Saturday with SMACC: Evidence-Based Education — What Works

Victoria Brazil Evidence-Based Education — What Works– from Social Media and Critical Care on Vimeo.

From SMACC Gold: Victoria Brazil asks what educational modalities and interventions are effective in medical education, what does “effectiveness” really mean and how do we measure it. Here are links to some of the studies and resources she mentions:

The Great Dr. Fox Lecture: A Vintage Academic Hoax

Hunt et al: Pediatric resident resuscitation skills improve after “rapid cycle deliberate practice” training

Best Evidence Medical Education (BEME) Collaboration

BondVH: virtual hospital app

More than you ever wanted to know about synthetic cannabinoids

crazy.clown_.synthetic.marijuana-298x3003 out of 5 stars

Synthetic cannabinoids: Epidemiology, pharmacodynamics, and clinical implications. Castaneto MS et al.  Drug Alcohol Depend 2014 Aug 18 [Epub ahead of print]


This article is not really readable, but I’m not sure it was meant to be read. Rather, it’s a reference paper with (by my count) 228 citations through the year 2014. It will be invaluable for anyone surveying the medical literature on synthetic cannabinoids

The authors’ goals was to review comprehensively the pharmacology and toxicology of various chemicals found in synthetic cannabinoid products such as “Spice,” “K2,” and “Crazy Clown.” Their extensive literature search identified 215 relevant articles.

Because of the multiple substances covered and mix of laboratory, animal, and human studies, it would have been difficult to synthesize and integrate the material, and the authors make little attempt to do so. The paper reads more like a “notebook dump,” and I couldn’t find clear take-home lessons to summarize. Nonetheless, anyone writing grant proposals, papers, or chapters about synthetic cannabinoids in the future will have to consult this article.


TPR Podcast Episode #6: I’m tripping and I can’t get down

TPR Podcast Episode 6: I’ve Tripped and I Can’t Get Down

Written by Theresa Kim, MD




1)     Synthetic cathinones

2)     Piperazine compounds

3)     Gamma-hydroxybutyric acid (GHB)

4)     25C-NBOMe



This month’s podcast was inspired by the New York Times article “A Year After Drug Deaths, the Electric Zoo Music Festival Tries Again” which covered designer drug related deaths associated with summer music festivals



Synthetic Cathinones


o   examples: mephedrone, methedrone, MDPV, methylone

o   “bath salts” generally contained one or more synthetic cathinones

o   Schneir et al performed a comprehensive analysis of the composition of “bath salts”, finding great variability in components and concentrations

  • Synthetic cathinones release norepinphrine, dopamine, serotonin

o   Norepinephrine > sympathomimetic manifestations

o   Serotonin > serotonin syndrome, hallucinations

o   Dopamine > abuse potential

  • Routes: oral , nasal, parenteral
  • Effects: euphoria, agitation, paranoia, tachycardia, sweating, confusion, chest pain, palpitations, restlessness
  • Complications: hyponatremia, hyperpyrexia, serotonin syndrome, rhabdomyolysis, agitated delirium, multi-system failure
  • Treatment: supportive

o   chemical restraint, aggressive cooling if indicated, fluids, anticipate potential complications




  • purely synthetic compounds with no naturally occurring form
  • piperazine was initially produced/licensed in the 1950s as a veterinary anti-helminthic drug
  • examples: BZP, MDBZP, TFMPP
  • generally stimulate actions of norepinephrine, dopamine, and serotonin
  • route: usually ingestion in pill or loose powder form
  • effects similar to those of MDMA and amphetamines: anxiety, palpitations, sweating, confusion, agitation, vomiting, hallucinations, hyperventilation
  • can cause false positive results on amphetamine screen
  • complications: seizures, metabolic acidosis, hyponatremia, hyperthermia, multi-organ failure, psychosis, seizures
  • treatment: supportive
  • Symptoms commonly persist > 24 hrs





