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In this special holiday bonus episode, Ryan takes a look back at some of the most captivating episodes of The Poison Lab from 2022. Get ready for an ultimate test of your toxicology differential diagnosis skills as we compile all the "Stump the Toxicologist" segments into one streamlined, binge-worthy episode. Explore eight unique poisoning cases, be sure to check the show notes for a description of each case. time stamp of where it begins, and links to the original episodes, where you can dive deeper into the discussions and unravel the mysteries behind these intriguing cases!
Case Teasers and Time Stamps
Episode 13, March 2nd, 2022: Dr. Howard Greller
0:06:19 Case 1: A 19-year-old male collapses at home and presents to the ED unresponsive, tachycardic, and hypotensive, with a wide QRS complex on EKG and a serum lactate of 20. 0:22:58 Case 2: A 16-year-old female presents to the ED 9 hours after ingesting 100 tablets of an unknown medication in a suicide attempt. She presents with vomiting, lethargy, bloody diarrhea, and a metabolic acidosis. An abdominal x-ray shows numerous radiopaque tablets in her GI tract. She is treated with a redacted antidote and whole bowel irrigation, but her condition worsens and she develops liver failure. She is transferred to a tertiary care center for a liver transplant, but recovers. On day 12, she develops a lower GI bleed and bowel perforation and dies. 0:34:42 Case 3: A seven-month-old child presents with crying, cough, vomiting, and respiratory distress. 0:37:42 Case 4: A 32-year-old male with a history of alcohol use and depression presents to the ED seven hours after ingesting two handfuls of an unknown medication and alcohol in a suicide attempt. He is initially anxious and tremulous, but has normal vital signs and labs, aside from an elevated ethanol level. He has a seizure nine hours after ingestion. His EKG shows a widened QRS, and he becomes hypotensive. He is intubated, placed on vasopressors, and undergoes extracorporeal membrane oxygenation (ECMO) and targeted temperature management (TTM), but dies three days later.Episode 15, July 6th, 2022: Dr. Josh Trebach
0:46:11 Case 1: Two British medical students present to the ED after developing nausea, vomiting, paresthesias, myalgias, pruritus, and cold allodynia 12 hours after sharing a meal. Their neurological symptoms persisted for 4 weeks and the cold allodynia for 10 weeks.0:54:18 - 1:05:23 Case 2: A 16-year-old female presents to the ED unresponsive and cyanotic after intentionally ingesting a substance purchased online. Her oxygen saturation is in the 70s and a methemoglobin level is greater than 30%. 1:05:25 - 1:10:18 Case 3: A 48-year-old female, and co-author of the published case report, presents to the ED 10 minutes after eating a “peppery” tuna steak. She is tachycardic, hypotensive, flushed, and has conjunctival erythema. She also experiences abdominal pain, nausea, vomiting, diarrhea, headache, and chest pain. Her EKG shows tachycardia with ST depression. She requires phenylephrine to maintain her blood pressure. She is treated with famotidine and discharged from the hospital 43 hours later. 1:10:20 – 1:13:16 Case 4: A 63-year-old female presents to the ED 12 hours after ingesting five capsules of a weight loss product. She is bradycardic and has nausea, vomiting, and hyperkalemia.Episode 17, November 9th, 2022: Dr. Emily Kieran
1:16:35 Case 1: A 34-year-old female presents to a clinic in West Bengal, India, with a three-year history of skin changes. She has hypo-pigmented macules on a background of hyperpigmentation, creating a “raindrop” like appearance on her... -
Join host Ryan Feldman in an insightful episode of "The Poison Lab" as he sits down with Dr. John Downs, Director of the Virginia Poison Center, and one of the leading experts on per- and polyfluoroalkyl substances (PFAS), commonly known as "forever chemicals." Known for their persistence in the environment and human body, PFAS have raised significant public health concerns over the past few decades. Dr. Downs shares his journey through occupational medicine, toxicology, and public health, which uniquely positioned him to provide expertise on PFAS exposure, health risks, and ongoing regulatory efforts. Together, they delve into the origins, uses, and potential health effects of these ubiquitous compounds, while examining government policies, environmental impact, and strategies to reduce exposure. A must-listen for anyone interested in the intersection of environmental health and toxicology!
