Questions of the Week

The Toxicology Question of the Week is a venue that addresses interesting questions that have been asked of the Poison Center or are topics of relevance. 

The TPC toxicologists will contribute to the Question of the Week.  If you have any subjects you would like to have addressed, please email Dr. Seger at

         If you wish to be added to the distribution list, please email Brittaney Jenkins at

Sept 14, 2020: How Should “Massive” Ingestions of Acetaminophen be Treated?

Ten to fifteen percent of Acetaminophen (APAP) is metabolized via Cytochrome P450 2E1 to a toxic reactive metabolite, N-acetyl-p-benzoquinone (NAPQI), which is conjugated and detoxified by endogenous glutathione.  Following APAP overdose, endogenous glutathione is depleted, and N-acetylcysteine (N-ac) is administered to donate glutathione to detoxify NAPQI.

Aug 26, 2020: What is the Treatment of Antihistamine Overdose?

Allergy season is in full swing in Tennessee and the use of allergy medication increases as a result.  2020 is a unique year; in that, Tennesseans are spending more time outside working in their yards, walking and exercising due to the quarantine and social distancing mandates.  Antihistamines are one of the most common OTC medications used

Aug 12, 2020: What Medications Should be Avoided with Peanut Allergies?

Poison Centers have the unique responsibility to provide appropriate recommendations when medications are accidently ingested. Recently a mother called the Poison Center, asking if her healthy 4-year-old son would be ok after accidentally ingesting one of her Prometrium.  The active ingredient in Prometrium is progesterone, which alone is not a problem.

June 1, 2020: Does COVID-19 Impact the Exposures Managed by the Tennessee Poison Center?

 The last few months revealed not only an increase in exposures  in the homes of Tennesseans, but included unique and uncommon exposures such as boiling disinfectants to sanitize the air, dermal exposures to concentrated cleaners or disinfectants, caustic concentrations of food grade hydrogen peroxide, and questions about the safe injection or ingestion of dis

May 19, 2020: What is the Toxicity of Azithromycin?

Azithromycin is a widely prescribed antibiotic of the macrolide class. It also is a semisynthetic derivative of erythromycin.  It has recently received more attention as a potential therapy for COVID-19.

May 6, 2020:When is Bleach Dangerous?

Most household bleaches are dilute hypochlorite 3-6 % solutions. Hypochlorite is an aqueous solution produced by mixing chlorine gas with water. Household bleach containing products are commonly used as laundry bleach, toilet bowl cleaners and bathroom cleaners.

April 13, 2020: Thoughts on COVID-19 Vaccine

A safe and effective vaccine for COVID 19 would be an excellent solution to the problem with this virus.  For many other highly infectious diseases such as measles, polio, and smallpox, vaccines have effectively prevented their global transmission. Vaccine development for coronaviruses is progressing.

March 13, 2020: Can One Make Hand Sanitizer?

As the coronavirus makes its way to Tennessee, hand sanitizers and disinfectants are flying off store shelves. With the increased use and shortage of these products, people panic and misuse disinfectants or try to make their own hand sanitizer with dangerous ingredients not intended for skin application. Online recipes for homemade hand sanitizer include bleach, powder or liquid disinfectants, vinegar, hydrogen peroxide, and concentrated essential oils.

Feb 3, 2020: When Does Ondansetron Prolong the QT Interval?

A common question we address in the Poison Center is if QT interval prolongation is a concern when ondansetron is administered. A 2012 safety announcement by the FDA  warned healthcare professionals that administration of ondansetron could cause QT prolongation and potentially Torsades de Pointes (TdP). This announcement was based on preliminary results from a clinical study regarding an intravenous 32mg single dose of ondansetron.

Nov 26, 2019: What Steps Does the FDA Recommend to Prevent Foodborne Illness?

Foodborne illness can occur at any time of the year, but the holiday season presents increased opportunities to be exposed to foodborne disease. Holiday parties, whether held at a restaurant or at home or offices as pot lucks, and family get togethers can expose people to food that has been improperly cooked, prepared, or stored.

Nov 19, 2019: Does the Recent Ranitidine (Zantac®) Recall Mean You Should Stop Taking Zantac®?

Vanderbilt University Medical Center (VUMC) is responding to a recent, widespread voluntary recall of certain ranitidine (Zantac®) oral tablets, capsules and solution from various manufacturers.  The recall is due to trace contamination with a probable human carcinogen.  The FDA has performed a full assessment of the contamination in multiple ranitidine products and has concluded the risk

May 1, 2019: What is Epidiolex®?

  Epidiolex is the first FDA approved medication consisting of highly purified, plant based, pharmaceutical grade cannabidiol (CBD) extract.

April 18, 2019: What should you do if someone is bitten by a North American pit viper?

Warm weather has arrived in Tennessee which means snakebite season is upon us. The venomous snakes native to our region are the pit vipers and consist of copperheads (Agkistrodon contortrix), cottonmouths / water moccasins (Agkistrodon piscivorus), and various species of rattlesnakes (genera Crotalus and Sistrurus). Their bites are rarely life-threatening but may require treatment with antivenin.  

April 1, 2019: What is PRIS, what are markers of severity, and how is the syndrome treated?

Propofol is one of the most commonly used intravenous anesthetic agents used in ICU and OR settings. Propofol infusion syndrome (PRIS) is a term that describes a rare clinical syndrome that was first described in the 1990s through case reports where patients suffered cardiovascular collapse in the setting of prolonged and high-dose propofol infusions.

March 27, 2019: Why do we give glucagon in beta blocker overdose?

Beta blockers competitively inhibit myocardial β1 receptors. These receptors normally act through a second messenger system (Gs proteins*) to activate adenyl cyclase (AC) and increase cyclic AMP (cAMP), which results in the influx of intracellular calcium through L-type calcium channels. β1-receptor antagonism results in decreased calcium entry and, subsequently, decreased inotropy and chronotropy. 

Dec 3, 2018: Bits and Pieces

Thanks to all who helped with updating our distribution lists.  It has been a long haul but I think it is finally completed.

Oct 2, 2018: What should you do about bradycardia following overdoses??

I recently received a call from a health care provider regarding a beta blocker overdose.  The patient had a reasonable blood pressure but was bradycardic.  (It is not unusual to get calls regarding overdoses that cause bradycardia i.e., beta blockers, clonidine, calcium channel blockers, and organophosphates.

Aug 23, 2018: What is Palytoxin?

Biotoxins are not common exposures, but if you love aquariums, this toxin could be in your home! Palytoxin is one of the most potent biotoxins reported, posing a risk to patients via ingestion, inhalation, dermal, and even ocular routes.

June 12, 2018: Can consumption of home-brewed poppy tea be lethal?

This question was prompted by the death of Stephen Hacala and recent comments from Arkansas Senator Tom Cotton to Congress about the regulation of unwashed poppy seeds. Hacala, a 24 year-old Arkansas man, was found dead in his apartment on April 3rd 2016 with no obvious cause.

April 16, 2018: What diagnosis should you consider when you see a patient with unexplained Vitamin K dependent coagulopathy?

Answer-adulterated synthetic cannabinoid.  There is a widespread outbreak of synthetic cannabinoid tainted with brodiafacoum, a long-acting anticoagulant.  Why this is occurring is unknown.  Illinois has had the greatest number of cases, and although the initial number of cases were in the Midwest, now multiple cases have been reported from multiple states.

April 9, 2018: How Can You Dispose of Unused/Expired Medications?

Poisoning continues to be the leading cause of injury death in Tennessee. In 2017, 60% of the exposure calls to Tennessee Poison Center were for pharmaceuticals. Too often, unused prescription drugs find their way into the wrong hands. Pharmaceutical drugs can be just as dangerous as street drugs when taken without a prescription or a doctor’s supervision. That can be dangerous and often tragic.  

March 26, 2018: Does naloxone reverse clonidine toxicity?

The issue of administering hi-dose naloxone to pediatric patients has caused more anxiety than you can imagine.  I have had many calls from physicians when the Poison Center recommends administering 10 mg naloxone IVP  to children.  Pharmacists have refused to fill the order, nurses have refused to administer it, and I have even received a  call from a Chief of Staff regarding our recommendations.  This is not a mg/kg dose/response issue.

