• Toxicology

• Emergency Medicine
• Toxicology

Mark B. Mycyk, MD, Cook County Health and Hospitals System, Chicago, Illinois, USA, advised that clinicians learn to recognize the latest trends in toxicological emergencies, identify easily missed toxicological complications, and develop a rational emergency department (ED) approach to new sources of overdose.

Several common household items have been reported to cause serious effects when taken in excess. For example, massive ingestion of soy sauce has been reported to cause hypernatremia [Carlberg DJ et al. J Emerg Med. 2013]. Excessive intake of Diet Coke led to seizures and hyponatremia [Mortelmans LJ et al. Eur J Emerg Med. 2008].

Laundry detergent pods are among the newer household items that can cause potentially serious effects [Scharman EJ. Clin Toxicol (Phila). 2012]. According to one study, when ingested, they can lead to gastrointestinal, neurologic, and metabolic toxicity [Smith E et al. J Med Toxicol. 2014]. Despite the absence of oral erythema, ulcers, or swelling, of the 3 patients who ingested laundry detergent pods, all developed some degree of esophageal injury. Another study showed that the most significant clinical characteristics of children aged ≤ 5 years exposed to laundry pods were vomiting and drowsiness/lethargy (P < .001 for both; Table 1) [Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2012].

Another newer item with potential for harming children is liquid nicotine. Following reports of children overdosing on this form of nicotine used in e-cigarettes [Chatham-Stephens K et al. MMWR Morb Mortal Wkly Rep. 2014], pediatricians are calling for childproof packaging.

Indeed, half of all poisonings occur in children aged ≤ 5 years. Buprenorphine, which is taken for the treatment of opioid dependency in adults, is involved in a disproportionate number of unsupervised ingestions by children, accounting for 9.5% of all pediatric overdose admissions [CDC. MMWR Morb Mortal Wkly Rep. 2013]. Unintentional ingestion of buprenorphine can cause dose-dependent respiratory depression in children [Kim HK et al. Pediatrics. 2012].

Overall, the United States is experiencing a rising number of deaths due to overdoses of prescription opioid analgesics and cocaine [Okie S. N Engl Med. 2010].

Levamisole, a veterinary antiparasitic drug, has been found in up to 70% of cocaine confiscated at the US border [CDC. MMWR Morb Mortal Wkly Rep. 2009]. Side effects of levamisole include necrotizing vasculitis. This type of poisoning should be considered in cocaine users presenting with atypical symptoms. A thorough skin examination should be performed, and patients should be watched for development of neutropenia.

In high doses, energy supplements containing caffeine, taurine, or guarana can cause confusion, tremors, seizures, and a significant increase in blood pressure [Franks AM et al. Ann Pharmacother. 2012]. Dr Mycyk presented a case report of intentional caffeine overdose that resulted in severe rhabdomyolysis and acute renal failure requiring hemodialysis [Campana C et al. Am J Emerg Med. 2014].

Cannabinoid hyperemesis syndrome (CHS) is a type of cyclical vomiting that results from heavy marijuana use. Standard anti-emetic treatment often fails, but abstinence and hot showers (!) can be successful. Haloperidol has been shown to successfully treat CHS in a single case study [Hickey JL et al. Am J Emerg Med. 2013].

Dr Mycyk recommends that clinicians caring for potential overdose patients pay close attention to collateral history, consider typical and atypical toxidromes, and not rely on standard “tox screens.” He recommends reading the Centers for Disease Control's Morbidity and Mortality Weekly Report and a weekly blog called The Poison Review.

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