews, 50 of African...
Grayanotoxins
Representative plants Azalea, rhododendron, mountain laurel, and local honey containing plant nectar. Toxins Parasympathomimetic oily diterpene grayanotoxins force open cardiac Na channels increasing cardiac automaticity and enhancing vagal tone, similar to digitalis effects. Antidote None. Diagnosis Gastrointestinal symptoms, SLUDE syndrome salvation, lacrimation, urination, defecation, emesis or DUMBBELS syndrome diarrhea, urination, miosis, bronchospasm, bronchorrhea, emesis, lacrimation,...
Differential Diagnosis of Sympathetic Toxidromes
Figure 9.4 Noncardiogenic Pulmonary Edema Crack Cocaine Injection. Frontal chest radiograph that demonstrates normal size and configuration of the cardio-mediastinal silhouette and bilateral diffuse pulmonary edema following the intravenous injection of crack cocaine. Noncardiogenic pulmonary edema may also follow opioid overdoses with the same radiographic patterns. Courtesy of Carlos R. Gimenez, M.D., Professor of Radiology, LSU School of Medicine, New Orleans, LA. Figure 9.4 Noncardiogenic...
Scombroid Fish Poisoning
Agents Toxic decomposition metabolites collectively called scombrotoxins the scombro-toxins are not bioaccumulated dinoglagellate or diatom exotoxins. Toxins Scombrotoxins histamine and its primary N-methylhistamine metabolite, saurine. LD50 No known human fatalities. Mechanism Scombrotoxins form during gut bacteria-catalyzed, normothermic decarbox-ylation Proteus, Klebsiella, Lactobacillus, E. coli, Enterobacter species of muscle L-histidine in decomposing finfish dangling on commercial long...
Narcotic adulterants usually white powders
Quinine Disguises bitter taste of heroin, causing dysrhythmias, headache, vertigo, tinnitus, blurred vision, temporary or even permanent blindness. Scopolamine CNS and peripheral anticholinergic toxidrome. Fentanyl analogs China white fentanyl 100X the potency of MS , sufentanil 10X fentanyl or 1000X MS , and methyl-fentanyl 6000X MS superpotent fentanyl-adulterated heroin, respiratory arrest, coma, and death. Treatment CPR, naloxone infusions. Miscellaneous adulterants Amphetamines, cocaine,...
Info Osr
FIGURE 1.4a Large therapeutic index. A large therapeutic index reflects a large therapeutic window in which large doses of a drug are relatively safe to administer, unless drug allergy exists. Ex. penicillin. FIGURE 1.4b Small therapeutic Index. A small therapeutic index reflects a small therapeutic window in which drug toxicity is possible even at low doses. Ex. digoxin, warfarin. The rate of a drug's elimination is directly proportional to its plasma concentration. The higher the...
Sympathomimetic Toxidrome
Features Fight or flight hypertension, tachycardia, sweating, fever, excitation-psychomotor agitation, tremor, seizures, dilated pupils. Causes Amphetamines diet drugs, cocaine, theophylline, caffeine, methylphenidate, mono-amine oxidase inhibitors over-the-counter cold medications, especially those containing phenylpropanolamine PPA , ephedrine, and pseudoephedrine. Mechanisms Increased release of catechol-amines amphetamines , blockade of cat-echolamine re-uptake cocaine , inhibition of...
I
FIGURE 1.3a One-compartment distribution model. Some xenobiotics rapidly enter the central circulatory compartment for rapid distribution to tissues plasma concentrations mirror tissue concentrations. FIGURE 1.3b Two-compartment distribution model. Most xenobiotics do not instantaneously equilibrate with tissues, but are initially distributed to highly perfused organs, and subsequently distributed to less perfused peripheral tissues. Ex barbiturates, digoxin, lidocaine. Mechanisms Preparative...
