Tox on the Web: deadly cocaine/fentanyl combination, the rising price of naloxone, and more


Cocaine/Fentanyl Kills 3 in North Carolina: WTVD-ABC Eyewitness News in Raleigh, North Carolina reports that 3 people local Chatham County died over the weekend — and another 6 were taken to hospital — after using cocaine that had been surreptitiously adulterated with fentanyl. This is somewhat unusual, although many deaths in the past have been caused by fentanyl-laced heroin. A similar death occurred recently in Upstate New York.

Naloxone Sticker Shock: The New York Times reported that with demand for intranasal naloxone increasing exponentially as take-home programs and use by police departments and other first-responders become more accepted, the price of the antidote has increased by 50% or more.

Podcast of the Week: Free Emergency Medicine Talks has just posted a lively lecture by Bob Hoffman about “Controversies in Emergency Medicine.” Nothing if not opinionated, Dr. Hoffman has interesting things to say about thiamine and Wernicke’s encephalopathy, gastric decontamination, hyperbaric oxygen therapy, and several other topics. At one point Dr. Hoffman takes on TPR‘s position that gastric lavage has known risks and no clear benefits, and should no longer be advocated. I won’t go into detail about all the points of his argument with which I disagree, but will point out the sly way in which at 15:20 he tries to advance the notion that adverse effects caused by lavage are not really complications, but bad technique, and “bad technique is not a complication of the procedure but it’s a complication of the operator and it may be bad luck.” The lecture is worth a listen, and can be accessed by clicking here. [HT @EMSwami]

Saturday SMACCdown: Should Real Airway Docs Use a Checklist?

In this verbal cage match from the 2014 SMACC Gold conference, Dr. Tim Leeuwenburg (@KangarooBeach) goes up against Dr. Minh Le Cong (@ketaminh) to debate the question: “Should real airway docs use checklists?” Very entertaining, and both sides make good points.

Remember, SMACC Chicago takes place June 23-26, 2015. Many of the pre-conference workshops have already sold out, and registration for the conference itself has been brisk even at this early date. You can view the program and the amazing list of speakers lined up at the SMACC Chicago website. This is really the one conference in 2015 you won’t want to miss!


Related posts:

Saturday with SMACC: Weingart on sepsis in New York City

Saturday with SMACC: Motorbike Mayhem

Saturday with SMACC: Evidence-Based Education — What Works

Saturday with SMACC: The Art and Science of Fluid Responsiveness

Saturday with SMACC: Resuscitation Dogmalysis

Saturday with SMACC: 17 Minutes

Palytoxin: deadlier than fugu?



3 out of 5 stars

Hyperkalemia, Hyperphosphatemia, Acute Kidney Injury, and Fatal Dysrhythmias After Consumption of Palytoxin-Contaminated Goldspot Herring. Wu M: et al. Ann Emerg Med 2014 Dec;64:633-6.


Palytoxin, a huge heat-stable molecule, is one of the most deadly of all the marine toxins. Fortunately, cases of severe palytoxin poisoning are relatively rare. This paper from Taiwan describes 4 patients from a single family who became symptomatic after eating fish soup made from the local catch. One person died. The presence of palytoxin was confirmed in samples of leftover fish.

The following questions are based on point made in the paper. Click on the question to reveal the answer:

Palytoxin poisons the membrane sodium-potassium pump, impairing the ability of cells to maintain electrical gradients. Essentially, it turns the normally carefully regulated pump into an open non-specific cation channel. Sodium ions rush into the cell — creating a permanent state of depolarization —  along with calcium ions that ultimately cause cell death. Calcium also mediates release of neurotransmitters, histamine, and catecholamines.

Palytoxin is a potent vasoconstrictor, especially affecting heart and kidney vessels.

    • Goldspot herring (Herklotsichthys quadrimaculatus)
    • boxfish
    • filefish
    • trigger fish
    • cowfish
    • parrotfish
    • freshwater puffer fish
    • Sea anemones
    • Crabs
    • mackerel
    • Anchovies
    • Sardines

Palytoxin itself is probably produced by dinoflagellates such as Ostreopsis Fish and other marine creatures acquire the toxin by eating plankton.

  • Neurological: dizziness, perioral and limb paresthesias, weakness.
  • Gastrointestinal: nausea, vomiting, diarrhea, abdominal pain
  • Cardiovascular: hypertension, bradycardia, dysrhythmias
  • Renal: acute renal failure (from rhabdomyolysis), anuria
  • Other: myalgia, muscle spasm, respiratory distress,arthralgia, acute hyperkalemia, acute hyperphosphatemia

Many marine envenomations can present in a similar manner, including tetrodotoxin poisoning, neurotoxic shellfish poisoning, paralytic shellfish poisoning (saxitoxin). The major alternative diagnosis is usually ciguatera.

Supportive care with aggressive hydration to maintain urine output.

