Death after use of recreational marijuana, and other Tox on the Web

More on e-cigarette nicotine liquid: On KSTP-TV news in Minneapolis/St. Paul, medical toxicologist Dr. Ben Orozco discusses the hazards of e-cigarette refill liquid, and the signs and symptoms of nicotine toxicity.

Suicide by hydrogen sulfide: The St. Charles (LA) Herald-Guide reported the tragic story about a 32-year-old research scientist who killed herself by releasing hydrogen sulfide in her car. She had posted hazmat warnings in the windows to protect first responders. TPR has written previously about these s0-called “chemical suicides,” a phenomenon that started in Japan and often takes place in the victim’s automobile. HT @NaturesPoisons

Risks of fluoroquinolones: At Academic Life in Emergency Medicine, Matthew DeLaney discusses the clinical and medical-legal risks of fluoroquinolones, including tendinopathy and peripheral neuropathy.

Use of opiates to treat headache increasing in U.S. emergency departments: HealthDay reports that recently there has been a large increase in the number of prescriptions for opioid analgesics written to treat headache, according to a  presentation at the March 2014 American College of Medical Toxicology conference in Phoenix:

The researchers analyzed national data from 2001 to 2010 and found a 65 percent increase in emergency department use of narcotic prescriptions for headaches during that period. The largest rise (450 percent) was in the use of hydromorphone, and there was also a significant increase in the use of oxycodone.

As the report notes, both the American College of Emergency Physicians and the American Academy of Neurology recommend that opioids not be first-line drugs for treating headache. (HT @LNelsonMD)

A related story in the Boston Globe describes how an effort by Blue Cross Blue Shield in Massachusetts to place restrictions on physicians’ ability to prescribe large amounts of opiate analgesics reduced scripts written for such agents by 20-50%. (HT @DavidJuurlink)

Fentanyl-laced heroin – a deadly combination: In Emergency Medicine News, Jim Roberts makes recommendations for treating heroin overdose in 2014, at a time when the number of cases are skyrocketing and drugs used to adulterate the supply on the street are becoming more varied.

Does legalizing weed make the roads safer?: In Forbes magazine, Jacob Sullum makes the counter-intuitive argument that loosening restrictions on the medical and recreational use of marijuana leads to decreased numbers of motor vehicle collisions and traffic fatalities. The argument rests on the notion — which is controversial but backed by some evidence — that increased use of marijuana results in decreased consumption of alcohol. (HT @NaturesPoisons)

Death after use of recreational marijuana: BBC News reports that in Denver a 19-year-old exchange student from the Republic of Congo died after falling from a hotel balcony. The accident occurred after the man ate a cannabis cookie, and after the autopsy the medical examiner listed marijuana intoxication as a factor in the death. although in Colorado use of recreational marijuana is not legal for anyone under the age of 21, the cookie had been purchased by another individual. (HT @Rx_Ed)

It’s 10 am. Do you know where your medical school Dean is?: The Wall Street Journal reports on the disturbing trend in which leaders of academic medical centers also serve on the boards of pharmaceutical companies:

The dual roles may create conflicts because these individuals “wield considerable influence over research, clinical and educational missions” at the same time they are chartered with promoting the fortunes of a drug maker, according to the paper in the Journal of the American Medical Association, or JAMA. The board members, by the way, were compensated an average of $312,564 in 2012 by the drug makers.

A recent survey of 17 U.S. drug makers found that 16 of them had at least one academic leader on its board. These included deans, university presidents, executive officers, and clinical department chairs. The conflict of interest created by this type of relationship should be obvious. The Milwaukee Journal-Sentinel has a related story. HT @pharmalot.

