The Poison Lab

Dr. Adam Blumenberg, MD (@ABlumenbergMD) Join's the show. He is an emergency medicine physician, medical toxicologist, and Assistant Professor at Columbia University Medical Center in New York City. He hosts his own toxicology youtube series (www.ToxicHistory.com) and has developed multiple free medical education software programs in toxicology (www.toxicrunner.net) and medical simulation (www.medsimstudio.com). Most impressively, he has produced his own free base lidocaine crystals on a stove top, if you ask nicely he might just loan you one. He joins the show to sleuth the cause of fatal poisoning cases and tackle internet questions from reddit.com/r/askdrugs

• Dr. Blumenberg' s projects
• www.ToxicHistory.com
• www.medsimstudio.com (medical vital/imaging simulator)
• www.toxrunner.net (toxicology question bank)
• Things discussed in the intro
• Mithradata
• Ohio vinyl chloride disaster
• Arizona nitric acid spill
• Ohio metal factory explosion

Cases

Case 1

• Case 1 triage guidelines
• Case 1 video demonstration

Case 2

• Full text

Case 3

• Review article
• Mechanism

Case 4

• Full text

Case 5

• Not the actual case from the show but close enough

Questions

• BHO explosions

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The GOTTA PICCEM Poisonous Mushroom Game!

The Poisonus Fungus Amongus Children's Book!

• Full book reading (6 minutes!)

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• Email: [email protected]

More Show Resources

• Ryan's Medical Games and Resources
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Ready for a high-octane dose of knowledge? 🔥🧠 Ryan's got you covered with this electrifying mini-episode on managing a bupropion overdose! 💊💥 Beware - there are plenty of pitfalls you'll want to avoid. Check out the full episode and other mini-episodes for even more tips and tricks! 🎧👀

1. Bupropion is the #1 antidepressant cause of major (life threatening) reported to U.S. Poison Centers
2. It is difficult to manage due to
3. Potential for delayed seizures
4. Unique cardiogenic shock in overdose
5. Potential wide complex arrhythmia refractory to Sodium Bicarbonate
6. Potential interference with brain death testing
7. Treatment
8. Decontamination
9. Aggressive whole bowel irrigation or charcoal may be indicated if large ingestion
10. Supportive care
11. Intubation if airway compromised
12. Benzodiazepine for agitation
13. Benzodiazepines and GABA-ergic AED's for status epileptics
14. Tachycardia, tremor, and agitation are risk factor for seizures
15. Tachycardia may be masked by alpha 2 agonist co ingestions
16. Seizures may occur 24 hour out
17. Sodium bicarbonate for wide QRS (it may be refractory)
18. Inodilators and vasopressors for cardiogenic shock
19. ECMO for refractory shock or arrhythmia
20. Awareness that severe bupropion toxicity can mimic brain death
21. send analytical confirmation of bupropion if possible to rule out confounding
22. Enhanced elimination
23. limited options due to protein binding, not routine
24. Focused antidote
25. Consider IV fat emulsion if the patient is peri arrest
26. Observation times
27. Talk to a toxicolleague about observation times, decontamination, and use of invasive therapies to avoid falling into a trap

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In this episode of The Poison Lab, Ryan is joined by Dr. Filip, Dr. Olives, and Dr. Reyes to discuss a unique and heartbreaking poisoning scenario involving an antidepressant now recognized as the #1 cause of major life-threatening effects in antidepressant overdoses in the U.S. Check out the mini-episodes for more details!

• #1 Cause of Major (Life-Threatening) Effects in overdoses reported to U.S. Poison Centers.
• Difficult to manage due to:
• Delayed seizures.
• Unique cardiogenic shock in overdose.
• Wide complex arrhythmia refractory to sodium bicarbonate.
• Potential interference with brain death testing.

• Increases dopamine and norepinephrine.
• Blocks gap junctions in cardiac myocytes:
• Rohr 2004: Gap junction blockade causes a wide QRS.
• Vink 2004: Connexin 43 is critical for cardiac signal transmission.
• Callier 2012: Similar effects on cardiac action potential as other gap junction blockers.
• Burnham 2014: Bupropion's IC50 for connexin 43 is >50 µM, higher than fluoxetine and lamotrigine.
• Shaikh Quereshi 2014: Bupropion interferes with connexin 43 production/localization in chicken cardiac myocytes at >50 µM.

• Seizures: Delayed, typically occurring 8–24 hours post-ingestion.
• Tachycardia: May precede seizures but could be masked by co-ingestions.

• Patients often present with neurologic symptoms and tachycardia before seizures.
• Do not discharge patients without consulting a toxicologist or poison center regarding observation time.
• Avoid dismissing tachycardia and anxiety as situational in bupropion overdose cases.

