Methanol Poisoning

 

Substance

-       Methanol

-       CH₃OH

 

Common name or Trade name

-       甲醇

-       Used in 抗凍劑, 溶劑, 皮革工廠, 染料塗料

 

Involving system [1]

-       Metabolic acidosis. lethargy

-       GI system:

-       Neurologic system: after poisoning 8 months to 2 years, secondary Parkinsonism.

-       Eye: Retinopathy, blindness.

 

 Presentation [1]

-       6—12 hours, 18—24 hours even 60 hours. After ingestion.

-       Blurred vision.

-       Stupor, coma.

-       Headache

-       SOB

-       Nausea. Abdomen pain, diarrhea.

-       High anion gap acidosis.

-       High osmolar gap acidosis

 

Antidote and Treatment [2]

-       Decontamination.

-       Carbomix (activated charcoal) is useless.

-       Intubation while acute respiratory failure.

-       ACLS

-       Ethanol: competition of aldehyde dehydrogenase, 1 gm/kg BW= 紹興(18%) 6ml/ kg BW till seral ethanol level 100—150 mg/dl. [1]

-       Fomepizole: 10—20 mg/kg / day * 3—5 days. (inhibit metabolism of methanol). [1]

-       Hemodialysis. [1]

-       Folic acid: 50 mg IV every 4 - 6 hours until toxicity resolves (increase formic acid oxidation into carbon dioxide and water). [3]. https://www.ebmconsult.com/articles/methanol-toxicology

-       Leucovorin dose: 1 mg/kg (50-70 mg adults) IV q4-6hr. (Folinic acid or leucovorin, the biologically active forms of folic acid, must be used for reversing toxicity due to dihydrofolate reductase inhibitors.)

Disposition 

-       Admit to ICU if severe acidosis, SOB, respiratory failure, or acute kidney injury  

-       Consult ophthalmologist if there is symptoms of eye.

  

REFERENCES

[1]. 急診醫學會, AILS 三版 p.255—265

[2]. Barceloux DG, Bond GR, Krenzelok EP, Cooper H, Vale JA; American Academy of Clinical Toxicology Ad Hoc Committee on the Treatment Guidelines for Methanol Poisoning. American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning. J Toxicol Clin Toxicol. 2002;40(4):415-46. doi: 10.1081/clt-120006745. PMID: 12216995.

[3]. Lim CS, Bryant SM. Forgoing the Folate?-Contemporary Recommendations for Methanol Poisoning and Evidence Review. Am J Ther. 2016 May-Jun;23(3):e850-4. doi: 10.1097/MJT.0000000000000059. PMID: 24531405.

edited  by Yu-Jang Su          Nov 28, 2020

 

Isoniazid Intoxication

Substance

 Isoniazid (one of the anti-TB regimen, some are accidental. Some are intentional)

-       Accounts for 5% of Intoxication related seizure

Common name or Trade name

INH

 

Involving system

- In adults, toxicity can occur with the acute ingestion of as little as 1.5 g of isoniazid. [1]

- ingested in amounts of 80 to 150 mg per kg or more, isoniazid can be rapidly fatal. [1]

- CNS: Doses larger than 30 mg per kg often produce seizures. [1]

Mechanism: This reduction in GABA levels increases the susceptibility to seizures. [1]

 

 Presentation

-       nausea, vomiting, slurred speech, dizziness, tachycardia, and urinary retention

-       stupor [1]

-       seizure [1, 2]

-       intractable seizure, acidosis, metabolic acidosis and coma [1, 3, 4]

-       dementia [5]

-       status epilepticus in children [6]

-       elevated anion gap and metabolic acidosis, hyperglycemia, hypokalemia, glucosuria, and ketonuria [1]

 

Antidote and Treatment 

-       Decontamination, irrigation, Charcoal 50 gm, 1gm/ kg

-       BZD for seizure, valium IV.

-       pyridoxine intravenously [6]

-       If the amount of ingested isoniazid is unknown, 5 g of pyridoxine is given intravenously over five to 10 minutes [1]

(Dose: Given in gram-per-gram amounts of the isoniazid ingested, pyridoxine (vitamin B6) usually eliminates seizure activity and helps to correct the patient's metabolic acidosis. [1])

Mechanism: -      pyridoxine is a necessary cofactor for the production of the neurotransmitter gamma-aminobutyric acid (GABA). Pyridoxine must be activated to produce GABA. [1]

-       NaHCO3-, if the ABG pH is less than 7.1. A good starting dose is 1 to 3 mEq per kg

-       continuous veno-venous hemodiafiltration [2]

Disposition 

-       consult social worker, psychiatrist, suicide prevention unit.