Gamma-Hydroxybutyric Acid (GHB)


  • colorless oily chemical
  • GABA analogue
  • effects: CNS depression, disinhibition, nausea, dizziness, agitation, urinary incontinence, aggression
  • Complications: coma, respiratory depression, rhabdomyolysis
  • relatively short duration (generally < 3 hours)
  • treatment: supportive





  • Structural analogue of ketamine
  • often (mistakenly) touted as “bladder friendly”
  • street names include MXE, mexxy, KMax, rolfcoptr,” legal” ketamine, minx, jipper
  • NMDA receptor antagonist
  • routes: insufflation, oral, sublingual, rectal, paranteral routes reported
  • effects: similar to ketamine
  • Animal studies show that prolonged exposure of mice to methoxetamine results in renal toxicity and bladder fibrosis in a similar way that ketamine has been known to do
  • treatment: supportive


Synthetic Cannabinoids


  • synthetic versions of , delta-9-tetrahydrocannabinol (THC), the active psychoactive component found in marijuana
  • action: cannabinoid receptor agonism
  • route: usually smoked or vaporized
  • effects: euphoria, altered perception, cognitive slowing
  • Complications: cases of acute kidney injury, myocardial infarction, and psychosis have been reported
  • treatment: supportive



  • derivative of the psychedelic compound phenethylamine 2C-C MOA: partial agonist of 5-HT2A receptor
  • routes: sublingual, buccal, inhalation
  • Complications: vasoconstriction, serotonin syndrome, hyperthermia, hypertension, metabolic acidosis, rhabdomyolysis, seizures, renal failure, disseminated intravascular coagulation
  • treatment: supportive


Past Quizzler


Q: Which founding father owned a paper mill that incorporated hemp into its paper making production?

A: Benjamin Franklin

Congratulations Jessica Folk!


Current Quizzler


Posted at the end of the podcast

Submit responses and any feedback to

The first correct response wins a $10 amazon gift card and a Poison Review t-shirt (bonus prize!)



Thank you for listening, and please subscribe on iTunes and submit any responses either via iTunes or email at



Bersani, F.S., Ornella, C., Albano, G., Valeriani, G., Santacroce, R., Posocco, F.B.M., Cinosi, E., Simonato, P., Martinotti, G., Bersani, G., Schifano, F. (2014). 25C-NBOMe: preliminary data on pharmacology, psychoactive effects, and toxicity of a new potent and dangerous hallucinogenic drug. Biomed Research International.


Feuer, A. (2014, Aug 15). A year after drug deaths, the electric zoo music festival tries again. The New York Times.


Schneir, A., Ly, B.T., Casagrande, K., Darracq, M., Offerman, S.R., Thorton, S. , Smollin, C., Vohra, R., Rangun, C., Tomaszewski, C., Gerona, R.R. (2014). Comprehensive analysis of “bath salts” purchased from California stores and the internet. Clinical Toxicology 52, 651-658


Smith, C., & Robert, S. (2014). ‘Designer drugs’: update on the management of novel psychoactive substance misuse in the acute care setting. Clinical Medicine 14(4), 409-415.


Zawilska, J.B. (2014). Methoxetamine – a novel recreational drug with potent hallucinogenic properties. Toxicology Letters.




Rosary pea ingestion: no testing needed

A. precatorius seeds

A. precatorius seeds

2.5 out of 5 stars

A Case of Abrin Toxin Poisoning, Confirmed via Quantitation of L-Abrine (N-Methyl-L-Tryptophan) Biomarker. Wooten JV et al. J Med Toxicol 2014 Feb 13 [Epub ahead of print]


The decorative rosary pea or jequirity pea (Abrus precatorius) contains the toxin abrin, a protein that inhibits the function of mRNA, leading to impaired protein synthesis and cell death. The mechanism is quite similar to that of the toxin ricin, found in castor beans.

