Case Report: Synthetic Cannabinoid K2 and Myocardial Infarction

K2-Weed-thumb-300x20012.5 out of 5 stars

K2—Not the Spice of Life; Synthetic Cannabinoids and ST Elevation Myocardial Infarction: A Case Report. McKeever RG et al. J Med Toxicol 2014 Aug 26 [Epub ahead of print]

Abstract

Use of synthetic cannabinoids has been associated with a broad range of adverse effects, including tachycardia, hypertension, seizures, psychosis, renal injury, and cyclic vomiting.

This article describes 16-year-old male who presented to hospital with 1 day of substernal chest pressure associated with nausea, vomiting, and dyspnea that started 2 hours after he smoked the synthetic cannabinoid K2. Workup revealed elevated ST segments in the inferolateral leads and elevated troponin that peaked at 8.29 ng/ml (normal 0-0.3 ng/ml). Echocardiogram and cardiac catheterization were unremarkable. Urine drug screen was positive only for opiates and benzodiazepines, both of which the patient received in the hospital before the specimen was obtained. Specimens for additional toxicology tests were sent to an outside lab but never arrived.

The authors claim that this is “the first report of ST-elevation myocardial infarction (STEMI) in the setting of synthetic cannabinoid use without concomitant marijuana use.” To my mind this claim is a bit disingenuous. A 2011 paper by Mir et al — cited in this article — described several teenagers who presented with chest pain and STEMI after smoking K2 but had no history of proximate marijuana use.

Conservative treatment for asymptomatic body packers?

Body packer

Body packer

2 out of 5 stars

Asymptomatic body packers should be treated conservatively. Glovinski PV et al. Dan Med J 2013 Nov;60:A4723

Abstract

Kudos to the authors for putting their general conclusion in the title. Unfortunately, there’ s less here than meets the eye.

This is a retrospective review of 57 patients suspected of body packing, seen at Hvidovre Hospital in Denmark. However, actual body packing was confirmed in only a little over half of these cases, meaning this is really a study of only 29 patients.

All confirmed body packers were admitted, given a laxative and “monitored using a scope.” (I’m not quite sure what this means. After passing two stools not containing packets, they received a non-contrast CT to confirm that the GI tract was clear. The treatment protocol indicated surgery only for GI tract obstruction or evidence of drug intoxication suggesting packet rupture.

No patient developed signs or symptoms of obstruction or rupture, and none required surgery. One patient treated conservatively did not clear his GI tract until the 17th hospital day.

There is a consensus in recent literature that surgery in body packers is generally not required. Certainly, evidence of GI tract obstruction or packet rupture is an indication. The open question is whether delayed progression of drug packets calls for surgery. The authors note that some studies have recommended surgery for packets retained more that 5-7 days.

The authors conclude that, based on their study “Package retention per se is not an indication for emergency operation.” I think they are probably correct, but since their study included as few as a single patient with delayed passage and retention, it is not a conclusion that is ready for prime time.
Related posts:

Body packers: can CT determine the number of drug packets?

MRI for body packers?

Low-dose abdominal CT is superior to plain film for imaging suspected body packers

Cannabis body packers

Treatment protocol for symptomatic body packers (mules)

Cocaine mules: what to do with body packers

 

 

 

 

 

Do pediatric patients require endoscopy after ingesting a laundry pod?

Laundry_pod23 out of 5 stars

Laundry Detergent Pod Ingestions: Is There a Need for Endoscopy? Smith E et al. J Med Toxicol 2014 Sep;10(3):286-91

Abstract

The authors never answer their title question definitively, but you wouldn’t expect that they’d be able to on the basis of this small case series and the limited data published to date.

Ingestion of laundry detergent pod (LDP) ingredients can present with manifestations affecting a number of systems:

  • Gastrointestinal
  • Pulmonary
  • Neurological
  • Metabolic

The paper presents 3 cases of pediatric LDP ingestion in patients ages 13 months to 3 years. Presenting signs and symptoms included vomiting, stridor, respiratory distress, cyanosis, lethargy and decreased level of consciousness, and lactic acidosis. One child required intubation for respiratory distress. No child had visible oropharyngeal lesions but all had superficial esophageal erythema or sloughing. One child developed swallowing abnormality and evidence of silent aspiration on a barium swallow study.

In their discussion, the authors note that the contents of LDPs are in fact less alkaline than the corresponding loose detergents. They do contain propylene glycol, which may be responsible for the drowsiness and lactic acidosis often seen in these patients.

The authors conclude:

If a patient presents with significant gastrointestinal symptoms, including persistent vomiting, dysphagia, drooling, or oral aversion, it is reasonable to evaluate with an upper endoscopy.

They do note, however, that they were unable to find any reported cases of esophageal stricture after LDP ingestion.

 

Related posts:

Laundry ‘pods’: more toxic than your mom’s detergent

Just when you thought it was safe to go back to the laundry room . . .