March 6, 2018: What can the DEA tell you about changing patterns in use/trafficking of Drugs of Abuse?

Last week I attended the Midyear Meeting for Poison Centers, a meeting that addresses primarily issues of funding/evaluation/functioning of the poison center.  Two DEA agents gave an update on current Drug of Abuse use/trafficking, I’m sharing my notes with you.  I thought some of the new patterns, as well as the reason for them, was quite interesting.  ds •    Much of the fentanyl is coming from China and Mexico.  It is then combined with heroin in a pill press.  The resultant tablet resembles oxycodone 30 mg tabs, but is much cheaper than actual oxycodone. 

March 12, 2018: Who Am I and How Did I die?

  Indications for Crofab include: systemic symptoms, coagulopathy , and progression of swelling.  Most of the snakes in our state cause swelling as opposed to coagulopathy or systemic symptoms (although of course some do).  First aid includes elevation of extremity.  Progression of swelling means that swelling is progressing and the distal part of the extremity is not decreasing in size, as would occur with gravity, i.e. the swelling decreases distally and increases proximally (which is what you want).  Call the TN Poison Center to discuss indications for Crofab.  ds

Feb 19, 2018: What is the Tide Pod Challenge?

We have had many requests for information about tide pods.  There are two age groups that are exposed-the toddlers and the teenagers.  Unfortunately, bad things can happen to either group.  ds

Feb 12, 2018: Why is Tennessee Poison Center Celebrating?

On February 25, 1988, Vanderbilt University Medical Center (VUMC) established Middle Tennessee Poison Center (MTPC) in response to the community’s need for a comprehensive poison resource center. VUMC provided essential support to establish a poison center that would provide services for the pubic and healthcare professionals in Nashville and 43 surrounding counties. That first year, MTPC provided service to 11,649 hotline callers.

Jan 10, 2018: Does Biotin Interfere with Lab Tests?

  Thanks for all the comments about Propofol . The question of anticonvulsant activity is much misunderstood.  Just remember that it is dose-dependent and that at many of the doses used for sedation, there is not anticonvulsant activity.   According to a recent JAMA article, ingesting 10 mg/d of biotin for 1 week was associated with potentially clinically important assay interference in some but not all biotinylated assays studied. 

Jan 3, 2018: Does propofol have anticonvulsant properties?

  Propofol is an intravenous short-acting hypnotic medication with FDA indications for the induction and maintenance of general anesthesia, monitored anesthesia care, ICU sedation for intubated adults, and procedural sedation. Most recently, propofol is being used off-label as an adjunct in the treatment of refractory status epilepticus. However, anticonvulsant doses are typically much higher than sedation requirements and are comparable to that for the induction/maintenance of general anesthesia.

Nov 13, 2017: How do toxicokinetics determine lithium toxicity and its treatment?

Lithium is a very unique drug. Prescriptions are increasing since SSRIs haven’t done as well as hoped with bipolar disorder. As prescriptions increase, lithium overdose and toxicity also increases. Understanding toxicokinetics is the key to developing a treatment strategy in a patient with lithium toxicity.  Formulation of lithium plays a part in determining length of time to complete absorption.  Lithium carbonate has limited aqueous solubility and large ingestions can cause concretion in the GI tract and GI absorption can be prolonged.  

Oct 26, 2017: Can a Kit predict Potential for Opiate Addiction?

A new spin on opiate addiction. ds PAINWeek celebrated their 11th conference in Las Vegas at the beginning of September. This conference allows pain providers to get together and discuss the best practice and new options for pain patients. I had the great opportunity to attend this year as the itinerary offered educational sessions on the opioid crisis, ketamine as an adjuvant for pain, as well as an informational naloxone course where providers were encouraged to co-prescribe it with all their opioid prescriptions.

Sept 18, 201: What is the Role of ketamine in Major Depressive Disorder?

A full page ad in the Sunday New York Times promoting IV ketamine for the treatment of depression made me ponder the mechanism of action and actual clinical practice.  So when Jose Vigo (AKA “Beto”), a Fellow in Psychosomatic Medicine, rotated with us, I asked him to educate all of us about this relatively new modality.  See what you think…  ds  

Aug 21, 2017: August 21, 2017 Why Does The Tennessee Poison Control Center Seldom Recommend GI Decontamination?

Recommendations regarding GI decontamination are not consistent between Poison Centers.  With a new academic year, it is always good to review the basis for the recommendations of the TN Poison Center.  Although single dose activated charcoal used to be administered in 70% of ingestions, the national data demonstrates that it is now administered in less than 10% of ingestions. Administration has markedly decreased due to understanding of the significant morbidity from charcoal aspiration. ds 

July 24, 2017: What protection is required by Emergency Responders when exposed to fentanyl?

There has been a lot in the news lately about this-both information and misinformation (otherwise known as fake news).  Below is a joint position statement from the American Academy of Clinical Toxicology and the American College of Medical Toxicology.   I am interested in any questions you would like answered in the Question of the Week.  Please email me with any suggestion at

Aug 14, 2017: How many visits to the Emergency Department does Tennessee Poison Center prevent (and how much money does that save)?

A call survey was completed of persons who called Tennessee Poison Center (TPC) in April 2017 and received treatment advice to manage the poisoning at home.  The callers answered several questions including, “Would you have gone to the ED if Tennessee Poison Center had not been available?” 52% of the callers who agreed to answer the survey replied that they would have gone to the ED if the poison center were not available. It was determined from the survey that 42% of the calls that would go to the ED receive state medical assistance or are uninsured. 

July 17, 2017: What is the toxicity of fentanyl analogs?

Fentanyl and fentanyl-analogs are powerful synthetic opioids that pose an increasing public health threat. From 2012 through 2014, the number of reported deaths involving fentanyl more than doubled (from 2628 to 5544), and it is estimated that 41% of the 7100 heroin-related deaths during that period involved fentanyl. The increasing use of fentanyl reflects the drug’s potency (50-100 times more than morphine) and cheap production costs. Heroin costs approximately $65,000 per kilogram, while illicitly manufactured fentanyl is available at $3,500 per kilogram.

June 13, 2017: How does glucagon ameliorate the hypotension caused by beta-blocker toxicity?

Glucagon is a hormone secreted from pancreatic alpha cells. It has inotropic and chronotropic cardiac effects. When the beta receptor is stimulated, cAMP is increased and calcium influx (via L-type calcium channels) also increases. When the beta receptor is blocked, glucagon stimulates the same subcellular protein to increase cAMP production and increase calcium influx. Glucagon administration is indicated for hypotension, bradycardia or conduction impairment. It may also be effective in treating hypotension in calcium channel blocker and other overdoses with cardiac toxicity.

May 16, 2017: What is Tianeptine?

A few weeks ago, I came across a drug of which I was not aware. A hospital called regarding a patient who overdosed on “tianeptine”. The patient presented with lethargy and hypotension, and the ER staff requested information on the drug and treatment recommendations.  

May 8, 2017: Hazards lurking in your garage?

  When warm weather arrives. It’s time for the great outdoors. We are busy with spring cleaning and working in the yard. The garage is a resting place for many toxins and chemicals. 

March 30, 2017: Why is trisodium phosphate in my cereal and is it dangerous to my health?

Recently, the Tennessee Poison Center has received numerous calls from the public about why their popular brand of cereal (e.g. Cinnamon Toast Crunch) contains a poisonous chemical called trisodium phosphate. Callers had read on the internet or heard by word of mouth that trisodium phosphate is a highly toxic industrial strength cleaner, and they were worried about their children eating it.  

April 10, 2017: Why Would Antiretroviral Drugs Be Abused?

     Over the last five years, antiretroviral (ARV) medications have gained popularity as recreational drugs. This misuse began in South Africa, which has the largest HIV/AIDS population in the world. Unfortunately, the abuse of this product has reached the United States (US) with reported use in Florida.

Jan31, 2017: What should I know about exposure to e-cigarettes?