Episode Breakdown:
2:42 – What Are Forever Chemicals?8:01 – History of PFAS and Associated Health Concerns15:41 – Government Regulation of PFAS20:42 – Shortcomings in PFAS Regulation25:20 – How Individuals Can Mitigate Risk31:15 – Testing for PFAS Levels and Exploring Treatment Options41:14 – Future Directions and Research Needs for PFAS45:29 – Conclusion and OutroKey Topics Discussed
2:42 – What Are Forever Chemicals?
PFAS are a large group of man-made chemicals that are persistent in the environment and human body.The podcast focuses primarily on PFOA (perfluorooctanoic acid) and PFOS (perfluorooctanoic sulfonic acid), as these were the first compounds identified as having very long elimination half-lives, measured in years, and not undergoing significant human metabolismThe podcast mentions that there are potentially thousands of different PFAS compounds and that more research is needed to determine if they all induce the same health effects as PFOA and PFOSCommonly used for their water- and oil-resistant properties in nonstick cookware, fast food wrappers, firefighting foams, and more.8:01 – History of PFAS and Associated Health Concerns
First created by Dupont chemical, used widely in 1940's in TeflonLarge contamination of water by PFAS identified in West Virginia townLed to landmark study in West Virginia (the C8 study) on epidemiological data of PFAS-related health risks.Effects noted: High cholesterol, thyroid dysfunction, ulcerative colitis, hypertension in pregnancy, decreased immune response to vaccine, and certain cancers (testicular and kidney cancer).PFAS in the Environment
PFAS are not easily degraded, leading to bioaccumulation in humans and animals.Non-stick cookware: Teflon, the trade name for non-stick cookware, was one of the earliest applications of PFAS, utilizing PFOA.Firefighting foam: PFAS was used in firefighting foams, particularly for aviation fuel fires. This has led to contamination of groundwater around military installations and airports.Fast food wrappers and other consumer products: PFAS are used to make products water and oil resistant, including fast food wrappers, clothing, upholstery, and popcorn bags.Biosolids: The nitrogenous waste produced after wastewater treatment, have been found to contain concentrated PFAS. These biosolids are sometimes sold to farms as fertilizer, potentially contaminating water and crops.Ski wax: Ski waxers have been found to have a high degree of PFAS... -
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Ryan on others shows
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In this exciting live episode from the 2024 North American Congress of Clinical Toxicology (NACCT) in Denver, Ryan dives into 12 of the most impactful research abstracts presented at the conference directly with the authors themselves. Covering a wide range of toxicology topics—from the NACSTOP2 trial on acetaminophen overdose, ECG intervals, cannabis toxicity in young children, and more—each guest breaks down their study’s findings and clinical relevance. If you missed the conference or want a deeper understanding of the year's most important toxicology research, this episode is for you. Check the show notes for links to the published abstracts, the full list of studies discussed, and time stamps for where you can find those studies.
Link to published abstract manuscript
Abstracts
07:48-Abstract #1. The NACSTOP2 trial: a multi-center randomized controlled trial investigating the early cessation of n-acetylcysteine in acetaminophen overdose
Guest- Dr. Anslem Wong, MD, PhD21:33- Abstract #36. ECG intervals: does one size really fit all?
Guest- Dr. Caitlin Roake, MD, PhD25:41- Abstract #85. Do abnormal electrocardiographic intervals predict death in poisoned patients older than 65 years?