Magic mushroom intoxication: In a very amusing read, reprints a 1914 first-hand account of mushroom intoxication from the journal Science. A man and his niece feasted on a large amount of the little brown mushroom Panaeolus papilionaceusThis species is generally considered non-intoxicating, but can contain psilocybin. In this instance, it apparently did:

Next, say about half an hour after eating, both of us had an irresistible impulse to run and jump, which we did freely. I did not stagger, but all my motions seemed to be mechanical or automatic, and my muscles did not properly nor fully obey my will. Soon both of us became very hilarious, with an irresistible impulse to laugh and joke immoderately, and almost hysterically at times. The laughing could be controlled only with great difficulty; at the same time we were indulging extravagantly in joking and what seemed to us funny or witty remarks. Mr. Y., who was with us, said that some of the jokes were successful; others not so, but I can not remember what they were about.

Short and highly recommended.

“Leaves of three, let it be.”: The excellent “Nature’s Poisons” blog this week features uroshiol, the toxin behind the nasty effects of poison ivy and poison oak. In another post, Justin from the blog writes about solanine and chaconine, the toxic glycoalkaloids found in green tomatoes.

Long-read of the week: In Esquire magazine, Ryan D’Agostino goes deep into the problem of proliferating ADHD drugs in with his piece “The Drugging of the American Boy.” A must-read. HT @DavidJuurlink


Podcast of the week: At the Journal of Medical Toxicology Podcast, Howard Greller and Dan Rusyniak discuss that publication’s March 2014 issue, including articles about complications of antidotal intravenous lipid emulsion therapy, toxicology of HIV medications, and problems with declaring brain death in overdose cases.

Calls to poison centers related to nicotine-containing e-cigarette liquid skyrocketing

The Centers for Disease Control and Prevention released results from a study showing that reported exposures to nicotine-containing e-cigarette liquid have risen dramatically over the last several years.

Their data indicates that in September 2010, U.S. poison centers received just a single call related to these liquids. In February 2014, that number had increased to 215 calls for the month.

Over half the calls involved children less than 5 years of age. Routes of exposure included ingestion, inhalation, or absorption through skin or eyes. The refill liquids, that can contain more than the minimal dose of nicotine that can be lethal to a toddler, are often formulated with fragrances such as bubblegum, strawberry, and coconut that young children might find attractive. Although it is not clear from the summary how many of the poison center calls involved patients with manifestations of nicotine toxicity, the most frequent adverse effects reported were nausea, vomiting, and eye irritation.

No surprise here — the report is a bit of a “Duh!.” Since sales in the so-called “vape” industry are increasing exponentially, it would have been strange if the number of exposures hadn’t grown dramatically. However, poison center calls are not poisonings, and I’m still not sure how great a risk significant nicotine toxicity from these products represents.

Possibly a greater problem is that, as of this posting, the entire industry is unregulated. There is no guarantee that the dose of nicotine contained in a refill liquid could be much higher than advertised. The user can also not be sure what other chemicals are contained in the product, or possible lung effects. In addition, there is no requirement that packaging be child-proof.

The FDA is expected to correct this situation in the very near future when they issue a ruling establishing their authority to regulate e-cigarettes.


Do two dissimilar cases represent a case series?

amlodipine2 out of 5 stars

High-dose Insulin and Intravenous Lipid Emulsion Therapy for Cardiogenic Shock Induced by Intentional Calcium-Channel Blocker and Beta-Blocker Overdose: A Case Series. Doepker B et al. J Emerg Med 2014 Apr;46:486-490.



The problems with this confused and confusing paper start with the title, which suggests that it will describe a series patients who presented with overdose of a calcium-channel blocker (CCB) and beta-blocker (BB), who were treated with high-dose insulin (HDI) and intravenous lipid emulsion (ILE).

Well, this may be a case series, but the series includes only 2 patients, and it would have been nice if this limitation was made clear in the title. In addition, only one patient took both a BB and CCBs:

  • Patient 1: a 35-year-old man who took large amounts of amlodipine, verapamil, and metoprolol and presented with bradycardia and hypotension
  • Patient 2: a 59-year-old man who overdosed on metformin, amlodipine lisinopril and simvastatin and presented with bradycardia and hypotension.

Both patients did well after treatment with multiple interventions (calcium, glucagon, pressors) that included HDI and ILE.