E-cigarette use is increasing in both middle and high school students, according to the CDC. Up to 13% of high school students now report using e-cigarettes in the past 30 days, and increases in e-cigarette advertising is associated with increasing use in youth in the United States.  

Jan 3, 2017: How much nutmeg should you add to your eggnog to treat the post-holiday blues?

Nutmeg is one of the two spices derived from the dried seeds of the evergreen tree Myristica fragrans, which is indigenous to the Spice Islands of Indonesia but is now widely cultivated across the tropics and South America. Since medieval times, it has been used as a stimulant, carminative (relieves flatulence), emmenagogue (induces menstruation), and abortifacient.

Dec 16, 2016: What are the dangers of button batteries?

In 2014, approximately 3,500 adults and children across the United States reported an exposure with button batteries to state poison centers. Button batteries are found in many products including toys, greeting cards, watches, hearing aids, games, and flashing jewelry – all products in the average American household during the holidays.

Oct 18, 2016: What’s new in the toxicology lab?

The toxicology section of Vanderbilt University Medical Center’s Diagnostic Laboratories serves patients treated at VUH, VCH, One Hundred Oaks, and a variety of other clinics in the Middle Tennessee region.  Our specialized test menu includes confirmations for a variety of common drugs of abuse, analysis of toxic alcohols including ethylene glycol, and general unknown

Aug 30, 2016: School Is In Session: Can Plants Be a Problem?

Children are very curious about the world surrounding them and tend to be “oral explorers”. This could be a concern for children starting daycare or preschool. Plants are a most commonly a choking hazard, sometimes causing nausea and vomiting, or mild oral and throat irritation.

Aug 23, 2016: Where did I put that economy sized bottle of diphenhydramine?

Diphenhydramine is a commonly available over the counter medication. It is found in the majority of American households to treat a variety of ailments including seasonal allergies, anaphylaxis, and as a sleep aid. In an attempt to get high, adolescents (13 to 19 years of age) also abuse diphenhydramine.

May 17, 2016: What are the hidden hazards at a backyard BBQ?

May is National Barbecue month. The aroma of a steak sizzling on the grill tantalizes the taste buds. Perhaps it is chicken, vegetables or even grilled fruit. Add some side dishes, family and friends and let the good times roll.

April 26, 2016: What is Bromo-DragonFly?

Bromo-DragonFLY is a potent hallucinogen first synthesized in the late 1990s. It is an analogue of amphetamine and is related to the phenethylamine family of drugs. It is a Schedule I controlled substance in the United States.  

April 13, 2016: Are there any toxicity concerns with Spring plants?

Plants make for a beautiful Spring.  Many are considered poisonous.  However, the good news is that the majority of the time very little of the plant is ingested so there are usually very mild symptoms, if at all. Often with a child it is a choking hazard as they take a bite, don’t chew it well, and choke.

April 4, 2016: Are there innovative approaches to address prescription opiate use?

Prescription opiate use is now recognized as a national threat. However, a  police task force member told me that prescription opiates are decreasing in Nashville, and heroin use is on the rise as heroin is now easier (and cheaper) to obtain than prescription opiates. (probably due to a more functioning  CSMD (controlled substance monitoring database))

Jan 26, 2016: Do you DEWshine?

This past week, the poison center was involved in the care of 4 teenagers from Robertson County who drank Mountain Dew mixed with racing fuel (so called Dewshine). Racing fuel (used for drag racing) is almost 100% methanol.  There were two deaths.  

March 8, 2016: Do you know the seeds that kill?

Local and national media outlets recently reported a 22 year old died of complications after consuming an unknown amount of “pong seeds” purchased from Thailand via the internet.

Sept 1, 2015: Is female Viagra (flibanserin) efficacious?

(August 18, 2015)  After three applications and ownership by two drug manufacturers, the Food and Drug Administration (FDA) has approved flibanserin (brand name Addyi) for the treatment of acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women.

July 27, 2015: Are e-cigarettes still a concern?

The following is TN Poison Center data that was submitted to the FDA from Tennessee Department of Health.  There are two interesting facts.  The number of exposures has markedly increased-from 30 exposures in 2013 to 157 exposures in 2014 and potentially more in 2015.  However, the Poison Center kept most of these patients at home and prevented ED visits that were unnecessary and costly.   For dis

July 6, 2015: Why did evacuations occur when acrylonitrile caught fire?

On July 2 at 0100 EDT, the National Response Center reported a CSX train car was on fire.  A derailment was believed to have caused the fire.  The derailed car contained acrylonitrile.  Hazmat crews rushed to the scene and mandatory evacuations were initiated in Maryville TN.  The Red Cross set up a shelter at Heritage High School.  Physicia

June 8, 2015: Did you know Tea Tree Oil can cause life threats?

Tea Tree Oil (Melaleuca Oil) is a popular essential oil marketed and sold as a fungicidal and antiseptic.  It is available as 100% “pure oil” or in a diluted spray, cream, soap or similar preparation. Tea Tree Oil has gained popularity among its proponents who claim it can treat acne, warts, gingivitis, nail fungus, ear aches, thrush, eye and vaginal infections and asthma, to name a few.

May 18, 2015: What’s the important information to know about poison ivy, sumac and oak?

We find ourselves in the time of year where grass and flowers are growing, but so are those Toxicodendrons: poison ivy (Toxicodendron radicans), poison oak (Toxicodendron toxicarium, Toxicodendron diver-silobum), and poison sumac (Toxicodendron vernix).  In the United States, these are the cause for most common allergic reactions. Approximately 10-50 million Americans will develop and allergic rash after being exposed.

March 16, 2015: What exposures occur during refining?

Crude oil is a complex mix of hydrocarbons benzene, sulfur, nitrogen, chromium, toluene, and xylene. Crude oil is used to make fuel and other petroleum products.and is refined to produce gasoline.

March 9, 2015: What are the origins of oil?

Oil is a complicated mixture of different hydrocarbons. A hydrocarbon is a large organic molecule composed of hydrogen atoms attached to a backbone, or chain of carbon atoms.

Feb 2, 2015: Is RADON poisonous?

Recently I was interviewed by a television newscaster regarding radon because a couple had become concerned when they were told their dwelling contained a “high amount of radon”.  Everyone has questions about radon. 

Jan 26, 2015: What causes pediatric poisoning fatalities?

The 2013 National Poison Database System (NPDS) has just been released by the American Association of Poison Control Centers.  For the last four years, pediatric toxicologists have reviewed all fatal pediatric poisoning reported to poison centers nationwide.  This is what they reported:  

Oct 13, 2014: Why should we discuss the treatment of CCB overdose again?

Because there was such a huge response to the previous Question of the Week.  The following includes clarifications to some of the questions/comments and further elaboration on treatment.   Comments are based on the recommendations that one would obtain if you called the Tennessee Poison Center.

July 21, 2014: What can sting but cannot fly … yet?

“ … Out of the egg came a tiny and very hungry caterpillar … “   Eric Carle’s beloved children’s book depicts a colorful, sweet caterpillar. Fiction aside, beautiful and inviting does not always equal friendly.  

July 14, 2014: What is the life threat of Systemic Loxsoscelism?

We are familiar with the cutaneous lesions following brown recluse spider bite (BRSB). Central necrosis can occur although the bites usually heal very well if they are left alone.  No ointments, no debridement, no dapsone.  Ice works better than opiates for the pain. Hard for physicians to do nothing.  

July 1, 2014: How are minimum observation times determined?

The Tennessee Poison Control Center (TPC) receives approximately 45 new calls from healthcare professionals each day.  “How long do we need to watch the patient?” represents one universal question often asked by these healthcare providers.  So, how does the TPC devise its recommendations for minimum observation timeframes?  The recommendations stem from three main fac

May 19, 2014: How does one obliterate one’s insect enemies?

With the advent of good weather, our crawling “friends” come back in force, and our yearly battle begins again.   How do we deal with them?  Most commonly, in the home setting, we use three main categories of insecticides: pyrethrins, organophosphates and carbamates.  Used properly, these tend to work well and we go on normally with our live

April 14, 2014: Exposure to what toxin may have caused the deafness suffered by Ludwig Van Beethoven?