Guest- Dr. Michael Chary, MD30:06- Abstract #61. Minimum tetrahydrocannabinol dose that produces severe symptoms in children <6 years old with cannabis edible ingestions
Guest- Dr. Keahi Horowitz, MD36:25- Abstract #114. Frequency and severity of cannabis toxicity before and after legislative change to increase cannabis edible package size
Guest- Dr. Robert Hendrickson, MD38:24- Abstract #101. Quantification of acetaminophen line-crossers in the setting o f overdose with delayed gastric absorption
Guest- Dr. Jamie Sterr, PharmD41:41- Abstract #175. Cause for pause: bradycardia induced by transdermal rivastigmine in anticholinergic delirium
Guest- Dr. Santiago Batista Minaya, MD46:21- Abstract #199. Cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) Syndrome with poor neurological outcome in the setting of suspected opioid use
Guest- Jack Yang and Dr. Avery Michienzi, DO49:49- 191. Severity scores for caustic injury: Zargar they even used?
Guest- Dr. Amar Chakrabortya, MD53:!2- Abstract #9. Disparity in immune-mediated reactions to Crotalidae polyvalent immune fab (ovine) and Crotalidae immune F(ab’)2 [equine] in alpha-gal endemic regions and alpha-gal sensitized adults
Guest- Dr. Ari Filip, MD59:10- Abstract # 26. Acute propranolol overdose and dose thresholds of severe toxicity
Guest- Dr. Katherine Isoardi, MBBS1:06:05- 28. Risk of serotonin toxicity following acute lamotrigine overdose
Guest- Dr. Angela Chiew, MBBS, PhD (Introduction at 1:00:00)1:12:36- Interview with AACT President Elect
Guest- Dr. Jillian Theobald, MD, PhDSupport the show
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In this episode the poison lab hosts scientific discourse . Three listeners (Dr. Michael Mullins, Dr. Donna Seger, and Dr. Leon Gussow) write in their critiques surrounding specific recommendations and language used with the AHA 2023 Management of Poisoning Cardiac Arrest or Life-Threatening Toxicity guidelines. Lead author of the guidelines Dr. Eric Lavonas then responds to and addresses their points with counterpoints or appraisals. Tune in and draw your own conclusions!
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Have a burning question you have always wanted to ask a toxicologist? What are tips for managing an anticholinergic overdose? What is the deadliest poison? Why are they called lead pencils if there is no lead?! Send your questions in to [email protected] to take part in a future episode! (If you would like to be anonymous simply state it in the email)
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In this episode Ryan is joined by two expert guests to help read listener guesses for the cause of this poisoning murder and shed light on the toxin involved in the case, which puzzled medicolegal investigators. Ryan is joined by Dr. Dan McCabe, MD (emergency medicine physician, medical toxicologist, medical director of Iowa poison center) and Dr. Crissy Lawson PharmD (emergency medicine pharmacist).
SPOLIER ALERT Mystery case from the showReview Paper from Dr's Lawson, McCabe, and Feldman (PMID: 38613376)Toxo's show note references
TV special about Mary Yoder colchicine murderColchicine potential arrhythmic effectsGo fund me for Dr. Betty BowmanSupport the show
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In this bonus episode Ryan highlights some of the great episodes done in 2023 and compiles ALL of the stump the toxicologist segments from 2023 into one easy to consume episode. Test your toxicology differential skills with more than six poisoning cases. Check out the actual episodes for more information in the show notes on each of the poisonings.
Frank Paloucek EpisodeAdam Blumenberg EpisodeSupport the show
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Do you think you know the cause of these symptoms? Send your guesses to [email protected] to take part in the next episode
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A quick update to share some other shows Ryan has been on in the last few weeks! Check the show notes for links to each episode!
Ryan on "The Larry Meiller Show" discussing delta cannabanoids
Link to streamLink to downloadRyan on EMS2020 talking prehospital overdose
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In this episode Ryan interviews Dr. Alex Krotulski PhD from the Center for Forensic Science Research and Education. Together take a look at trends in novel opioids, benzodiazepines, stimulants, hallucinogens, synthetic cannabinoids, and "hemp products" that are showing up in your patients, drug products, and fatal overdoses. The conversation takes places around the Center for Forensic Science Research and Education quarterly report on Novel Psychoactive Substances found in patients and drug products.
