Crayola toxicology: life-threatening causes of bluish vomiting

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 Bluish vomiting: a rare clinical presentation of poisoning. Higny J et al. Acta Clin Belg 2014;69:299-301.


This case report describes a 65-year-old man who ingested an unknown substance and subsequently present with pharyngitis and mucositis, nausea, diarrhea, abdominal pain, and blue-green vomitus. The remainder of the physical exam and basic laboratory results were unremarkable.

The authors use the case to discuss 3 life-threatening ingestions that can cause bluish emesis. Unfortunately, their discussion of these causes is confusing and superficial. And, of course, must blue green vomitus will be due to food dye, blue raspberry Gatorade, or some other benign but brightly colored substance.

This article does serve to remind us of 3 important not-to-miss ingestions on the differential when a patient shows up barfing blue. Unfortunately, the authors misses an obvious mnemonic: Cerulean Blue Puke = Copper sulfate, Boric acid, Paraquat.

Related posts:

Green urine

Propofol causes green urine

An elderly woman with purple urine

Snorting bupropion

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An 11-year review of bupropion insufflation exposures in adults reported to the California Poison Control System. Lewis JC et al. Clin Toxicol 2014 Nov;52:969-972.


The abuse of bupropion by pulverizing and snorting the medication has been described at least as far back as 2002. Bupropion inhibits re-uptake of dopamine and norepinephrine, but apparently has little or no effect on serotonin. It is abused for its psychotropic effects that resemble those of amphetamine and cocaine..

A hallmark of overdose with sustained-release or extended-release bupropion formulations is delayed onset of seizures — sometimes more than 8 hours after ingestion. When these preparations are crushed and insufflated, absorption is rapid and manifestations would be expected to come on more quickly.

This observational case series from the California Poison Control System describes 67 cases of pure bupropion insufflation over an 11-year period. Although this study is certainly impaired by inherent limitations — including reporting bias and small sample size — some of its findings are worth noting:

  • the median dose reported was 1500 mg (range, 100-9000 mg; therapeutic 150-300 mg/day)
  • 30% of patients had seizure in the prehospital setting
  • there were not seizures after arrival at hospital
  • tachycardia was the most frequent manifestation
  • agitation and tremor also occurred

The authors conclude that “once the mechanical delayed release mechanism is disabled by crushing . . . no patient in this case series had a repeat seizure after arrival to [hospital].”

A major problem with this is that, as the authors admit, “there was no reliable way to correlate time from insufflation to seizure.” Therefore, there is no way of knowing whether the seizures seen occurred fairly immediately after insufflation, or were in fact delayed.

Methoxphenidine: a designer dissociative drug

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Acute toxicity associated with the recreational use of the novel dissociative psychoactive substance methoxphenidine. Hofer KE et al. Clin Toxicol 2014 Oct 28 [Epub ahead of print]


Methoxphenidine  (MXP) is a dissociative drug with actions apparently similar to those of phencyclidine (PCP), ketamine, and methoxetamine (MXE). It is often sold as a “research chemical” and labelled as “Not for Human Consumption.” The pharmacology and toxicology of MXP has not been well studied. Anecdotal reports on some drug forums describe anterograde amnesia and prolonged duration of effects (up to 18 hours).

Since it is as yet not highly regulated, MXP seems to be used more frequently as the other dissociative agents are put under legal restrictions.

This case report, from Switzerland, describes a 53-year-old man who presented after an apparent MXP ingestion, later confirmed in the laboratory. Presenting manifestations included somnolence, confusion, echolalia, miosis, hypertension, tachycardia, nystagmus, and apparent seizure activity.

The authors conclude:

. . .methoxphenidine appears to have a similar acute toxicity profile to other arylcyclohexylamines, such as PCP, ketamine and MXE. On the basis of the very limited evidence available, management of patients presenting with acute toxicity related to methoxphenidine use should be as for other dissociative drugs.”

Related posts:

Methoxetamine: a ketamine analog that is NOT bladder friendly

A “big Christmas cardigan”: recreational use of ketamine and methoxetamine

Acute cerebellar syndrome? Think methoxetamine

Methoxetamine: a designer ketamine analogue

Ban the Words: should the phrase “should be considered” be banished from the toxicology literature?

Interventions such as gastric lavage and whole bowel irrigation are labor intensive and associated with significant adverse effects. In addition, they have never been proven to improve clinical outcomes. Are we now at a point where we can stop discussing them, easing them into a dignified retirement along with ipecac-induced emesis? Many texts and review articles suggest that these interventions “should be considered” in selected toxicology cases. Should this phrase be banned from the literature?

I will be hosting a Twitter chat with @EM_News tomorrow from noon – 1 pm EST to talk about my November column for Emergency Medicine News. Follow me (@poisonreview) and tune into ask questions or comment using the hashtag #BanTheWords.

Saturday with SMACC: Weingart on sepsis in New York City

In this brilliant talk from smaccGOLD last March in Australia, Scott Weingart talks about lessons from the STOP Sepsis Collaborative project in New York City based on their experience with 15,000 severe sepsis patients.

In brief, the Collaborative achieved a 22% reduction of in-patient mortality in these patients by relatively simple measures that did not involve early goal-directed therapy or fancy invasive monitoring. The key steps in their protocol involved:

  • early recognition of the septic patient
  • source control
  • reasonable but not massive fluid administration
  • inotropes
  • early antibiotics
  • meticulous intubation (if indicated)

This lecture is absolutely not-to-be missed.

Here are links to some of the resources Scott cites in the lecture:

 A Randomized Trial for Protocol-Based Care for Early Septic Shock: The PROCESS Trial (NEJM)

Central or Peripheral Catheters for Initial Venous Access of ICU Patients: A Randomized Controlled Trial (Crit Care Med)

Intubating the Patient in Shock (EMCrit)

By the way, Dr. Paul Marik, who is mentioned in the lecture, will be at SMACC Chicago, coming June 23-26 2015. He will be giving talks on “Understanding Lactate” and also debating the proposition that “Predicting Fluid Responsiveness is a Waste of Time.” (He will take the “con” position.)

The entire program for SMACC Chicago can be accessed here. Registration opened earlier this week and the response has been nothing short of astounding. I will have more to say on the toxicology part of the program on a future post.

Sun Tzu and the Art of Focusing in Medical Toxicology

PocketSunTzuThe philosophy expressed in Sun Tzu’s classic The Art of War has been applied to everything from military strategy to business management. But what does it have to teach practitioners of emergency medicine and medical toxicology? In my current column for Emergency Medicine News I discuss a very important lesson from the book that will completely change the way you read recommendations about gastric lavage and whole bowel irrigation still included in many textbook chapters and review articles. The read the column, click here.

By the way, EM News will be hosting a Twitter Chat about the column to take place on Tuesday, November 11, at noon EST (11 am CST). Please join in if you have any questions or comments about the column, whole bowel irrigation, gastric lavage, or any other topic suggested by the column. To participate, just go to Twitter and follow the hashtag #BanTheWords.