This case report describes a 22-month-old girl who ingested approximately 20 rosary peas. She appeared asymptomatic until she started vomiting 6 hours after ingestion and was brought to hospital. Exam and basic laboratory work-up were negative except for evidence of dehydration (tachycardia and increased urine specific gravity.) The child was treated with fluids and ondansetron. She did well and was discharged the next day.

This unremarkable case hardly seems worthy of writing up. The hook is that the medical team sent a sample of the child’s urine to the CDC, where analysis detected a urine abrin concentration of 726 ng/mL. The authors claim that this case describes “the first application of a previously developed clinical assay for the quantitative detection of L-abrine.” Straining for relevance, the authors further claim that “this method is ideally suited for rapid screening of suspected abrin-exposed individuals in the even of a mass abrin exposure and public health emergency.”

Ii think not. For reasons I have discussed before in relation to ricin, it is virtually inconceivable that abrin would be successfully deployed as a biological weapon. Certainly such a test has no use in cases of accidental exposure such as the one described here, since there is no specific antidote, and — as with ricin — patients respond to supportive care and symptomatic treatment.


Must-listen podcast: anti-NMDA receptor encephalitis



As part of its “Best Case Ever” series, the Emergency Medicine Cases podcast has a superb discussion by Dr. David Carr of anti-NMDA receptor encephalitis, a relatively new but important diagnosis that is generally under-recognized and often missed. To listen to it, click here.

The reason this diagnosis is of interest to toxicologists is that during the early psychotic stage of the disease patients may be treated with a neuroleptic agent. During later stages when movement disorders and autonomic instability supervene, it is easy to misdiagnose the condition as neuroleptic malignant syndrome.

The television report from KYW CBS News in Philadelphia is also well worth watching, especially for the clips of how the disease presents. The following is also instructive:


Related post:

Must-read: Anti-NMDA Receptor Encephalitis

Tox on the web: narcotic noodles, intranasal narcan, and much more!

The Antidote: A long piece in the  The New Yorker by Ian Frazier describes the epidemic of overdoses from both prescription opiate analgesics and heroin, how that epidemic affects the New York City borough of Staten Island, and the potential role of intranasal naloxone in reducing the number of deaths. A little superficial regarding the origins of the epidemic and the medical use of naloxone, but well worth reading nevertheless. It is superb at portraying the human dimension of what Frazier justifiably calls an “iatrogenic disaster.”

By the way, the versatile Frazier is the author of one of the funniest parodies I’ve ever read, “Coyote v. Acme.”

Those noodles are so good they’re addictive: The Independent (U.K.) reports that a chef in China’s Shaanxi province was found to be lacing his noodles with narcotics in an attempt to develop an, um, loyal customer base. The chef, identified only as “Zhang,” bought 4.4 pounds of poppy buds, which he ground up and added to the dish. The scheme was detected when during a traffic stop a customer tested positive for opiates.

Psychotropic plants: The Guardian (U.K.) has a picture gallery of mind-altering plants — including peyote, salvia, and of course cannabis —  based on show currently on display at Kew Gardens in London.

It ain’t tox but . . .: I can recommend two recent non-tox related articles. A superb and heartbreaking New York Times report by Nina Bernstein describes the efforts of one woman to fulfill her father’s wish to die at home. She is stymied at every turn by a healthcare monolith that seems more interested in profits and bureaucracy than anything else, including efficiency and the rational use of funds . This is an absolute must-read.

Joseph Hooper’s article “When To Say No To Your Doctor” in — of all places — Men’s Journal is one of the smartest takes I’ve read in the popular press on the problems with medical over-treatment, screening health patients for various diseases, and spectrum bias in attacking mild presentations of common conditions such as hypertension and hyperglycemia. The piece, to good effect,  relies heavily on emergency medicine luminaries such as David Newman and Jonathan St. George. Again, essential reading, especially for anyone thinking of getting, or ordering, a prostate-specific antigen test, cholesterol panel, or lumbar spine MRI.