The episode starts with a discussion of the novel benzodiazepines market, highlighting bromazolam and how long it may remain in the market. Then they discuss the opioids highlighting where we are seeing carfentanil, what is happening with Para Fluorofentanyl, and other super potent opioids emergening (such as N -pyrrolidino etonitazene). After a quick discussion of synthetic cathinone's and PCP/ketamine derivatives they jump to synthetic cannabinoids, examining the history of brodifacoum contamination and how regulation has led to market changes.
Resourceshttps://www.cfsre.org/Quarterly report discussed on this episodeMore on Dr. KrotulskiPoster from Dr. Kortulksi on naming conventions for NPSTime stamps to jump to any portion of the episode you want to revisitIntroduction-5:00-32:50
06:30-25:16- Discussion CSFRE mission, history of NPS reports, and other available reports25:14- "Miscellaneous drugs: Furanyl UF17, medetomidine"28:15- Difference between GC/MS and LCqTOF
Novel Benzodiazepines- 32:50Novel Opioids-43:00Stimulants and hallucinogens- 1:01:43Synthetic cannabinoids- 1:07:40Novel psychedelics markets, hemp products, phenibut, tianeptine, and kratom-1:25:12Support the show
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Dr. Ann Arens, MD an emergency medicine physician and medical toxicologist with Oschner Medical center in New Orleans, LA joins the show to educate us on some HOT toxins, solve toxic cases, and opine on the philosophical and existential reasons drugs even exist. Tune in for a fantastic discussion with Dr. Arens and to hear the answer to our mystery case.
Case report for mystery caseReview paper cited by Dr. ArensInterview with DNP user by Chubby EmuCase 1Some also contain CALCIUM NITRATE and can cause methemoglobinemiaCase 2Case 3Support the show
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Do you think you know the cause of these symptoms? Send your guesses to [email protected] to take part in episode 29
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In this episode Ryan is joined by a guest panel (Dr. Grant Comstock MD, Dr. Joshua Trebach MD, Dr. Emily Kiernan DO, and Dr Frank Paloucek PharmD, DABAT) to review nine of the most interesting or clinically impactful research abstracts that were presented at the 2023 North American Congress of Clinical Toxicology (NACCT) in Montreal Canada. If you didn't get a chance to read all 363 research abstracts from some of Toxicology's best and brightest this year, tune in for a high yield review as well as clinical a break down of the studies and their relevance from the expert panel.
Check the show notes for a link to the published abstracts and the list of all studies discussed in the show
Abstracts available here
10:40- Abstract 1 (PDF #225) Methotrexate toxicity in the setting of therapeutic error, a multicenter retrospective review
Lead author: Andrew Chambers24:12- Abstract #2 (PDF #251) Oleander seeds in candlenut weight loss product strike again
Lead author: Masha Yemets31:16- Abstract #3 (PDF #2) Efficacy of sodium tetrathionate when administered intramuscularly for the treatment of acute oral cyanide toxicity in a swine model (Sus scrofa)
Lead author: Brooke Lajeunesse39:45- Abstract #4 (PDF #10) Is HOUR enough after out-of hospital naloxone for opioid overdose? Prospective preliminary data from real-world implementation of the modified St. Paul’s early discharge rule
Lead author: Stephen Douglas49:05- Abstract #5- Poster titles at NACCT 2013–2022: is NACCT experiencing a pun-demic?