Look-alike tox: is it a laundry detergent, or a piece of candy?

 

Tox Tunes #88: Junco Partner (Professor Longhair)

http://www.youtube.com/watch?v=DG6gPe1plWQ

 

Professor Longhair (Henry “Roy” Byrd, 1918-1980) combined classic New Orleans rhythm and blues piano with Afro-Cuban funk to produce music that was exciting and utterly original. Many years ago, I was working in a research lab in New York City, living in a West Village studio that rented for $78 a month. (Yes, it was that long ago.) I hated killing rabbits for their prostaglandin, and it was sort of a bleak time.

But during that period I came across an oddly compelling record — New Orleans Piano by Professor Longhair. It was magical, and taught me that the world was strangely wilder and much more interesting than I had ever imagined, and that I’d better go in search for it. I owe a lot to the Professor.

I thought Fess was my own private discovery. But the world has caught on. Just recently I was surprised, and pleased, that his music was featured in an excellent Subaru commercial:

 

For a more concentrated dose of Fess, watch this episode of the PBS/WTTW-Chicago music show Soundstage from 1974. It features the Professor along with Dr. John, Earl King, and the Meters:

http://www.youtube.com/watch?v=oPc-WR2sLi4

Related posts:

Junko Partner (Dr. John)

Junker’s Blues (Champion Jack Dupree)

Saturday with SMACC: The Art and Science of Fluid Responsiveness

Haney Mallemat – The Art and Science of Fluid Responsiveness from Social Media and Critical Care on Vimeo.

From SMACC Gold: In a great talk, Haney Mallemat from the University of Maryland discusses the limitations of static indices of fluid responsiveness such as blood pressure and respiratory-induced changes in inferior vena cava diameter. He argues persuasively that dynamic indices — such as change in stroke volume with passive leg raise — are more accurate and precise, although measurement is technically more difficult.

 

Must-read: consider hemodialysis in cases of massive acetaminophen overdose

APAP4 out of 5 stars

Extracorporeal treatment of acetaminophen poisoning: Recommendations from the EXTRIP workgroup. Gosselin S et al. Clin Toxicol 2014 Aug 18:1-12. [Epub ahead of print]

Abstract

These recommendations come from the Extracorporeal Treatments in Poisoning (EXTRIP) workgroup, a project established to provide some guidance on the use of hemodialysis and other techniques in toxicology cases, an area where high-quality evidence simply does not exist. Although there has been some disagreement among toxicologists about the value of this effort, I have found the papers that come from EXTRIP extremely interesting and helpful. The authors note that in the vast majority of acetaminophen (APAP) overdose cases, administering the antidote  N-acetylcysteine (NAC) is the most important treatment modality and extracorporeal treatment (ECTR) is not necessary. However, in cases of massive overdose, standard doses of NAC may not be sufficient, and there have been reported fatalities even when the antidote is given within 8 hours of acute ingestion:

Massive ingestions present rapidly with signs of mitochondrial dysfunction (metabolic acidosis and altered mental status) prior to the onset of severe liver injury and likely succumb either because the ingested dose overwhelms the protective effect of NAC, or NAC /is unable to completely reverse the mitochondrial injury.

An elevated lactate level early after acute ingestion might be another indication of mitochondrial failure. The EXTRIP group did a literature search to identify papers relevant to this topic, and had an extensive protocol for grading the level of evidence. (The methods are detailed in the paper.) They identified 24 eligible studies. The following are some of their key recommendations:

  • Since APAP is dialyzable and ECTR can also correct metabolic acidosis and possibly remove the toxic metabolite NAPQI, ECTR is suggested in severe APAP poisoning.
  • If ECTR is used to treat APAP overdose, it would be reasonable to continue treatment until clinical improvement is evident.
  • Intermittent hemodialysis is the preferred modality in these cases.
  • Since NAC is also dialyzable, it should be continued at an increased rate during ECTR. (The authors are not more specific about this.)

Bottom line:

EXTRIP recommends ECTR for APAP removal when signs of early mitochondrial failure such as early coma, elevated lactate concentration, and metabolic acidosis are present prior to the onset of hepatic dysfunction and in the setting of a substantially elevated APAP concentration. When these conditions are met, ECTR seems to be a beneficial adjunct to NAC treatment as there is a high risk of liver failure and mortality and a suggestion that standard NAC regiments may be insufficient. As NAC is removed by ECTR, its dose should be increased during the duration of ECTR.

Many clinicians do not even consider ECTR in cases of massive APAP overdose. I would think this paper will change that. Must reading.

NOTE: Because of an apparent editorial error, the reference citations in Tables 5 and 6 are completely off. Hopefully, this will be corrected before the paper appears in print.

Related posts:

What enhanced elimination techniques are useful in critical toxicology patients?

Hemodialysis and other extracorporeal modalities in toxicology cases