Recent analysis of Beethoven’s hair and bone indicates that he had lead poisoning.  A lock of his hair which was removed at the time of his death and stored in an airtight case was analyzed in 2000 by researchers in Illinois. Beethoven’s parietal skull bone was later analyzed in 2005. Both showed markedly elevated lead levels consistent with lead poisoning. The potential source for lead exposure may have been wine. At that time, lead was added illegally to inexpensive wine to improve the flavor.

March 31, 2014: What is Ebola?

Recent news has highlighted the first Ebola virus outbreak outside of Central Africa, in the West African country of Guinea.  The outbreak is occurring in the southeastern region of Guinea which borders Sierra Leone and Liberia.  Several cases have been reported including about 66 deaths which include 4 healthcare workers.

March 10, 2014: Does CO poisoning occur only during winter?

This Question of the Week was prepared by Bhavana C. Anand, MD, MPH, an occupational medicine resident from Meharry who is spending time with Dr. Benitez.  Please take a few minutes to complete the survey at the end of the question, as it is part of her toxicology project.

Feb 10, 2014: What is the clinical picture of Neuroleptic Malignant syndrome?

One of the consults that we receive is the question as to whether a patient has neuroleptic malignant syndrome (NMS).  I had a recent case where an adolescent female overdosed on a SSRI.  It led to a very informative discussion between the pediatric hospitalist and their pediatric resident team, psychiatry and toxicology.  I thought it might

Jan 14, 2014: West Virginia UPDATE

To clarify the event in West Virginia: the chemical release was UPSTREAM of the main water intake valve to the region’s water treatment plant.  Therefore, the regional water supply was contaminated. 

Sept 30, 2013: Why did the FDA require drug label changes for all fluoroquinolones?

Fluoroquinolones have become a very common antibiotic; approximately 23.1 million patients are prescribed oral fluoroquinolones (2011).  The most common fluoroquinolones dispensed are ciprofloxacin (70%), levofloxacin (28%), and moxifloxacin (9%); all others account for less than 1%.  Injectable fluoroquinolones were administered in the hosp

Aug 15, 2013: What is acetyl fentanyl?

In March-May of this year, Rhode Island had 14 overdose deaths that were related to a new injectable synthetic opioid.  All of these cases occurred in intravenous drug users who were located in the northern part of the state.  The RI Department of Health, working with the CDC, confirmed that the new synthetic opioid is acetyl fentanyl.  Ages of the victims ranged from 19-57 years old, ten of the fourteen were males. Analytical toxicology analysis showed other drugs in some of the victims.  Forty five percent of them died in the ED, with 36% dying in the home.

July 22, 2013: How toxic are pool chemicals?

What are pool chemicals?  Are they toxic?  To maintain commercial and private swimming pools, many chemicals are utilized to enhance and protect the water quality.  These chemicals minimize bacterial and algal growth, and maintain a pH to enhance disinfectant action while minimizing skin and eye irritation.  

July 15, 2013: Do hip prosthesis cause metal toxicity?

In 2010, Depuy, Johnson and Johnson recalled the metal-on-metal hip replacement system (articulating surfaces made of chrome cobalt steel with anatomically sized femoral head) because the five year failure rate of this product was approximately 13% which is unusually high.  The recall letter recommended that cobalt and chromium blood concent

May 13, 2013: What is the “Cinnamon Challenge”?

The Cinnamon Challenge is a popular dare to swallow a tablespoon of ground cinnamon in 60 seconds without drinking fluids.  It is almost impossible to do.  Just watch some of the videos where people attempt the cinnamon challenge on

May 6, 2013: What is the clinical picture of ricin poisoning?

The recent publicity of a ricin laced letters sent to Senator Wicker and President Obama demonstrates that as healthcare providers, we must be vigilant in considering biological agents while caring for our patients. Ricin is a toxin that is derived from Ricinus communis, which is the castor bean plant.

March 11, 2013: Why is poison prevention education important?

Poisoning is the 2nd leading cause of injury death in Tennessee, trailing only motor vehicle accidents and ahead of guns. Education is the key to poison prevention. Since 1962, the President of the United States has proclaimed the third week of March as National Poison Prevention Week to raise awareness about the dangers of poisoning. This year National Poison Prevention Week is March 17-23.  

Dec 3, 2012: What is the Toxicity of Common Holiday Hazards?

Holiday Plants Despite the common belief of toxicity, the Poinsettia is not a poisonous plant.  Poinsettia leaf ingestion should not cause any symptoms.  Playing with the leaves or rubbing the eyes after handling the plant may lead to local irritation.  Case reports of GI upset from Poinsettia ingestion generally involve animal cases or very large ingestions. 

Nov 12, 2012: What is the history behind the development of BAL?

The story behind British Anti-Lewisite (BAL) goes back to the time of World War I when there was the development of lewisite as a chemical warfare agent. Lewisite is a topical arsenical that comes as an oily, colorless liquid that has the odor of geraniums; however, it can be a vapor form as well.  Lewisite is classified as a vesicant or blistering agent.

Oct 29, 2012: Is there an outpatient medical toxicology clinic?

Yes there is!  The medical toxicology clinic is located at The Vanderbilt Clinic, Medical Specialties Section on the 2nd floor.  It is staffed by board certified physician medical toxicologists.  Some patients are referred for follow up from a recent hospitalization or from an ED visit.  Many patients are referred by primary care

July 23, 2012: What is “ozone”?

This summer we have experienced high ozone levels throughout Tennessee.  The Figure shows the high ozone levels that reached part of mid-Tennessee during ONE day this past month.  

May 21, 2012: Why should you be concerned about concentrated laundry detergent packets?

This is a press release from AAPCC.  Tennessee Poison Center has not received any calls about the packets.  Please be aware and call the Poison Center with any questions.   NEWS RELEASE For Immediate Release May 17, 2012                                                   For More Information, Contact: Loreeta Canton, communications manager or 703-894-1863                                                                                    

April 9, 2012: What is Radon and why does it matter to human health?

Radon (222Rn) is an element, formed as the sixth element in the radiation decay sequence of uranium (238U).  It is odorless, colorless and radioactive.  Radon itself is not toxic because of its chemical or radiological characteristics!  So why worry?  Radon continues to decay into several progeny, frequently called “dau

April 2, 2012:Why is Tennessee the state with the most pain meds prescribed per capita?

States with a high number of pain clinics have more diversion than states with fewer pain clinics.  Pain clinics can easily become pill mills containing dispensing doctors.  Tennessee has more than their share of Pain Clinics.  In fact, along the freeway, you can see a billboard stating “Pain Clinic next exit”.   But we can’t just get rid of the Pain Clinics as they h

March 26, 2012: Why are prescription drugs so available?

12,000 US residents die annually from unintended prescription drug overdose.  The US contains 4.6% of world population yet consumes 80% of the global hydrocodone supply.  The US rate of prescription drug use is 11.3 prescriptions per person.  In Tennessee, there are 17.3 prescriptions per person.  As this is an average, many persons have mor

Oct 17, 2011: Why would anyone want to lick a toad?

Well, it depends on which toad you are talking about. While the amphibians in the Tennessee area are probably more of a hazard to dogs (eating them), there is a toad that lives in the Sonoran desert called the Colorado River toad that has quite a reputation.

Oct 24, 2011: What is a hookah?

A hookah is an apparatus that was developed somewhere between India and Persia sometime in the 16th century.  It was developed as a way to heat tobacco and vaporize its’ constituents, filter the constituents through water, and then inhale the vapors.  It was thought that the water would purify the vapors from harmful substances an

Sept 12, 2011: Bath Salts Again ????

NEWS RELEASE For Immediate Release: Sept. 8, 2011                        For More Information, Contact:               Loreeta Canton, communications manager or 703-894-1863          Poison Control Centers Applaud DEA’s Ban of Bath Salts 

Aug 1, 2011:

It is summer and the snakes are quite active this season and are basking in the sun, just like we humans like to do.  In Tennessee there are four types of indigenous venomous snakes: the timber rattlesnake, the pygmy rattlesnake, the cottonmouth (also known as water moccasin, however this causes confusion as some people call any snake on or

Aug 8, 2011: Where is Djibouti and what does it have to do with bath salts?

