The Poison Lab

In this episode the poison lab hosts scientific discourse . Three listeners (Dr. Michael Mullins, Dr. Donna Seger, and Dr. Leon Gussow) write in their critiques surrounding specific recommendations and language used with the AHA 2023 Management of Poisoning Cardiac Arrest or Life-Threatening Toxicity guidelines. Lead author of the guidelines Dr. Eric Lavonas then responds to and addresses their points with counterpoints or appraisals. Tune in and draw your own conclusions!

• Link to guidelines
• Link to high yield review 

Have a burning question you have always wanted to ask a toxicologist? What are tips for managing an anticholinergic overdose? What is the deadliest poison? Why are they called lead pencils if there is no lead?! Send your questions in to [email protected] to take part in a future episode! (If you would like to be anonymous simply state it in the email)

In this episode Ryan is joined by two expert guests to help read listener guesses for the cause of this poisoning murder and shed light on the toxin involved in the case, which puzzled medicolegal investigators. Ryan is joined by Dr. Dan McCabe, MD (emergency medicine physician, medical toxicologist, medical director of Iowa poison center) and Dr. Crissy Lawson PharmD (emergency medicine pharmacist). 

• SPOLIER ALERT
  •  Mystery case from the show
  • Review Paper from Dr's  Lawson, McCabe, and Feldman (PMID: 38613376)
• Toxo's show note references 
  1. TV special about Mary Yoder colchicine murder
  2. Colchicine potential arrhythmic effects
  3. Go fund me for Dr. Betty Bowman 

In this bonus episode Ryan highlights some of the great episodes done in 2023 and compiles ALL of the stump the toxicologist segments from 2023 into one easy to consume episode. Test your toxicology differential skills with more than six poisoning cases. Check out the actual episodes for more information in the show notes on each of the poisonings. 

Do you think you know the cause of these symptoms? Send your guesses to [email protected] to take part in the next episode 

A quick update to share some other shows Ryan has been on in the last few weeks! Check the show notes for links to each episode!

• Ryan on "The Larry Meiller Show" discussing delta cannabanoids
  • Link to stream
  • Link to download
• Ryan on EMS2020 talking prehospital overdose
  • Link to episode 
  • Show homepage

In this episode Ryan interviews Dr. Alex Krotulski PhD from the Center for Forensic Science Research and Education. Together take a look at trends in novel opioids, benzodiazepines, stimulants, hallucinogens, synthetic cannabinoids, and "hemp products" that are showing up in your patients, drug products, and fatal overdoses. The conversation takes places around the Center for Forensic Science Research and Education quarterly report on Novel Psychoactive Substances found in patients and drug products.

The episode starts with a discussion of the novel benzodiazepines market, highlighting bromazolam and how long it may remain in the market. Then they discuss the opioids highlighting where we are seeing carfentanil, what is happening with Para Fluorofentanyl, and other super potent opioids emergening (such as  N -pyrrolidino etonitazene). After a quick discussion of synthetic cathinone's and PCP/ketamine derivatives they jump to synthetic cannabinoids, examining the history of brodifacoum contamination and how regulation has led to market changes. 

1. Resources
   1. https://www.cfsre.org/
   2. Quarterly report  discussed on this episode
   3. More on Dr. Krotulski
   4. Poster from Dr. Kortulksi on naming conventions for NPS 
2. Time stamps to jump to any portion of the episode you want to revisit
   1. Introduction-5:00-32:50
      • 06:30-25:16- Discussion CSFRE mission, history of NPS reports, and other available reports
      • 25:14- "Miscellaneous drugs: Furanyl UF17, medetomidine"
      • 28:15- Difference between GC/MS and LCqTOF
   2. Novel Benzodiazepines- 32:50
   3. Novel Opioids-43:00
   4. Stimulants and hallucinogens- 1:01:43
   5. Synthetic cannabinoids- 1:07:40
   6. Novel psychedelics markets, hemp products, phenibut, tianeptine, and kratom-1:25:12

Dr. Ann Arens, MD an emergency medicine physician and medical toxicologist with Oschner Medical center in New Orleans, LA joins the show to educate us on some HOT toxins, solve toxic cases, and opine on the philosophical and existential reasons drugs even exist. Tune in for a fantastic discussion with Dr. Arens and to hear the answer to our mystery case. 

• Case report for mystery case
• Review paper cited by Dr. Arens
• Interview with DNP user by Chubby Emu
• Case 1
  • Some also contain CALCIUM NITRATE and can cause methemoglobinemia
• Case 2
• Case 3

Do you think you know the cause of these symptoms? Send your guesses to [email protected] to take part in episode 18

In this episode Ryan is joined by a guest panel (Dr. Grant Comstock MD, Dr. Joshua Trebach MD, Dr. Emily Kiernan DO, and Dr Frank Paloucek PharmD, DABAT) to review nine of the most interesting or clinically impactful research abstracts that were presented at the 2023 North American Congress of Clinical Toxicology (NACCT) in Montreal Canada. If you didn't get a chance to read all 363 research abstracts from some of Toxicology's best and brightest this year, tune in for a high yield review as well as clinical a break down of the studies and their relevance from the expert panel.  

Check the show notes for a link to the published abstracts and the list of all studies discussed in the show

Abstracts available here

• 10:40- Abstract 1 (PDF #225) Methotrexate toxicity in the setting of therapeutic error, a multicenter retrospective review
  • Lead author: Andrew Chambers
• 24:12- Abstract #2 (PDF #251) Oleander seeds in candlenut weight loss product strike again
  • Lead author: Masha Yemets
• 31:16- Abstract #3 (PDF #2) Efficacy of sodium tetrathionate when administered intramuscularly for the treatment of acute oral cyanide toxicity in a swine model (Sus scrofa)
  • Lead author: Brooke Lajeunesse
• 39:45- Abstract #4 (PDF #10) Is HOUR enough after out-of hospital naloxone for opioid overdose? Prospective preliminary data from real-world implementation of the modified St. Paul’s early discharge rule
  • Lead author: Stephen Douglas
• 49:05- Abstract #5- Poster titles at NACCT 2013–2022: is NACCT experiencing a pun-demic?
  • Lead author: Dayne Laskey
• 52:40- Rivastigmine discussion
  • Lead author: none
• 58:40- Abstract #6 (PDF #5)  Randomized controlled trial of ANEB-001 as an antidote for acute cannabinoid intoxication in healthy adults
  • Lead author: Andrew Monte
• 1:08:00- Abstract #7 (PDF#216) Successful use of expired physostigmine to treat anticholinergic delirium in a pediatric patient
  • Lead author: Bryan Hayes
• 01:20:00- Abstract #8 (PDF #202) Enough negativity? Clinically significant salicylism with first detectable concentration twelve hours )post-ingestion
  • Lead author: Stacey Bangh
• 01:25:24 - Abstract #9 (PDF #267) High sensitivity troponin is frequently elevated after carbon monoxide exposure
  • Lead author: Abdullatif Aloumi