Lead author: Dayne Laskey52:40- Rivastigmine discussion
Lead author: none58:40- Abstract #6 (PDF #5) Randomized controlled trial of ANEB-001 as an antidote for acute cannabinoid intoxication in healthy adults
Lead author: Andrew Monte1:08:00- Abstract #7 (PDF#216) Successful use of expired physostigmine to treat anticholinergic delirium in a pediatric patient
Lead author: Bryan Hayes01:20:00- Abstract #8 (PDF #202) Enough negativity? Clinically significant salicylism with first detectable concentration twelve hours )post-ingestion
Lead author: Stacey Bangh01:25:24 - Abstract #9 (PDF #267) High sensitivity troponin is frequently elevated after carbon monoxide exposure
Lead author: Abdullatif AloumiSupport the show
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In this episode, Ryan dives into cutting-edge research on the treatment of acetaminophen (APAP) overdose, featuring interviews with authors of several key abstracts from the North American Congress of Clinical Toxicology (NACCT) in Montreal Canada (Abstracts and posters available in the show notes). We get first looks insights into research evaluating the impact of fomepizole high risk acetaminophen overdose, as well as who gets fomepizole for acetaminophen overdose and dies. Then we evaluate the effectiveness of standard N-acetylcysteine (NAC) treatment in high risk patients and high dose NAC in high risk patients. Join us for an insightful discussion on these advancements that are reshaping the management of APAP toxicity. Guests include Dr. Masha Yemets PharmD, Dr. Molly Stott PharmD, Dr. Alexandru Ulici PharmD, and Dr. Michael Moss MD.
Link to published abstracts(First guest) Abstract #126 Characterizing fomepizole use in acetaminophen deaths reported to US poison centers- Dr. Yemets(Second guest) Abstract #125 Clinical impact of fomepizole as an adjunct therapy in massive acetaminophen overdose- Dr. Stott(Third guest) Abstract #131 Comparison of low-risk and high risk acetaminophen ingestions using the standard prescott protocol of intravenous N-acetylcysteine- Dr. Ulici(Fourth guest) Abstract #130 High-risk acetaminophen overdose outcomes after treatment with standard dose vs. increased dose N-acetylcysteine- Dr. MossOther studies discussed regarding NAC dosingATOM 2 Angela ChiewOutcomes of massive APAP treated with regular NAC (Virginia group, lead author Dr. Downes)Support the show
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In this episode, Ryan sits down with Dr. Eric Lavonas MD, a seasoned EM resuscitation guideline writer, emergency medicine physician, medical toxicologist, and lead author of the latest update to the American Heart Association's guidelines for the management of cardiac arrest and life-threatening toxicity due to poisoning. They have an in-depth discussion as they explore the key aspects of the 2023 AHA treatment recommendations and the rationale behind each decision point. A great review to discover how to effectively apply these guidelines in real-world scenarios and find out what knowledge gaps exist in the realm of toxin resuscitation. Be sure to also check out the accompanying mini-episode for a high-yield review of the major treatment recommendations.
Link to guidelinesLink to high yield review Cyanide paper mentioned in the showAdult calcium channel blocker toxicity guidelinesSupport the show
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In this episode Ryan does a high yield "just the facts" break down of the recently released "2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care". Tune in to learn about the most recent treatment recommendations made by AHA via a panel of toxicology experts. This was released alongside a full interview with the lead author Dr. Eric Lavonas MD. Be sure to check out the full interview to hear it straight from the source! (link in show notes).
Link to guidelinesLink to full in depth interviewSupport the show
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In this enlightening episode, Ryan engages in a deep conversation with Dr. Paul Hutson, PharmD, a renowned researcher in the field of psilocybin and director of the Transdisciplinary Center for Research in Psychoactive Substances at the University of Wisconsin Madison. Dr. Hutson shares his extensive knowledge and insights into the promising role of psilocybin in the treatment of depression and substance use disorder.
Throughout the discussion, they delve into the research that supports the use of psilocybin in medical therapy, shedding light on the rigorous processes involved in conducting such studies. Dr. Hutson elucidates the efficacy and safety findings that have emerged from his and others research, offering listeners a glimpse into the potential future of psilocybin in mainstream medical practices. Listeners will gain a deeper understanding of the meticulous approach to research that ensures both safety and effectiveness. Dr. Hutson shares firsthand experiences and observations, providing a rich and detailed perspective on the current state of psilocybin research. Moreover, the conversation ventures into the practical aspects of integrating psilocybin into contemporary medical practices, discussing the potential frameworks and guidelines that would govern its use. They explore what the future might hold for patients and practitioners alike as they stand on the cusp of a revolutionary shift in mental health treatment.