Djibouti, an independent state in the Horn of Africa, is bordered by Eritea in the north, Ethiopia in the west and south, and Somalia in the southeast.  The remainder of the border is formed by the Red Sea and the Gulf of Aden.  Population is 818,159 of which 66% live in the capital city (also called Djibouti) and the remainder are nomadic h

June 13, 2011: TPC Summer Newsletter

Attached is the summer newsletter from the TN Poison Center.  Feel free to make copies and give it to your patients.  Have a great summer!   /poison-control/sites/default/files/TPC%20SUMMER%202011%20NEWSLETTER.pdf  

March 14, 2011: Are there any new issues with acetaminophen and prescription products?

On January 13, 2011, the FDA announced a rule change asking manufacturers to limit the amount of acetaminophen in prescription drug products to 325 mg per dosage unit (tablet, capsule, etc).  Currently, many prescription pain medications contain 500 mg of acetaminophen per dosage unit.  In addition, the FDA added a “black box warning” to the

Feb 7, 2011: How does pyridoxine work as the antidote for INH poisoning?

Isoniazid (INH) is used for the treatment of active and latent tuberculosis because of its interaction with mycobacterial enzymes; however, INH also creates a net deficiency of pyridoxine. INH and its metabolites bind to pyridoxine and pyridoxal 5’ phosphate (the activated form) and enhance their renal elimination.

Jan 10, 2011: Are we going to discuss CO exposure again?

Yes we are.  This topic was requested by one of our readers and this topic is important enough to discuss every year.  This exposure causes unrecognized morbidity and mortality and is one of the most litigated exposures. Never underestimate the impact of CO on your patient or you.    

Dec 6, 2010: What is the Toxicity of Common Holiday Hazards?

Holiday Plants Despite the common belief of toxicity, the Poinsettia is not a poisonous plant.  Poinsettia leaf ingestion should not cause any symptoms.  Playing with the leaves or rubbing the eyes after handling the plant may lead to local irritation.  Case reports of GI upset from Poinsettia ingestion generally involve animal cases or very large ingestions. 

Nov 22, 2010: Why is pralidoxime used for organophosphate poisonings?

Organophosphates are class of xenobiotics which are available as insecticides; however, certain organophosphates are considered chemical warfare agents.  “Nerve agents” are extremely potent organophosphates and examples include sarin, tabun, soman, and VX.  The mechanism of action of these compounds is the same.

Sept 20, 2010: What is the life threat of Systemic Loxsoscelism?

We are familiar with the cutaneous lesions following brown recluse spider bite (BRSB). Central necrosis can occur although the bites usually heal very well if they are left alone.  No ointments, no debridement, no dapsone.  Ice works better than opiates for the pain. Hard for physicians to do nothing.  

June 22, 2010: How do you avoid a “STARI, STARI” night?

With the time of year that brings delicate lightening bugs out at dusk, also brings one of my nemeses:  ticks. My many summers as a camp counselor had certain rituals associated with the usual daily activities of swimming, canoeing, archery, horseback riding, campfires, etc. Every night after showers, I lined up the kids to do the dreaded “tick check”.

May 24, 2010: Is nicotine solution toxic?

  Recently the TPC had a call about a child who ingested the contents of a bottle containing a nicotine refill solution for an electronic cigarette.  Electronic cigarettes use a tar-free, odorless, nicotine liquid which vaporizes during use.  The solution may contain a high, medium, low or non-nicotine content.  Several flavors are available for users.  Each “cigarette” has a lithium battery, a charger and an atomizer.  So is this toxic?

May 10, 2010: Are there any “PiHKALs” in Tennessee?

Absolutely.  PiHKAL stands for “phenylethylamines I have known and loved” with the most readily recognized PiHKAL being 3-4 methylenedioxy-n-methylamphetamine, better known as ecstasy.  This classification includes any compound whose primary structure has a phenylethylamine skeleton, which is the basic structure for most amphetamine derivatives.  This skeleton is modi

March 1, 2010: What is “parachuting” and what does it have to do with drug abuse?

“Parachuting” is a term that is used to describe the technique of crushing up a pill, placing the crumbs into a tissue, wrapping this into a “parachute”, and then swallowing the tissue wrapped crushed drug. The intent is to increase the immediate absorption of the drug by increasing its surface area. The purpose of “parachuting” is a faster onset, higher intensity effect of the xenobiotic.

Feb 15, 2010: What is HIE therapy?

HIE or Hyperinsulinemia-Euglycemia therapy is a relatively novel way of treating cases of severe calcium channel blocker (CCB) poisoning.  HIE is variously known as HIET (hyperinsulinemia-euglycemia therapy), HDIT (high dose insulin therapy), and occasionally other acronyms.  

Dec 8, 2009: What is the Toxicity of Common Holiday Hazards?

Holiday Plants Despite the common belief of toxicity, the Poinsettia is not a poisonous plant.  Poinsettia leaf ingestion should not cause any symptoms.  Playing with the leaves or rubbing the eyes after handling the plant may lead to local irritation.  Case reports of GI upset from Poinsettia ingestion generally involve animal cases or very large ingestions. 

Sept 21, 2009: What are the current indications for H1N1 vaccination?

It is flu season. The EDs are seeing many patients with the flu and many patients who are concerned that they have the flu.  Therefore the Tennessee Poison Center is partnering with the Department of Health to provide a free Flu Information Line between the hours of 11 am and 7 pm.  The number is 1-877-252-3432.  Hopefully we can answer questions and prevent unnecessary ED visits.   Donna Seger

Aug 10, 2009: Are garter snakes venomous?

Garter snakes belong to the Colubridae family of snakes which is one of the largest families of snakes. Garter snakes (Thamnophis sp.) actually are venomous—but you really have to work at it to become envenomated. Published case reports of envenomation involve prolonged bites (e.g.

Aug 3, 2009: How toxic are pool chemicals?

What are pool chemicals?  Are they toxic?  To maintain commercial and private swimming pools, many chemicals are utilized to enhance and protect the water quality.  These chemicals minimize bacterial and algal growth, and maintain a pH to enhance disinfectant action while minimizing skin and eye irritation.  

May 18, 2009: Where can healthcare professionals learn to manage HAZMAT situations?

Situations such as acts of terrorism, industrial accidents, or chemical spills on the country's interstate or railroad systems, may cause life-threatening hazmat exposures.  Pre-hospital medical care providers and hospital staff must rapidly recognize the symptoms of toxic exposure and immediately provide appropriate treatment.  At the Tennessee Poison Center (TPC) we are frequently contac

April 28, 2009: What are some pitfalls with Tylenol® and Toddlers?

Acetaminophen is commonly used as an antipyretic and pain reliever in young children and overall is quite safe considering the amount used by families for their children every day. Unfortunately, on occasion a therapeutic misadventure occurs and a young child develops severe acetaminophen induced liver injury.

April 21, 2009: How toxic are fertilizers?

Planting season is upon us and therefore many homeowners are purchasing and using fertilizers.  Household fertilizers typically contain nitrogen, phosphoric acid (phosphorus) and potash (potassium).  Frequently, fertilizers are described by the initials NPK, which represent the content of nitrogen, phosphorus and potassium respectively or may be described by a set of 3 numbers, i.e. 10-5-4, which represent the percentages of NPK by weight.  

March 24, 2009: Why is agranulocytosis occurring in cocaine users?

The New Mexico Department of Health (NMDOH) has issued a health alert regarding a cluster of patients who presented with agranulocytosis over the past 15 months and had cocaine use in common. Most of the cases are in New Mexico, but there also have been cases  in Arizona and in Colorado. NMDOH believes that levamisole, an antimetabolic drug used in veterinary practice as a de-worming agent, may have contaminated the cocaine.

March 9, 2009: What products in the home contain ethanol?

Do you know what products contain alcohol (ethanol) in your home?  Many products used on a daily basis contain ethanol as part of their normal constituents.  Increasing patient awareness of these products educates and prevents accidental poisoning.  Normally we think of beer, wine, whiskey and other “drinking” alcohol as containing ethanol.  Typical ethanol concentrations in these products are 4-6% for beer, 10-20% wine, and “hard liquors” 20-50%.  

March 2, 2009: Ahhh, Spring is in the air . . . Any toxicities with the bulbs?

Narcissus species contain lycorine and other related alkaloids. Most of the poisonings related to narcissus are from ingesting the bulbs that were mistaken for onions. Ingestion of bulbs may lead to abdominal cramping, nausea, vomiting, and diarrhea. The gastroenteritis resolves within a few hours.  Interestingly, one of the alkaloids that daffodils contain is galanthamine with is a competitive reversible acetylcholinesterase inhibitor.

Feb 16, 2009: Who suffers delayed Neuropsychiatric Sequelae following Carbon Monoxide Exposure?

Tough Question.  In the 1980s it was assumed that CO bound to the hemoglobin molecule and created a functional anemia.  Once the CO was gone, everything was fine as long as anoxia hadn’t occurred during the time the CO was attached to hgb.  However, in Korea, where homes were frequently heated with charcoal briquettes under the slats of the floor, there were over 2000 admissions/year for CO poisoning.  A simple telephone survey calling the patients that had been discharged with the diagnosis of CO poiso

Feb 9, 2009: How do you know which CO detector to buy?

There are 3 types of carbon monoxide detection sensors:  biomimetic, semiconductor, and electrochemical.   Biomimetic sensors use color change in the presence of the gas for detection.   Semiconductors measure change in resistance in a silicon chip when the gas is present.   Electrochemical sensors send an electronic signal when a chemical reaction occurs in the presence of carbon monoxide.  

Jan 26, 2009: TVA Roane County Fly Ash Disaster – What happened and what it means?

The TVA Kingston Fossil Plant produces fly ash as a result of burning coal to create electricity. Fly ash is the leftover ash from the power generating plant.  In order to reduce air pollution, the air being released through the smokestacks is “scrubbed” to capture the fly ash waste.  This is “wetted” (mixed with water) and then kept in retention ponds on site. Due to heavy rains, one of the dikes containing an 80 acre pond with fly ash sludge  broke on December 22, 2008 just before 1 am.  This ash-slide covered an estimated area of 250-400 acres and was up to 4-6 feet deep.  

Jan 5, 2009: Is anything new in GI decontamination?

Although GI decontamination has been considered a mainstay of treating poisoned patients, there is no evidence that GI decontamination procedures change outcome.  Aggressive GI decontamination procedures are a product of this country-in Europe, toxicologists seldom recommend GI decontamination. The recommendations of the TN Poison Center are based on available literature and clinical experience.  

May 18, 2007: What are the clinical aspects of Cyanide Poisoning?

  In the last Question, I addressed the new antidote for cyanide poisoning, hydroxycobalamin.  This question addresses the clinical aspects of this poisoning.   Cyanide is toxic via all routes of exposure (ingestion, inhalation, and dermal).

March 30, 2007: Why the Agony about Ecstasy?

One percent of the population uses Ecstasy once a month. Twenty four percent of college students use this drug regularly. The majority of 16 year-olds believes Ecstasy (Adam, XTC, M&M, E) use is “safe”. 


  Last year, more than 127,000 Tennesseans called Tennessee Poison Center for help in a poison emergency or for information regarding poisons. As you are aware, children are the most likely victims of accidental poisoning. The lack of safety latches on cabinets, the careless handling of prescription or over-the-counter drugs, and the natural curiosity of children are only some of the conditions that contributed to these accidental poisonings.

May 22, 2006: Is DEET safe and effective?

Application of DEET has been recommended to prevent bites from insects/ticks that can cause West Nile Virus or Lyme disease. DEET (N,N-diethyl-m-toluamide) is the most effective of insect repellents. Non-DEET repellants do not demonstrate appropriate protection against insect bites. An estimated 29% of American children are exposed to DEET.

March 6, 2006: What is the initial evaluation of children living in homes with methamphetamine labs?

  Recently, there has been media attention regarding the medical community’s evaluation of children living in homes where there is a methamphetamine lab. The medical community is being asked to assess the child that has been found in such a house. Multiple protocols have been proposed, based on little research data.  Protocols range from “do nothing” to “do everything,” including CT scans, drug analysis, etc. 

Nov 10, 2005: What is the antidote for dabigatran-induced bleeding?

  On October 16, the Food and Drug Administration (FDA) granted a special accelerated approval to Praxbind (idarucizumab). Praxbind is indicated for patients treated with Pradaxa (dabigatran etexilate) when reversal of the anticoagulant effects are needed for life-threatening or uncontrolled bleeding.  

Nov 7, 2005: What is the toxicity and treatment of ethylene glycol? Part II

Last week we discussed the physiology of ethylene glycol poisoning.  Treatment is based on understanding that physiology. Treatment The goal of antidotal therapy is to prevent the metabolism of ethylene glycol to its toxic metabolites.  This is done by blocking the enzyme alcohol dehydrogenase. The parent compound (ethylene glycol) is then slowly excreted via the kidneys. 

Oct 26, 2005: What is the toxicity and treatment of ethylene glycol?

One of our readers has asked to have this question addressed.  It is a good subject as the treatment is based on an understanding of the toxicity and the laboratory results. Ethylene glycol ingestion occurs more frequently in TN than in most other states.  I will address it in two parts. Part I Ethylene glycol is a colorless, odorless liquid found in antifreeze. Absorption Once ethylene glycol is ingested, it is rapidly absorbed with peak concentrations occurring one to four hours after ingestion. 

Oct 3, 2005: What is the Stability of Refrigerated Medications at Room Temperature ?

Several common medications have labels instructing consumers to store them in the refrigerator.  Following catastrophic events, such as Hurricanes Ivan last year and Katrina this year, numerous people were left without power for an extended amount of time. News journalists reported diabetics not taking their insulin due to lack of refrigeration. Non-compliance with medications such as insulin is a significant health risk.

Aug 15, 2005: Last Thoughts on Acetaminophen

The indications for NAC in the acute acetaminophen (APAP) OD and chronic supratherapeutic ingestion have been discussed.  IV NAC is also indicated for the treatment of APAP-induced hepatic failure as defined by pH<7.30, PT>100s, Cr>3.4.  In this setting, NAC acts as an antioxidant and free radical scavenger, increases liver blood flow and has other possible actions.  A retrospective study and small unblinded controlled prospective study demonstrated IV NAC reduced mortality in APAP-induced hepatic failure.1,2  A large randomized controlled trial has not been performed.

Aug 1, 2005: What special considerations alter your approach to acetaminophen (APAP) toxicity?

In acute single-time overdose, the approach to APAP toxicity must be altered if the patient is taking a cytochrome P-450  inducer (such as certain anticonvulsants, ethanol, some AIDs drugs)  or if the patient is nutritionally deplete (AIDS, Cancer).  The Rummack-Mathew nomogram should be cut in half in these cases.  For example, rather than administering NAC to a patient with a 4-hour APAP concentration of 140 mg/mL, NAC should be administered if the 4-hour APAP concentration is 70 mg/mL. (The Poison Center can help you determine if drugs are cytochrome inducers.) 

July 25, 2005: IV NAC Protocol (Prescott Protocol)

The FDA has approved the administration of IV NAC (mucomyst). Loading Dose:  NAC 150mg/kg in D5W 200cc                            Infuse over one hour Followed by Continuous Infusion #1:                             NAC 50mg/kg in D5W 500cc                            Infuse over 4 hours Followed by Continuous Infusion #2:                             NAC 100mg/kg in D5W 1000cc                             Infuse over 16 hours Acetadote is the only FDA-approved formulation currently available for intravenous administration.

July 25, 2005: What are the indications for administering the IV preparation of N-acetylcysteine (Acetadote) in Acetaminophen toxicity?