-       Depends individualized.

  

REFERENCES

 

[1] Romero JA, Kuczler FJ Jr. Isoniazid overdose: recognition and management. Am Fam Physician. 1998 Feb 15;57(4):749-52. PMID: 9490997.

 

[2]. Skinner K, Saiao A, Mostafa A, Soderstrom J, Medley G, Roberts MS, Isbister GK. Isoniazid poisoning: Pharmacokinetics and effect of hemodialysis in a massive ingestion. Hemodial Int. 2015 Oct;19(4):E37-40. doi: 10.1111/hdi.12293. Epub 2015 Mar 16. PMID: 25779481.

 

[3]. Khoharo HK, Ansari S, Abro A, Qureshi F. Suicidal Isoniazid poisoning. J Ayub Med Coll Abbottabad. 2009 Apr-Jun;21(2):178-9. PMID: 20524502.

 

[4] Kürşad H, Kizilkaya M, Sahin M, Dogan N, Ilgaz A. Treatment of acute isoniazid toxicity of unknown dose. South Med J. 2003 Jan;96(1):101. doi: 10.1097/01.SMJ.0000049841.49028.41. PMID: 12602731.  

 

[5]. McLay RN, Drake A, Rayner T. Persisting dementia after isoniazid overdose. J Neuropsychiatry Clin Neurosci. 2005 Spring;17(2):256-7. doi: 10.1176/jnp.17.2.256. PMID: 15939987.

 

