Tox Tunes #97: Resurrection Mary (Ian Hunter)

Combining Chicago lore, poisons, and a ghost, this is the perfect “Tox Tune” to post the weekend before smaccUS descends on the Windy City.

“Resurrection Mary,” which appeared on Ian Hunter’s 1996 album The Artful Dodger, recounts the famous Chicago ghost story involving about a vanishing hitchhiker who is periodically sited near the Resurrection Cemetery in southwest suburban Justice. Legend has it that the hitchhiker is the ghost of a young girl killed by an automobile in the late 1920s or early 1930s while trying to get away from her boyfriend.

As recounted by Wikipedia:

Since the 1930s, several men driving northeast along Archer Avenue between Willowbrook Ballroom and Resurrection Cemetery have reported picking up a young female hitchhiker. This young woman is dressed somewhat formally in a white party dress and is said to have light blond air and blue eyes. There are other reports that she wears a thin shawl, dancing shoes, carries a small clutch purse, and/or that she is very quiet. When the driver nears the Resurrection Cemetery, the young woman asks to be let out, whereupon she disappears into the cemetery. According to the Chicago Tribune, “full-time ghost hunter” Richard Crowe has collected “three dozen . . . substantiated” reports of Mary from the 1930s to the present.

As for toxicology, the narrator in the song relates that he  formerly worked for Mickey Finn, the legendary Chicago bartender who pioneered the use of chloral hydrate as a knockout drop. In addition, given the narrator’s drinking history as described in the first verse, the entire encounter with Resurrection Mary might have been an alcohol-related hallucination.

Watch as the Travel Channel retells the tale of Resurrection Mary:

And for more Chicago ghost stories:

Looking back: the first FOAMed meeting in the U.S.

FOAM mtg 2010

This photograph, from November 2010, documents what was to my knowledge the first #FOAMed get-together on U.S. soil. Gathered that evening at a tapas restaurant in San Francisco during the “Essentials of EM” conference were (from left to right):

It is truly amazing to realize that only four-and-a-half years later, 2000 foamheads from around the world are descending on Chicago for the 3-day festival of life and learning called smaccUS. A lot has happened in that short time, and I think it’s fair to say that the world of medical education has been revolutionized by social media. TPR is looking forward to meeting everyone coming into town this week.

What a short, strange trip it’s been!

 

Illustrated case report of phenol exposure

Phenol

Phenol

3.5 out of 5 stars

Phenol Toxicity Following Cutaneous Exposure to Creolin®:A Case Report. Vearrier D et al. J Med Toxicol 2015 Jun;11:227-231.

Abstract

This paper is worth looking at for the excellent color photographs of the partial thickness skin burns induced by exposure to Creolin®, which contains carbolic acid (phenol), sodium hydroxide, and isopropanol.

A 9-year-old girl was brought to the emergency department because of respiratory distress and unresponsiveness. Symptoms came on quickly and started within 4 minutes of the mother pouring 8 oz Creolin® over the patients hair in an attempt to get rid of head lice. Some liquid made contact with the girl’s neck, back, shoulder, and upper arm.

On arrival at hospital the patient was intubated because of decreased level of consciousness. Exam showed erythema and hyper pigmentation over areas that contact the liquid. External decontamination was accomplished by sponging with soap and water. Brief runs of monomorphic ventricular tachycardia were treated with lidocaine. Endoscopy did not find any GI lesions, and the paper was extubated within 12 hours of exposure. Ultimately, 17% body surface area partial thickness burns were documented. Many of these areas desquamated after several days. When the patient was seen again in the emergency department 2 years after this incident, there no residual scarring was seen.

Some points from the paper:

  • Phenol is caustic, causes coagulative necrosis, and is rapidly absorbed through the skin.
  • Although scant and inconsistent data from some animal models suggest that decontaminating phenol exposure with isopropanol or low-molecular-weight propylene glycol offers improved outcome over soap and water, these are often not readily available.
  • Since phenol easily penetrates protective gloves commonly used in the emergency department, treating staff should use neoprene gloves or, if these are not available, put on double gloves and change them frequently.

Not much really new here, but the photographs are really impressive.

Case series: 11 hospital workers symptomatic after ingesting “synthetic marijuana” brownies

brownie3 out of 5 stars

Cluster of Acute Toxicity from Ingestion of Synthetic Cannabinoid-Laced Brownies. Obafemi AI et al. J Med Toxicol 2015 May 13 [Epub ahead of print]

Abstract

This case series describes 11 patients brought to hospital after inadvertently ingesting brownies laced with the synthetic cannabinoid AM-2201.