• Shepherd 2004: Seizures primarily associated with sustained-release products; often preceded by neuropsychiatric symptoms.
• Starr 2009:
• XL products linked to seizures.
• Tachycardia, tremor, and agitation are predictors.
• Seizures occurred as late as 24 hours; 25% occurred after 8 hours.
• Offerman 2020:
• Tachycardia >120 bpm predicts seizures.
• Late seizures occurred only in symptomatic patients.
• Prehospital seizure correlated with cardiac arrest.
• Rianprakaisang 2021:
• QTc and HR >140 bpm predict seizures.
• ToxIC review confirmed tachycardia as a risk factor.

• Whole bowel irrigation or activated charcoal may be needed for large ingestions.

• Airway Management: Intubate if compromised.
• Benzodiazepines for agitation or seizures.
• Use GABA-ergic AEDs for status epilepticus.

• Sodium bicarbonate for wide QRS (though may be refractory).
• Inodilators/Vasopressors for shock.
• ECMO for refractory shock or arrhythmias.

• Late seizures can occur up to 24 hours post-ingestion.
• Discuss observation times with a toxicologist.

• Severe toxicity can mimic brain death—send for analytical confirmation if possible.
• Limited enhanced elimination options due to high protein binding.
• Consider IV lipid emulsion if the patient is peri-arrest.

• All ingestions are unique. Collaborate with a toxicologist to guide management and avoid pitfalls.

Rohr 2004: "Role of gap junctions in the propagation of the cardiac action potential"

• PubMed Link

Vink 2004: "Connexin 43 is the most important protein for connexon formation and cardiac signal transmission"

• PubMed Link

Callier 2012: "QRS widening and QT prolongation under bupropion: a unique cardiac electrophysiological profile"

• PubMed Link

Shaikh Quereshi 2014: "Bupropion interferes with connexin43 production and localization in chicken cardiac myocytes at concentrations >50 µM"

• PubMed Link

Shepherd 2004: "Seizures after overdose of sustained-release bupropion"

• PubMed Link

Starr 2009: "Seizures in extended-release bupropion overdoses"

• PubMed Link

Offerman 2020: "Predictors of seizures and death in bupropion overdoses: a 10-year retrospective study"

• PubMed Link

Rianprakaisang 2021: "Risk factors for seizures in bupropion overdose: a ToxIC database study"

• PubMed Link

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• Full book reading (6 minutes!)

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• Email: [email protected]

More Show Resources

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1. Rohr 2004- Gap junction blockade can cause a wide QRS
2. Vink 2004 Connexin 43 is the most important protein for connexon formation and cardiac signal transmission
3. Callier 2012- Bupropion does not block sodium channels, and does exhibit similar effects on the cardiac action potential as known gap junction
4. Burnham 2014 Bupropion has an IC50 for connexin 43 >50 uMol, larger than other drugs such as fluoextine and lamotrigine
5. Shaikh Quereshi 2014 Bupropion interferes with connexin43 production and localization in chicken cardiac myoctes at concentration >50 uMol

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• Full book reading (6 minutes!)

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• Email: [email protected]

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• Seizure Risk: Patients can seize 8–24 hours post-ingestion. Neurologic symptoms and tachycardia often precede seizures.
• Delayed Symptoms: Co-ingestions may mask tachycardia, and symptoms can be significantly delayed.
• Key Management Advice:
• Do not discharge patients without consulting a toxicologist or poison center about observation times.
• Do not dismiss tachycardia and anxiety as situational in cases of bupropion overdose.

• Spiller 1994: Review of instant-release bupropion overdoses.
• Shepherd 2004: Seizures predominantly occur with sustained-release products. Most cases had prodromal neuropsychiatric symptoms.
• Starr 2009: Analysis of XL products:
• Symptoms predicting seizures: Tachycardia, tremor, and agitation.
• Tachycardia may be masked by coingestions and symptoms may be very delayed
• Seizures occurred as late as 24 hours, with 25% occurring after 8 hours.
• Offerman 2020: Study of sustained/extended-release products:
• Tachycardia (duration and rate >120 bpm) predicts seizures.
• Hypotension and neuropsychiatric symptoms also predictive.
• Prehospital seizures associated with cardiac arrest—indicative of poor outcomes.
• Rianprakaisang 2021: ToxIC database review of seizure risk factors:
• QTc prolongation and HR >140 bpm are predictive of seizures.

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• Full book reading (6 minutes!)