[6] Caksen H, Odabas D, Erol M, Anlar O, Tuncer O, Atas B. Do not overlook acute isoniazid poisoning in children with status epilepticus. J Child Neurol. 2003 Feb;18(2):142-3. doi: 10.1177/08830738030180021101. PMID: 12693784.

~~~~~~~ edited by Yu-Jang Su Oct 31, 2020 ~~~~~~

 

Ractopamine

Substance

Ractopamine 

Common name or Trade name, used in 

瘦肉精 

The Joint FAO/WHO (Food and Agriculture Organization World Health) Expert Committee has set the acceptable daily intake (ADI) of ractopamine in 2006.

Ractopamine can be added in feed in the United States and Canada [1]. 

 Involving system 

- CV [2] 

- GI [2] 

- Neuro-muscular [2] 

- lifespan [3] 

 Presentation 

 - GI: nausea, vomiting. [2] 

- CV: palpitation, facial flush. [2] 

- Neuro: trunk or limb numbness, tremor, headache, weakness [2] 

- General: chill, and dyspnea [2]. 

- Promote increasing heart diseases and life expectancy reduction [3] 

- Laboratory: hypokalemia, leukocytosis, and hyperglycemia [2]. 

 Antidote and Treatment 

- intravenous hydration and potassium supplements, which gradually ameliorated their symptoms [2]. 

Disposition 

- admission: They were discharged after hospitalization for 3 (66.7%) or 4 days (33.3%) [2]. 

 - Patients’ symptoms were completely resolved within 1 week after the exposure [2]. 

-in an animal study, the cumulative risk and incidence rate of death was 75 to 90% greater in animals administered the βAA (β-adrenergic agonists) compared to contemporaneous controls [4]. 

HALF of the deaths among groups administered the βAA were attributed to the administration of the drug [4]. 

- Animal study: Postdosing 77.8% dogs developed cardiac arrhythmias and had elevated troponin levels indicating myocardial damage. Mild myocardial necrosis and fibrosis. Scattered arteries exhibited segmental medial and perimedial fibromuscular dysplasia [5]. 

 References 

 [1]. Li JH, Yu WJ, Lai YH, Ko YC. Major food safety episodes in Taiwan: implications for the necessity of international collaboration on safety assessment and management. Kaohsiung J Med Sci. 2012;28(7 Suppl):S10-S16. doi:10.1016/j.kjms.2012.05.004 

 [2]. Wu ML, Deng JF, Chen Y, Chu WL, Hung DZ, Yang CC. Late diagnosis of an outbreak of leanness-enhancing agent-related food poisoning. Am J Emerg Med. 2013;31(10):1501-1503. doi:10.1016/j.ajem.2013.07.001 

 [3]. Onishchenko GG, Popova AIu, Tutel'ian VA, et al. Vestn Ross Akad Med Nauk. 2013;(6):4-8. doi:10.15690/vramn.v68i6.666 

 [4]. Loneragan GH, Thomson DU, Scott HM. Increased mortality in groups of cattle administered the β-adrenergic agonists ractopamine hydrochloride and zilpaterol hydrochloride. PLoS One. 2014;9(3):e91177. Published 2014 Mar 12. doi:10.1371/journal.pone.0091177 

 [5]. Yaeger MJ, Mullin K, Ensley SM, Ware WA, Slavin RE. Myocardial toxicity in a group of greyhounds administered ractopamine. Vet Pathol. 2012;49(3):569-573. doi:10.1177/0300985811424752

-- Sep 3, 2020  Yu-Jang Su ~~

NPS (New Psychoactive Substances)

Substance [1, 2]

  NPS (New Psychoactive Substance).

        * so-called ‘legal highs’

* synthetic, such as designer drug.

* structural easily modified.

* difficult to detect by traditional urine test.

* novel and diverse appearance and package.

* not controlled by the 1961 Single Convention on Narcotic Drugs, or the 1971 Convention on Psychotropic Substances, posing a public threat.

 

History told by Patient (46%), Family (39%), EMT (22%), Friend (15%), Police (11%) [2]

 

 

Common name or Trade name [1, 2]

  管制一級

      Desomorphine (Krokodial) 鱷魚

  管制二級

      PCP-based. (Angel dust)

      MDPV(浴鹽)

      GHB (液態快樂丸), 神仙水

             MDMA 快樂丸、搖頭丸.

      PMMA (happy粉) 

      25B-NBOMe (毒郵票)

  管制三級

      Mephedrone (Meow Meow)喵喵

      bk-MDMA (Methylone)卡西酮

            ketamine (K仔、Special K或K)

Nimetazepam(一粒眠)

  管制四級

      5MeO DiPT (火狐狸), Tryptamine類.

 

  Mixed type (6—12種)以Ketamine為based + Cathinone, MDPV 等.混10種很常見

 

 

Involving system [1]

    * Cardiovascular: HTN, tachycardia.

* Urologic: cystitis, bladder atrophy

* GI: cramping pain

* Mental: executive dysfunction, defected memory

* Psychosis

    * addiction.

 

 

Presentation [2]

-          Respiratory rate< 10 /min, and > 16/min (88%)

-          Tachycardia + bradycardia (59%)

-          SBP >140 mmHg, <90 mmHg (32%)

-          BT (<35 degrees Celsius, > 38 degrees Celsius) 12%

-          low oxygen saturation < 90% (5%)

 

 

Antidote and Treatment [3]

-          no antidote

-          evaluation of blood morphology, coagulation parameters, biochemistry screening  

-          Symptomatic treatment of patients, fluid therapy and sedation if irritable/ aggressive behavior 

-          Management the complication, trauma, infection and so on.

 

Disposition [2]

 

  急診暫留 (52%)

Admission (16%)

ICU (14%)

Transfer (2.2%)

OHCA (0.6%)

IHCA (0.3%)

 

 

REFERENCES

 

1.      Morning meeting, July 24, 2020. Emergency Department, MacKay Memorial Hospital, Taipei, Taiwan.

 

2.      藥物濫用個案醫療救護訓練. 台灣急診醫學會. 亞東紀念醫院July 20, 2020.

 

3.      Jalali R, Dmochowska P, Godlewska I, et al. Designers Drugs-A New Challenge to Emergency Departments-An Observational Study in Poland. Medicina (Kaunas). 2020;56(7):E354. Published 2020 Jul 17. doi:10.3390/medicina56070354

 

~~ Aug 4, 2020 by Yu-Jang Su

 

 

 

 

研討會訊息: 強化醫療端新興濫用藥物監測機制計畫」 藥物濫用個案醫療救護訓練

Aug 11, 2020 高雄場: 

https://www.sem.org.tw/Activity/Details/24070

Aug 18, 2020 台中場: 

https://www.sem.org.tw/Activity/Details/24069

主辦單位: 社團法人台灣急診醫學會 

指導單位: 衛生福利部 食品藥物管理署

July 20, 2020 台北場: