Name that poison! Kent R. Olson, MD Medical Director, SF Division California Poison Control System

Case n 9 month old being watched by grandmother n Found flaccid, grunting, with decreased level of consciousness n HR 70/min, BP 105/59 n Resp agonal, O2 sat 80% n Pupils pinpoint

Continued... n No response to naloxone n Treated supportively, eventually recovered n Initial Hx: GM takes lisinopril, HCTZ n Also using eye drops for glaucoma

Continued... n Alphagan™ (brimonidine 0.2%) –used for open-angle glaucoma n Stimulates  -2 receptors (similar to clonidine) –CNS depression, bradycardia, HOTN –Peripheral: alpha-agonist can elev BP –J Tox Clin Tox 1997; 35:506 also describes a case w/ recurrent episodes of hypotonia, bradypnea

Case n What’s that?!?

Radiopaque pills and poisons n “CHIPS” –Chloral hydrate –Iron, lead, other metals –Phenothiazines –Sodium n Also: –Potassium, Calcium –Pepto-Bismol –Some SR preparations

Iron pills

Pepto-Bismol

Enteric-coated Potassium Enteric-coated Potassium

Case n Young woman with a headache n BP 138/100 HR 38/min, irregular

Phenylpropanolamine n Strong alpha agonist: –  vascular resistance –Elevated BP –Reflex bradycardia or even AV block not due to “Cushing reflex” n Treatment: –Vasodilator (eg, phentolamine, NP) caution if pt has already stroked –Do NOT give atropine for bradycardia!

: FDA’s MedWatch n “FDA is taking steps to remove phenylpropanolamine hydrochloride from all drug products due to the risk of hemorrhagic stroke... n “...FDA has significant concerns because of the seriousness of stroke and the inability to predict who is at risk… ”

Case n Healthy 2 yo F became agitated n T F n HR 163/min RR 43/min n Pupils widely dilated n Profusely diaphoretic n Bowel sounds present n Accuchek blood glucose normal

Continued... n The parents brought in a half-empty bottle of Amp II Pro Drops™ that had accidentally been left open and was found near the child n Product is a weight loss supplement containing ephedrine

“...Based on thermogenesis, which increases the rate at which the body burns fat. Amp II Pro Drops is a synergistic, unique blend of ingredients. From improved metabolic system functions, more energy can be achieved and weight management maximized. It contains 5 herbal extracts, DMAE and B-12. It is an appetite controller with energizers; stimulates free breathing, enhances athletic performance, increases stamina, endurance and alertness. (Do not use if you have high blood pressure, are pregnant or lactating)...”

Case n 6 yo F acting strange n Talking nonsense, ? hallucinating n Tremulous, ataxic n T 38º C, HR 160/min n Pupils a little dilated, bowel sounds present, skin dry but not flushed n Urine toxicology screen negative

Continued... n CT and LP negative n Blood Cx negative n Special analysis for dextromethorphan was positive

Dextromethorphan (“DMX”) n Common OTC cough suppressant n Odd pharmacology: –d-isomer of opioid levorphanol –antitussive but not analgesic –antagonizes NMDA receptors –inhibits serotonin reuptake n Popular drug of abuse in teens –OTC cough syrups, Coricidin

What's the DXM Trip Like? “Well, that depends on how much you take. There are four different kinds of experiences, based on the dosage; these are called plateaus. The first plateau is a mild stimulant effect with a little bit of a buzz... The second plateau is more intoxicating and has been compared to being drunk and stoned at the same time. The third plateau is dissociative, like a lower dose of ketamine. The fourth plateau is fully dissociative like a higher dose of ketamine. ”

More on dextromethorphan... n Anecdotal reports of cases of dramatic and unexpected responses (esp. in Orientals) n Potential mechanism: genetically- related poor liver metabolism (CYP2D6 isoform)

Case n Young woman had a seizure n Had been at a “Rave” party the night before n Na 116 mEq/L n Had consumed about 5 L water during the evening

Ecstasy-induced hyponatremia n SIADH? or n Excessive water intake? –a common practice in rave clubs to reduce the risk of dehydration and heat stroke