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Conference 4/23/2020

As we roll into our sixth week of virtual conference, just wanted to shout out everyone for their perseverance during these pandemic times, and the willingness of everyone stepping up to the plate to make it all happen. Kudos! We appreciate every one of you!

This week we look forward to lectures from Drs Starwalt, Rice, Roberts, and Q&A with Dr R Kirby. We are coming off a great lecture series with Dr Phillips and his great online whiteboard adaptations for toxicology lectures!

Speaking of Dr Starwalt, please check out this great article posted on National Doctors Day about his journey to become a Physician!

Speaking of Dr Rice, he was the clinician of the last quarter, congrats! Here is a feature shout out to him via twitter on doctors day last year!

In other news..

We certainly have had some awesome beards here that have gone the way of the Dodo in favor of N95 masks. Take a look at these guys minus their famous beards and see if you can even recognize who they are?!

From left to right – Dr C. Holmes (Core), Dr Abdel-Raziq (PGY2), Dr Philpott (PGY1)
Photo courtesy of K. Soliman MD

In even other news…

If you haven’t heard – McDonalds is offering free meals to frontline healthcare workers 4/22-5/5 so I figured I’d throw it out here for you guys in case you are craving some post-shift grub. I think this post just made me crave some chicken nuggets…

Now onto business

“The Toxic Neuron”
https://unsplash.com/@alinnnaaaa

This is the last week of Toxicology. We covered a clinical case of toxic alcohols as part of oral board review during the last virtual conference, and it would be pertinent to review this to cement the teaching points.

Please take a look at this FOAMed article from LITFL for a review of methanol vs ethanol vs isopropyl alcohol.

Check out EMDOCs post on toxic alcohols which goes in depth into the indications for fomepizole and hemodialysis (1,4) and see the takeaways below.

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EM Cases: Toxic Alcohols – Minding the Gap

Indications for fomepizole or ethanol in toxic alcohol poisoning

  1. If you have a patient with confirmed ingestion of methanol or ethylene glycol without access to rapid serum osmolality testing.
  2. Anion gap metabolic acidosis or elevated serum osmolar gap
  3. Serum methanol level over 8 mmol/L
  4. Serum ethylene glycol over 3.2 mmol/L
  5. Evidence of end organ damage such as ocular injury or renal failure

Indications for dialysis in toxic alcohol poisoning

  1. Metabolic acidosis with evidence of end organ damage (as above)
  2. Methanol level over 15 mmol/L
  3. Ethylene glycol level over 6 mmol/L
  4. Elevated OSM gap if actual toxic alcohol levels not available (by lab test)

Serotonin syndrome vs NMS

A quintessential question and differential that gets asked every time we see a tox patient with an ingestion of street drugs like MDMA “ecstasy”, SSRI’s or other antidepressants, pain meds such as fentanyl or meperidine, dietary supplements including ginseng, OTC meds such as Dextromethorphan, and the list goes on and on.

Did you know mixing Rx medications such as Linezolid and Citalopram can cause severe serotonin syndrome? think twice about that Zyvox Rx in someone who is on an SSRI. (8)

So how to we differentiate SS from NMS? well..

Serotonin syndrome is more rapid – think rapid onset, rapids movements like akathisia and hyperreflexia (along with myocolonus), resolves rapidly – minutes to hours.

NMS is more slow – slow onset, hyPOreflexia, rigidity, slow resolution – can take days to weeks.

NMS seems to have much higher sustained temperatures – although this can also be seen in SS. NMS can occur at therapeutic doses of many medications more frequently than SS, although theoretically its possible for SS to occur in therapeutic doses – it is less common. (5)

Stay tuned for conference this thursday. See you then..

References

  1. http://www.emdocs.net/em-cases-toxic-alcohols-minding-the-gap/
  2. https://foundationsem.com/tox-environmental/
  3. https://litfl.com/toxic-alcohol-ingestion/
  4. Kraut JA, Mullins ME. Toxic Alcohols. N Engl J Med. 2018;378(3):270-280.
  5. http://www.emdocs.net/toxcard-differentiating-serotonin-syndrome-neuroleptic-malignant-syndrome/
  6. LoVecchio F and Mattison E. Chapter 178: Atypical and Serotonergic Antidepressants. In: Tintinalli J, ed. Tintinalli’s Emergency Medicine. 8th McGraw Hill; 2016: 1219-1224.

Photo credits
K. Soliman MD

Stefan Meyering DO, FAAEM

Dad, Academic EM Attending Physician, Fish Nerd & Backyard Mechanic | APD @ Ft Worth EM | Interests: Graduate Medical Education, Risk Management and Legal Medicine, POCUS, Free Open Access Medical Education (FOAMed), Physician Wellness

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