Goldspot herring (Herklotsichthys quadrimaculatus)

Goldspot herring (Herklotsichthys quadrimaculatus)


Best paper yet on screening suspected body packers

Body packer

Body packer

4.5 out of 5 stars

Body packing: a review of general background, clinical and imaging aspects. Bert FH et al. Radiol Med 2014 Oct 10 [Epub ahead of print]


I’d say this is the best article on imaging suspected body packers we’re likely to see, but with the rapid evolution of radiological technology it will likely need to be updated every year or so. Nevertheless, it is the best review of the topic available, and has spectacular illustrations.

The five authors rely on their experience as radiologists in major European cities, as well as published medical  literature, to review test characteristics of various imaging modalities in detecting body packers as well as body pushers (smugglers who insert large drug packets into the rectum or vagina in an attempt to transport them surreptitiously.) The drug packets usually contain cocaine or heroin.

Some key points made in the paper:

  • Plain abdominal x-rays are relatively insensitive in detecting ingested drug packets, especially when fewer than a dozen are present (sensitivity 40-90% in various studies.)
  • Oral contrast does not increase sensitivity of the plain abdominal film.
  • Computed tomography is highly sensitive in detecting the presence of ingested drug packets (95 – 100%.)
  • Most current screening protocols published in the medical literature call for an abdominal and pelvic CT scan without oral or intravenous contrast.
  • As technology improves,  CT scanning is able to provide reliable screening information using radiation doses that are reduced an order of magnitude compared to those previously required.
  • The use of MRI for screening suspected drug packers or pushers is not yet ready for prime time.

This paper has many interesting x-ray, CT, and ultrasound images, as well as 30 references — some as recent as this year. Highly recommended.
Related posts:

Conservative treatment of asymptomatic body packers?

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
[Note: photograph of body packer is not from the paper discussed in this post]



Infants eliminate ethanol at rate comparable to that in adults

vodka-baby-bottle2.5 out of 5 stars

Accidental Acute Alcohol Intoxication in Infants: Review and Case Report. Minera G, Robinson E.  J Emerg Med 2014;47:524-526


This case report describes a 9-week-old 9.5 kg boy who was brought to the emergency department when he was observed to be “acting strangely.”  He smelled of alcohol.

History revealed that the grandmother had inadvertently prepared the infant’s formula with vodka instead of water.

The child’s respiratory rate was 22/min and oxygen saturation 99% on room air. Fingerstick glucose was 167 mg/dL on admission and serum alcohol level was 330 mg/dL. Repeat serum alcohol level 3 hours later was 270 mg/dL. (Note: In what is apparently an editorial error, the paper states that the 3 hour level was 0.27 mg/dL. This is clearly wrong, as indicated in the paper’s Figure 2.)

The patient was treated with D5NS and did well. The serum alcohol level was essentially zero 24 hours after presentation. Based on the first two alcohol measurements 3 hours apart. the elimination rate was 21.6 mg/dL/h. This rate is consistent with the elimination rate in adults (between 10 and 30 mg/dL/hr with a mean of approximately 18 mg/dL/h) and most previously reported rates in infants and children.

The authors helpfully review published case reports of alcohol intoxication in infants. Unfortunately, their discussion is somewhat confusing, since they do not clear distinguish between blood alcohol levels and serum alcohol levels.


Haff Time: fish-induced rhabdomyolysis

Buffalo fish

Buffalo fish (Ictiobus cyprinellus)

3 out of 5 stars

Haff Disease: Rhabdomyolysis After Eating Buffalo Fish. Herman LL, Bies C. West J Emerg Med 2014 Sept;15:664-6.


Haff Disease was first described in 1924 after an outbreak of acute muscle rigidity accompanied by dark  urine among patients living near the Königsberger Haff shores along the Baltic Coast.  Similar cases occurred in the following summers along the haff (a shallow lagoon.) Most victims gave a history of recently ingesting various fish — burbot, eel, pike, etc.

Cases of rhabdomyolysis after ingesting fish were not reported in the United States until 1984. Most were associated with eating freshwater buffalo fish. Haff disease is diagnosed when a patient develops rhabdomyolysis without another etiology within 24 hours of eating fish. The toxin causing the condition has not been identified, but appears to be heat-stable since cooking does not prevent illness. Common presenting signs and symptoms include back pain, chest pain, sweating, dyspnea, nausea and vomiting.

This case report, from Resurrection Hospital in Chicago, describes a 34-year-0ld woman who presented with chest pain, back pain and vomiting after consuming cooked buffalo fish. Evaluation revealed markedly elevated myoglobin and creatine kinase levels. Chest CT was unremarkable and troponin levels were normal.

The paper makes the following important points:

  • Because of the presentation, life-threatening conditions such as acute coronary syndrome and aortic dissection must be ruled-out.
  • The causative toxin may be similar to palytoxin, a potent vasoconstrictor found in several marine species.
  • In contrast to cases in Europe, U.S. outbreaks of Haff disease have been associated with ingestion of freshwater fish or shellfish (buffalo fish, crayfish.)
  • Many patients with Haff disease have a moderate leukocytosis
  • The key to treatment is supportive care focused on maintaining adequate urine output.
  • The benefit of alkalinizing the urine in rhabdomyolysis has not been proven.


Additional resources:

Illinois Department of Public Health February 2014 release on Haff disease

MMWR report on Haff disease