Whether you're a healthcare professional keen on the latest developments in medical research or someone interested in the evolving landscape of mental health treatment, this episode promises to be a rich source of information and insight. Tune in to be informed and to foster a deeper understanding of the promising horizon that psilocybin research is unveiling in the medical community.
Biography for Dr. Paul Hutson PharmDTransdisciplinary Center for Research in Psychoactive SubstancesDr Hutson's PublicationsSingle Dose Psilocybin for Major Depression- JAMA 2023Psilocybin and QTc in healthy volunteersMeta-Analysis of research supporting Psilocybin use in anxiety and depressionPharmacokinetics of PsilocybinSubjective effects of high dose PsilocybinOther referenced studiesSingle dose psilocybin for treatment resistant depression Psilocybin for alcohol use disorderPsilocybin for For tobacco cessationSupport the show
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New Art and New Tox Trinkets. If you want to share your tox joy in the real world, find some trinkets here: https://www.etsy.com/shop/thepoisonlab
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Mini episode- High-yield over view of Management of Acetaminophen Poisoning in the US and Canada Consensus Statement
In this Ryan sits down with Dr. Richard Dart MD, PhD. He is the lead author of the recently released "Management of Acetaminophen Poisoning in the US and Canada Consensus Statement" from the American Academy of Clinical Toxicology, American College of Medical Toxicology, Americans Poisons Centers, and the Canadian Association of Poison Centers. Listen to be informed on the most recent treatment recommendations. They dive in to the definitions established by the guideline and notable treatment recommendations, dissecting the ratinonale for each desiscion point and how to apply the guidelines. A mini episode was released along side this episode that is a high yield review of major treatment recommendations and definitions estabilished by the consensus statement.
Links :
Mini episode- High-yield over view of Management of Acetaminophen Poisoning in the US and Canada Consensus Statement Guidelines https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808062Definitions made by the guideline
Acute ingestionAny overdose taken with 24 hours periodOverdose "dose" not defined>7.5 g in 24 h was criteria for Rumack Matthew nomogramConsensus statementAdult overdose at 10g/d or 200 mg/kg/d in <24 hours= potentially toxicPediatric <6 year at 150 mg/kg/d in <24 h = potentially toxicRepeated Supra Therapeutic Ingestion (RSTI)Overdose "dose"Repeated dosing totaling6g/d or 150 mg/kg/day x 24-48 h = potential toxic4g/d or 100 mg/kg/day x >48 h = potential toxic (Recognize this means some people could be toxic at therapeutic dosing, but if they do not have symptoms not likely)High risk ingestionReported dose >30 grams OR[APAP] 2 x Rummack-Matthew nomogram treatment lineNAC stopping criteriaAPAP<10INR<2AST/ALT Normal for patient or decreased by 25-50%Patient clinically wellNotable treatment recommendations
RSTIIf patient has history of RSTI (>6 g x 24-48 h, >4 g x >48 hours) AND signs of APAP toxicity (vomiting, RUQ abd pain, AMS)Treat if APAP >20 ug/ml OR AST/ALT elevatedAcuteNon-detectable [APAP] between 2 and 4 hours excludes ingestionGive SDAC w/in 4 hours (something I’ve been a proponent of since ATOM2)TreatStart treatment with NAC if unable to plot on nomogram by 8 hoursNAC dose“Higher dose” NAC (undefined) for high risk ingestionMinimum NAC regimen should include 300 mg/kg orally or within 20-24 hoursCAP NAC dose at 100 kg (this was known with PO, but IV there was always some question since it delivers less overall)Unique scenariosLine crossersAPAP with anticholinergic or opioidIf 1st concentration below treatment line repeat in 4-6 hoursAPAP Extended releaseIf 1st concentration below treatment line @ 4-12 hours, repeat in 4-6 hoursDialysis-Dialyze If APAP... - Visa fler