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• Email: [email protected]

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All published abstracts can be found here

Abstracts

Category 1: Amlodipine Vasoplegia

• Abstract 1: Vasodilation in patients with calcium channel blocker poisoning treated with high dose insulin: a comparison of amlodipine versus non-dihydropyridines
• Study of HDI on propranolol poisoned pigs
• Study of Minnesota HDI protocol
• Abstract 2: Amlodipine anxiety: a 10-year review of amlodipine associated fatalities
• Abstract 3: Extracorporeal membrane oxygenation utilization for vasoplegic shock due to pediatric toxic ingestions
• Data of ECMO in poisoning

Category 2: Xylazine

• Abstract 4: “Tranq dope” opioid overdose: clinical outcomes for emergency department patients with illicit opioid overdose adulterated with xylazine

Category 3: Case Reports with Terrifying Clinical Implications

• Abstract 5: Recovery after poly-drug overdose despite blood flow imaging demonstrating no brain perfusion
• Abstract 6: Challenges in diagnosing an environmental cause of recurrent methemoglobinemia
• Abstract 7: Acute thiamine deficiency as a complication of insulin euglycemic therapy for an amlodipine overdose

Category 4: Comparative evidence, Prognostication, and Triage

• Abstract 8: Utility of pre four-hour iron concentration in predicting toxicology
• Abstract 9: Andexanet alfa vs 4-factor prothrombin complex concentrate for intracranial hemorrhage at a level I trauma hospital

Category 5: Rapid Review

• Abstract 10: Fentanyl and fentanyl analogue exposure among emergency personnel and first responders: a systematic review
• Abstract 11: Significance of falsely low creatinine values in diagnosing massive acetaminophen ingestion
• Abstract 12: Large dose intentional ciprofloxacin ingestion associated with false-positive urine immunoassay for oxycodone and fentanyl
• Abstract 13: Don’t make it a double?: a 20- year review of supratherapeutic amlodipine ingestions while on chronic therapy
• Abstract 14: Evaluation of pediatric lisdexamfetamine exposures reported to a statewide poison control system
• Abstract 15: An assessment of the reliability of stated quantity in acute acetaminophen overdoses reported to a regional poison center

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• Full book reading (6 minutes!)

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• Email: [email protected]

More Show Resources

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Do you think you know the cause of these symptoms? Send your guesses to [email protected] to take part in episode 19

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• Full book reading (6 minutes!)

Tox trinkets (Rep the show at home!)

• Email: [email protected]

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Dr. Emily Kiernan, DO (@em2kiernan) an emergency medicine physician and medical toxicologist with Emory university school of medicine joins the show to solve toxic cases, opine on recent healthcare related poisoning, and dive head first into the bongwater on this episode. (Remember friends, don't drink the bong water).

• Recent Healthcare poisoning in the news
• Nurse reportedly feeding children insulin (all information is uncomfirmed) and killing 7 neonates (not all insulin related)
• Anesthesiologist charged with murder for 2000 mcg fentanyl doses given during care in ICU
• Diethylene glycol and Ethylene glycol outbreak in Gambia
• Not talked about in the show but physician spiking liter bags with bupivicaine to try to kill a colleague in 2022
• Cases
• Case 1
• Case 2 toxins
• The burden of empty Gatorade bottles on society
• Case 3 toxins
• Case 4 toxins

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• Full book reading (6 minutes!)

Tox trinkets (Rep the show at home!)

• Email: [email protected]

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Phenibut is an emerging and unfamiliar drug taking hold in the US that is readily available online and legal to obtain. It acts as a GABA-B agonist and carries risks of dependency and withdrawal. In this episode Ryan interviews phenibut users as well as experts involved in phenibut treatment. They explore the history, current trends, toxicity, and management of phenibut, a novel GABA-B agonist. He is joined by guest Dr. Matthew Stanton PharmD and Dr. Benjamin Weston MD who listen in to an audio documentary by that includes clips from Dr. Janessa Graves PhD and Dr. Erica Liebelt MD who wrote a recent report on increasing phenibut exposures, Dr. Dan McCabe MD who is the author of the largest published phenibut case series, and Elliot, a recovered phenibut user who we would like to sincerely thank for sharing his story of use and recovery.

+Update- a systematic review of phenibut withdrawal treatment strategies authored by the poison lab host himeself, Ryan!+

• More on St Anthony's fire
• CDC MWR Study documenting increased poison center exposures (Dr. Graves & Dr. Liebelt)
• Phenibut case series from Dr. McCabe
• All published cases of phenibut withdrawal, reported baclofen regimens, clinical outcomes, multimodal therapies
• THEORETICAL UNTESTED Phenibut withdrawal treatment schema (Not tested, not intended as treatment, intended to stimulate discussion and highlight key considerations in managing withdrawal)

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• Full book reading (6 minutes!)

Tox trinkets (Rep the show at home!)

• Email: [email protected]

More Show Resources

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Do you think you know the cause of these symptoms? Send your guesses to [email protected] to take part in episode 16

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• Full book reading (6 minutes!)

Tox trinkets (Rep the show at home!)

• Email: [email protected]

More Show Resources

• Ryan's Medical Games and Resources
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