The intravenous preparation of N-acetylcysteine (N-ac) that is now FDA approved changes the length of time a patient is required to remain in the hospital for acetaminophen (APAP) toxicity. The approach to this exposure is the same as when we were administering the oral formulation.  One obtains serum concentrations 4 -16 hours after the exposure.  If the concentration falls above the Rumack-Mathew treatment line on the nomogram, the patient should undergo therapy with N-ac.

July 5, 2005: Is there new evidence of Adderall toxicity?

Health Canada suspended the sales of Adderall XR based on 12 post-marketing cases reported to MedWatch from 1999 to 2003.  After the FDA reviewed the 12 cases, they did not feel that there needed to be an immediate change to the product labeling or approved use of the drug.  They did not find a cause and effect relationship between Adderall use and sudden death.  Shire recently applied for approval of Adderall in adult ADHD and the company had to s

April 18, 2005: Is the administration of promethazine (Phenergan®) in pediatric patients less than 2 years of age dangerous?

Wyeth has added a black box warning regarding the use of promethazine (Phenergan®) tablets and suppositories in pediatric patients less than two years of age.  The reason give is the potential for fatal respiratory depression.  The use of promethazine in children less than two is also listed in the Contraindications section of the package insert.  According to the company, there was not a recent increase in the number of cases of fatal respiratory depression that prom


Last year, more than 30,000 children in Tennessee were harmed by poisonous substances found in their own homes. The lack of safety latches on cabinets, the careless handling of prescription or over-the-counter drugs, and the natural curiosity of children are only some of the conditions that contributed to these accidental poisonings.  


Josephine Darwin, Director of Community Outreach for Tennessee Poison Center, recently attended a statewide meeting of health professionals, law enforcement officials and community volunteers to discuss the widespread abuse of inhalants among Tennessee youth.   Tennessee ranks 7th in the United States for inhalant abuse, according to CDC data.

Feb 21, 2005: Has the Tennessee Poison Center’s Call Volume changed since becoming the only statewide Poison Center?

Background: Prior to February 2004, the Southern Poison Center in Memphis provided poison control coverage for west Tennessee and part of east Tennessee from 7am-11pm. Upon their closure on January 30, 2004, the Middle Tennessee Poison Center began providing service to the entire state 24 hours/day, 7 days/week based on an agreement with the Tennessee Department of Public Health.

Jan 24, 2005: What is the toxicity of Lindane?

A recent case report suggests the association of neurotoxicity from repeated application of lindane (Kwell) in a 10-month old infant with anemia and hypoproteinemia. Although toxicity from a single application is unusual, repeated applications or accidental ingestion can result in neurotoxicity.    Lindane (gamma benzene hexachloride), a scabicide, is a chlorinated hydrocarbon insecticide. The organochlorine insecticides are well absorbed from the skin, GI track and lungs.  They are distributed into fat where they can accumulate. 

Jan 10, 2005: What is the New Warning for Strattera?

Strattera (atomoxetine HCl) is a selective norepinephrine reuptake inhibitor that is FDA-approved for the treatment of Attention-Deficit/Hyperactivity Disorder (ADHD). Mechanism of action is thought to be related to selective inhibition of the pre-synaptic norepinephrine transporter.

Nov 22, 2004: What is the toxicity of Strattera®?

Strattera® (atomoxetine)is a highly selective norepinephrine reuptake inhibitor. Its current approved indication is for the treatment of attention deficit/hyperactivity disorder (ADHD), but it is being used investigationally in the treatment of depression.  

Nov 1, 2004: What is the risk of Atrovent® use in patients with peanut allergies?

Response:    Atrovent® (ipratropium) inhalation aerosol is an anticholinergic bronchodilator indicated for the treatment of bronchospasm associated with COPD.  The inhalation aerosol, not the nebulizing solution, contains soya lecithin as a suspending agent.  Thus, the medication is contraindicated in patients with a history of hypersensitivity reactions to soya lecithin and related food products, which includes peanuts.  Due to this warning, patients with documented allergies to soy and peanut products have been excluded from clinical trials evaluating Atrovent®.

Oct 18, 2004: What medications should be avoided in patients with peanut allergies?

Response:    Recent epidemiologic studies suggest that nearly 4% of Americans are afflicted with food allergies, a prevalence much higher than appreciated in the past. It is estimated that peanut allergies account for 28-55% of all food allergies.  In addition, the prevalence of peanut allergy was found to have doubled in American children less than 5 years of age in the past 5 years.

Oct 4, 2004: What herbs are used for performance enhancement in sports?

Tribulus terrestris is an annual herb that is most common in subtropical areas, but grows worldwide.  It is administered to treat sexual impotency, abdominal distension, and cardiovascular disease in India, Chile, and Bulgaria. It is one of the growing number of herbs used in the US to enhance physical performance.

Sept 20, 2004: Did the 2004 Institute of Medicine (IOM) report regarding the possible association between thimerosal-exposure and autism produce any new findings?

Until 1999, Thimerosal (ethylmercury) was present in over 30 vaccines. The 2001 IOM study on Thimerosal and neurodevelopmental disorders stated that the evidence is inadequate to accept or reject a causal relationship.  Case reports were uninformative with respect to causality, there were no published epidemiological studies, and unpublished studies provided weak and inconclusive evidence.  The public health response was to discard thimerosal vaccines on the shelf and remove thimerosal from other vaccines.  Thimerosal was removed from all recommended vaccines by March 2001.

July 19, 2004: Does the treatment of ADHD with stimulants contribute to subsequent Drug Use/Abuse?

Treatment of Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) with stimulants has been and is a hot bed of controversy.  Stimulant administration for this disorder has markedly increased in the last 10 years. Children with ADD or ADHD are at risk for learning disabilities and educational failure, impaired social relationships and various psychiatric disorders. PET scans have demonstrated abnormalities in children with this disorder.

July 12, 2004: Is DEET safe and effective?

Application of DEET has been recommended to prevent bites from insects/ticks that can cause West Nile Virus or Lyme disease. DEET (N,N-diethyl-m-toluamide) is the most effective of insect repellents.  Non-DEET repellants do not demonstrate appropriate protection against insect bites.  An estimated 29% of American children are exposed to DEET.  The concern has been caused by case reports associating use in children with precipitation of seizures.

June 8, 2004: What are the conclusions of the Institute of Medicine Study?

The Institute of Medicine (IOM) was asked by the Maternal and Child Health Bureau to assist in developing a systematic approach to stabilizing poison prevention and control services.  This report had a significant impact as financial recommendations as well as recommendations for the number of poison centers were included in it.  At one point, a single large center serving the entire country had been considered.  Fortunately the committee did not recommend a single large center.   The recommendations are as follows:  (My comments are in parenthesis)

March 22, 2004: How much tuna is safe for pregnant women, nursing mothers, and young children?

The FDA has just released an Advisory recommending that women planning to become pregnant, pregnant women, nursing mothers, and young children may eat up to 12 ounces a week of a variety of fish and shell fish low in mercury.  This group should not eat shark swordfish, King Mackerel or Tilefish, and not more than 6 ounces of albacore tuna per week.  The reason is the concern about methymercury.


Last year, more than 30,000 children in Tennessee were harmed by poisonous substances found in their own homes. The lack of safety latches on cabinets, the careless handling of prescription or over-the-counter drugs, and the natural curiosity of children are only some of the conditions that contributed to these accidental poisonings. The third week of March (21st - 27th) is the forty-third observance of National Poison Prevention Week. This is a time when communities should call attention to the steps we can take to prevent accidental poisonings. 

Feb 9, 2004: What were the concerns with the recent Ricin discovery?

Recently, ricin was discovered in a senate office and this country became concerned with potential exposure. Fear occurred as information about ricin was distributed.  Much of the information was erroneous.  Facts about ingestion of ricin and inhalation of ricin were confused. Ricin comes from castor beans.  Most of our experience with ricin comes from accidental ingestions of castor beans by toddlers.  One or two beans can be extremely toxic, however, the bean has to be masticated to release the ricin.  If the bean is swallowed whole, there should be no toxicity.  