All 11 patients were hospital workers who ingested brownies brought to work by a staff member. In each patient, symptoms started within an hour of ingestion and generally resolved within 2 to 4 hours (although two persons felt tired and dizzy for up to 10 hours post-ingestion.) The most common neurological manifestations included memory impairment (10/11) and “inappropriate giggling” (4/11.) All patients reported numbness and tingling, dry mouth, and lightheadedness. There were no gastrointestinal manifestations. All patients had negative routine urine drug screens.

Laboratory analysis of a remaining brownie was positive for AM-2201. No analytical tests were done on biological specimens.

Note that this report’s findings are not generalizable, since the next patient you see with exposure to a synthetic cannabinoid could have ingested an entirely different agent and/or a radically different dose. Your mileage may vary.

And of course, whenever we refer to marijuana brownies — or even synthetic marijuana brownies — we have to replay this clip:

Related post:

First case of cycle emesis associated with synthetic cannabinoids

 

[Photo of brownie from en.wikipedia.org]

Podcast: Managing the crashing tox patient with ECMO

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As I wrote about in a recent column for Emergency Medicine News, extracorporeal membrane oxygenation (ECMO) may be the next big thing in managing the severely ill, crashing overdose patient in whom usual therapy is not working. On the new podcast posted today at the EDECMO website, Steve Aks and I got together over Skype with Joe Bellezzo, Zack Shinar, and Scott Weingart to discuss the potential benefits, as well as the potential risks and complications, involved in using ECMO in the sickest tox patients.

Some of the topics we discuss:

  • What overdose patients might benefit most from ECMO?
  • What vascular access is needed for ECMO?
  •  Would ECMO be effective in treating poisoning from agents such as carbon monoxide and cyanide that are not primarily cardiodepressants?
  • Should ECMO and lipid reduce therapy be done simultaneously?
  • Can hemodialysis be done safely in a patient on ECMO, and if so can the dialysis circuit be in series with the ECMO pathway?

To listen to the podcast, click here.

Here are links to some of the papers mentioned during our discussion, and even more recent literature:

Bellezzo J et al. Emergency physician-initiated extracorporeal cardiopulmonary resuscitationResuscitation 2012 Aug;83:966-70.

De Lange DW et al. Extracorporeal membrane oxygenation in the treatment of poisoned patients. Clin Toxicol 2013 Jun;51:385-393.

Escajeda JT et al. Successful treatment of metoprolol-induced cardiac arrest with high-dose insulin, lipid emulsion, and extracorporeal membrane oxygenationAm J Emerg Med 2015 Jan 16 [Epub ahead of print]

Johnson NJ et al. A Review of Emergency Cardiopulmonary Bypass for Severe Poisoning by Cardiotoxic DrugsJ Med Toxicol 2013 Mar;9:54-60

Lee HM et al. What are the adverse effects associated with the combined use of intravenous lipid emulsion and extracorporeal membrane oxygenation in the poisoned patient?  Clin Toxicol 2015;53:145-150.

Wang GS et al. Extracorporeal Membrane Oxygenation (ECMO) for Severe Toxicological Exposures: Review of the Toxicology Investigators Consortium (ToxIC)  J Med Toxicol 2015 May 27 [Epub ahead of print]

Dramatic recent increase in cases and deaths associated with use of synthetic cannabinoids

black-mamba-300x2194 out of 5 stars

Increase in Reported Adverse Health Effects Related to Synthetic Cannabinoid Use —United States, January-May 2015. MMWR 2015 Jun 12;64:618-619.

Full Text

I have to say that this report shocked me some. Although I was aware of an increased number of news reports of incidents related to synthetic cannabinoids, I really had no idea the increased number of cases involving exposures reported to poison centers with major adverse effects and death were so dramatic.

As this report points out:

“Synthetic cannabinoids include various psychoactive chemicals or a mixture of such chemicals that are sprayed onto plant material, which is then often smoked or ingested to achieve a ‘high’.”

In April, the National Poison Data System alerted the Centers for Disease Control and Prevention about a spike in reported cases, which increased from 349 in January 2015 to 1501 in April 2015. The most common adverse effects reported were agitation, tachycardia, lethargy, vomiting, and confusion. From January through May of this year, there were 335% cases with outcomes classified at major (life- or limb-threatening.) There were also — and this really surprised me — 15 deaths, with only one of these being associated with polysubstance exposure.

It would, of course, be very valuable to have much more information about these cases, including mechanisms of death (trauma? cardiovascular collapse? seizure?) and any laboratory confirmation of specific agents. In addition, I’d be interesting in knowing how many patients used the synthetic cannabinoid in the hopes of passing a urine drug test at work or school.

For a very good discussion about these agents, see Alice Walton’s 2014  article “Why Synthetic Marijuana Is More Toxic To The Brain Than Pot” on the Forbes website.

Fortunately, as this chart from the MMWR report demonstrates, the number of poison center calls related synthetic cannabinoids declined rapidly from mid-April to mid-May:

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