Nutmeg and Mace
Representatives East and West Indian nutmeg tree. Latin Myristica fragrans. Toxin Myristicin hepatically biotransformed to methamphetamine metabolites. Antidote None. Diagnosis Nausea, vomiting, dele-euphoria, deep sleep with hypo- Representative Ephedra ma-huang . Toxins Ephedrine, pseudoephedrine. Antidote None. Diagnosis Sympathomimetic effects headache, nervousness, anxiety, flushing, vomiting, hypertension, tachycardia, mania and psychosis, seizures myocardial infarction MI and...
Info Aqf
CNS abnormalities, bleeding tendency, noncardiogenic pulmonary edema possible
Head Computerized Tomographic CT Scan
FIGURE 3.10 Opioid bowel colonic ileus in a methadone abuser. Abdominal radiograph KUB that demonstrates air distension of the small bowel and transverse colon consistent with chronic constipation and colonic ileus in a methadone abuser. Courtesy of Carlos R. Gimenez, M.D., Professor of Radiology, LSU School of Medicine, New Orleans, LA. Intracranial hemorrhage Suspect intraparen-chymal cerebrovascular accident or subarach-noid hemorrhage amphetamines, cocaine, ephedrine and pseudoephedrine,...
Info Fzj
Soft tissues Half-life weeks to months figure 3.1 Ingested lead distributes in a three-compartment model. Ingested lead is distributed in a three-compartment model in which the heavy metal is initially distributed to a central circulatory compartment then to a highly perfused visceral organ compartment and finally to the least perfused third compartment composed of bone, teeth, nails, and hair. FIGURE 3.2 Ingested lead distributes in a five-compartment model. Ingested lead is distributed in a...
Cholinergic Toxidrome
SLUDE Muscarinic features Salivation, Lacrimation, Urination, Defecation, Emesis, plus miosis, bronchorrhea and broncho-spasm DUMBBELS Diarrhea, Urination, Miosis, Bronchorrhea, Bronchospasm, Emesis, Lacrimation, and Salivation. Nicotinic features Weakness, fascicula-tions, sweating, tachycardia, hypertension. Figure 4.1 Mydriasis, left or mydriasis characteristic toxidrome. Figure 4.1 Mydriasis, left or mydriasis characteristic toxidrome. eye. Pupillary dilation of an anticholinergic CNS...
TCA Effects
Hypothermia gt 24 C rectally note the characteristic J Wave of Osborn in the terminal phase of the QRS complex. Hypothermia gt 24 C rectally note the characteristic J Wave of Osborn in the terminal phase of the QRS complex. Sinus tachycardia Prolonged PR, QRS, QT intervals AV and bundle branch blocks Prominent S waves in lead I and AVL, prominent R wave in AVR All supraventricular and ventricular arrhythmias, including torsades de pointes Asystole FIGURE 3.16a Electrocardiographic evidence of...
Electrolyte Disturbances
Hyperkalemia Tall tented T waves with progressive widening of the QRS complex see Figure 3.13a . Hypokalemia Progressive decrease in T wave amplitude with inverted T waves, U waves, and eventual fusion of T and U waves see Figure 3.13b . Hypercalcemia Short QT and ST intervals antacids, vitamins A and D, hydrochlorothiazide HCTZ containing diuretics see Figure 3.14a . Hypocalcemia Prolonged QT and ST intervals fluoride, hydrofluoric acid, calcitonin, ethyl-ene glycol, phosphates see Figure...
Theophylline Overdose Supraventricular Tachycardia
Astemizole terfenadine overdose or CYP 34A Interactions torsades de pointes, prolonged QT intervals, and VT. FIGURE 3.18 Electrocardiographic Evidence of Chloral Hydrate Toxicity. Electrocardiogram ECG tracing in a patient sedated with oral chloral hydrate for a magnetic resonance imaging procedure that demonstrates the ventricular ectopic or premature beats premature ventricular contractions characteristic of chlorinated hydrocarbon toxicity from chloral hydrate or halogenated hydrocarbon...