Unfortunately, the cases were so dissimilar, and so many different treatment modalities were administered at different doses and times, that it is impossible to derive any take-home lessons from the cases. Also, looking at figures 1 and 3 in the paper, it is clear that the mean arterial pressures (MAP) in both patients were already improving at the time HDI was administered, and did not markedly improve further after treatment. The authors state:

In our case series, vasopressors could be discontinued in both patients within a short period of time after initiating HDI treatment.

Really? In patient 1, vasopressors were turned off 2 hours after HDI was started. In patient 2, that interval was over 10 hours. These are hardly short periods of time in my book.

By the way, in the abstract the authors state: “To our knowledge, these are the first two successful cases reported using the combination of HDI and ILE for reversing [cardiogenic shock] induced by intentional ingestions of CCBs and BBs.” Yet, they reference a 2011 paper that described just such a case.

Just when you thought it was safe to enjoy a refreshing ice tea . . .

800px-Iced_tea3 out of 5 stars

Multiple Poisonings with Sodium Azide at a Local Restaurant. Schwarz ES et al. J Emerg Med  2014 Apr;46:491-494.


This is an interesting report describing at incident in April 2010 in which 5 persons came down with symptoms of sodium azide poisoning after drinking ice tea from the same self-serve urn at a local restaurant. All patients recovered.

Unfortunately, this paper does not add much to the complete report published in MMWR 2 years ago, except for some additional detail about individual patients and the treatments they received. To read TPR‘s discussion of the MMWR report, click here.

To read my Emergency Medicine News column about a similar incident at Harvard — The Case of the Contaminated Coffee Pot —  click here.


Tox Tunes #80: Weed Head Woman (Champion Jack Dupree)

The great boogie-woogie blues pianist Champion Jack Dupree (?1908 – 1992) got his nickname from the fairly successful boxing career that preceded his taking up music as a career. According to wikipedia, after being encouraged by Joe Louis he entered 107 fights, winning the Golden Gloves and other championships.

Although he was originally from New Orleans, Dupree did much of his early recording in Chicago. “Weed Head Woman” was recorded in 1941.

In 1966, he jammed with Eric Clapton and John Mayall:

Related posts:

Tox Tunes #31: Junker’s Blues (Champion Jack Dupree)

Tox Tunes #64: Reefer Head Woman (Aerosmith)

Complications associated with lipid emulsion therapy

intralipid_10672_5_(big)_3 out of 5 stars

Complications Following Antidotal Use of Intravenous Lipid Emulsion Therapy. Levine M et al. J Med Toxicol 2014 Mar;10:10-14.


Known complications of intralipid administration include pancreatitis, acute respiratory distress syndrome (ARDS), and interference with laboratory tests. While these complications can be seen when intralipid is administered for parenteral nutrition, there is interest concerning to what extent they occur when lipid emulsion therapy (LET) is given as a rescue antidote to treat lipophilic drug toxicities. The authors retrospectively reviewed registries at two tertiary care medical centers from the years 2005 thru 2012 to identify cases of patients who received LET after known or suspected drug overdose, and developed defined complications.

Nine patients were identified who received LET.  Six patients developed complications. In 4 patients, lipemia interfered with laboratory testing. Two patients developed pancreatitis (lipase > 1,000 IU/L plus symptoms of abdominal pain, nausea, and/or vomiting. Three patients developed ARDS. (These numbers add up to more than 6 because some patients developed multiple complications.) Of course, as the authors point out, these were critically ill patients, and the association of LET with complications such as ARDS do not necessarily prove causation.

Interestingly, despite some literature suggesting otherwise, in the cases in which lipemia interfered with laboratory testing serial ultracentrifugation of the samples did not enable laboratory analysis.

The authors conclude that because of the possibility for compilations “[LET} should be reserved for hemodynamically unstable patients in whom supportive efforts have failed.”

This paper is worth looking at, despite the limitations of retrospective design and very small sample size.

Related posts:

Lipid rescue therapy can interfere with critical lab values

Lipid emulsion overdose