Jan 19, 2004: What are the Date Rape Drugs? Part 2

GHB is an endogenous short-chain fatty acid that is a naturally occurring metabolite in many tissues. It induces both NREM and REM, anesthesia, hypothermia, and a trance-like state and has been considered a model for petit mal epilepsy.  GHB increases brain dopamine.  It is found in the CNS, kidney, heart, skeletal muscle and brown fat.

Jan 5, 2004: What are the Date Rape Drugs?

One in four women in the US will be raped in their lifetimes.  Almost 75% of all rapes are date or acquaintance rapes.  These numbers may be underreported due to victim’s intense feelings of guilt and the common belief that the victim was somehow responsible for the sexual assault.  Date rape is one of the most serious and complicates forms of rape secondary to controversial social issues. Rape drugs are used by perpetrators to induce sedation and amnesia prior to sexual assault. Drugs most easily used must be tasteless, colorless, and dissolve readily.

Dec 22, 2003: What will happen when Southern Poison Center closes on January 30, 2004?

On January 30, 2004, Southern Poison Center (SPC) will close due to lack of funding.  At that time, Middle TN Poison Center (MTPC) will initiate state coverage.  The State Dept of Health will provide the funding to expand our services.  The funding will not cover the current deficit, but will cover the expansion.  Continuation of services in the 38 counties served by SPC means that every county in the US remains covered by a Poison Center.  


Kim Barker Pharm D., Managing Director of the poison center, provides some insights on this topic: Christmas trees such as cedar, fir, and other popular evergreens are non-toxic.  All may cause dermal irritation or mechanical injury if ingested.  

Nov 25, 2003: Who will answer the poison center calls for 38 counties on December 19 when the Southern Poison Center closes?

Due to lack of funding, Southern Poison Center will be closing on December 19, 2003. No provisions have been made to date for coverage of the 38 counties that call SPC from 7 am to 11 pm. Since 2001, Middle TN Poison Center (MTPC) has been covering the entire state from 11 pm to 7 am and will continue to do so.  MTPC is certified by the American Association of Poison Control Centers and adheres to the strict requirements regarding poison control standards.

Nov 3, 2003: What is the AAP's new policy on poison treatment in the home?

The American Academy of Pediatrics announced its new policy on Poison Treatment in the Home in a plenary address yesterday at its annual meeting in New Orleans. It appears as a formal statement in this month's issue of Pediatrics (Pediatrics 2003; 112; 1182-1185). The most notable recommendation is that the AAP no longer recommends ipecac in the home as a treatment intervention. Here are the recommendations from that policy statement...


Background: Recent FDA approval for the over-the-counter (OTC) sale of Claritin® (loratadine) may increase ingestion of this class of antihistamine. Loratidine is a 2nd generation antihistamine.  Other 2nd generation antihistamines were recalled due to concerns with QT interval prolongation.  The question is unanswered as to whether high concentrations of Loratidine could prolong the QT. There are three classes of H1 Antagonists:

Sept 22, 2003: What is the role of the Poison Center following Chemical Agent Exposure?

Chemical exposure can cause unexplained and unusual symptoms, which must be diagnosed and treated early.  Protective equipment and decontamination play a significant role in preventing morbidity and mortality when there is a mass release of an agent.  Previously standardized protocols have been developed to manage accidental releases of hazardous material (HAZMAT).  These protocols are not applicable when there is an attack using chemical weapons.

Aug 24, 2003: What is the status of Ipecac?

Due to the recent article about Ipecac in the Tennessean, a number of readers asked me to address Ipecac (again) in the Question of the Week. Ipecac has gained attention because the FDA is considering removing it from OTC status.  This is a very interesting as there is no new data regarding ipecac.  What is even more interesting is the controversy that has been generated by the FDA’s consideration. One of the reasons for removing it from the market is the potential for abuse by bulimic patients.

July 28, 2003: How could Ricin be used as a Weapon of Mass Destruction?

Ricin gained notoriety in 1978 (in London) when the Bulgarian journalist and political exile, Georgi Markov was stabbed by an umbrella which left a hollow metallic sphere the size of a head of a pin in his posterior thigh.  He died from severe gastroenteritis and multiorgan failure as a result of the ricin injection.  Ricin was recently found in the possession of known terrorists. Ricin is readily available.  Castor beans are used in the production of castor oil, a brake, and hydraulic fluid constituent.    

July 14, 2003: What is the toxicity of mole beans?

The Poison Center received a call about two children who had ingested “mole beans.”  These plants are popular in Tennessee.  But, mole beans contain ricin. Ricin is one of the most toxic substances known and the most toxic substance of plant origin.  Ricin is a glycoprotein, which interferes with protein synthesis.  The majority of the information about ricin toxicity comes from reports of castor bean ingestion.  Castor beans are used in making ornamental necklaces.  

June 16, 2003: What is the bioavailability of rectally administered benzodiazepines?

Diazepam and lorazepam are the two drugs most frequently administered rectally to control seizures.  Both are highly lipid soluble and therefore are absorbed well through rectal tissue.  There have been few studies of rectal administration of lorazepam.  In adult males, rectal absorption is variable, with 50-100% bioavailability (amount actually reaching the bloodstream) following rectal administration.  Peak concentrations of diazepam can be reached in 4-20 minutes following rectal administration (0.7 mg/kg) Rectal absorption of diazepam is also variable. (50+/-17 % bioavailability)

April 21, 2003: What are the chronic effects of toluene inhalation?

Toluene is an aromatic hydrocarbon found in gasoline, paint thinners, lacquers, and adhesives. Toluene is the inhalant that demonstrates the greatest toxicity when chronically. abused. Although all inhalants can cause neurotoxicity, toluene causes a pattern of cognitive dysfunction that includes apathy, poor attention and concentration, memory loss, visuospatial dysfunction and impaired complex cognition. White matter

Feb 17, 2003: What is the new certification for dietary supplements?

I thought you would be interested in information about the USP certification for dietary supplements.  The USP is a non-government organization that promotes public health by establishing standards, which are developed by a process of public involvement.  The USP is a not-for-profit organization that is primarily supported by volunteers representing pharmacy, medicine, and other health care professions.  For information on USP visit  

Feb 10, 2003: How do you make methamphetamines?

If one assesses the number of labs that have been discovered by metro police, it appears that this information is almost common knowledge. Methamphetamines can be manufactured in illicit laboratories using over-the counter ingredients. The following is the list of ingredients listed on the Internet as required for the manufacture of methamphetamine:

Jan 27, 2003: What are the actions of methamphetamine?

Amphetamines selectively enhance the release of dopamine and norepinephrine and block the reuptake of these catecholamines at the synapse. The marked increase in dopamine level may be related to the “high”.   There is increase of α and β receptors stimulation.  Increased norepinephrine in the locus cereleus causes anorexia, increased alertness, and locomotor stimulation. 

Jan 20, 2003: What is the history of methamphetamine?

Methamphetamine, (“crystal meth” “Hawaiian ice” “crank”, “zip” “crusty”) is an N-methyl homologue of amphetamine.  Use of this drug originated in East Asian countries in the 80s, and then spread to Hawaii.  Hawaii is centered between the continental US and Asia.  Geography and culture have resulted in increased use of the smokeable meth in Hawaii, which predated more widespread use in the continental US.  Tennessee ranks as one of the top 5 states where this drug is most frequently used.

Dec 16, 2002: What are the effects of “Ecstasy”?

MDMA (3,4 methyl-enedioxy-methamphetamine), is a pheyethylamine with structural similarities to both amphetamine and mescaline.  It has been classified into a novel pharmacological class termed “enactogens because it has a characteristic psychoactive profile that distinguishes it from classic hallucinogens and stimulants.  Acute psychological effects include euphoria, elevated self-confidence, and heightened sensory awareness.  Individuals feel closer to other individuals and groups of people.  Adverse effects include depersonalization, derealisation, and cognitive disturbances.

Dec 9, 2002: What are Designer Drugs? What is MDMA (Ecstasy)?

 To discuss Designer Drugs, it is worthwhile to first review the history of Designer Drugs.  A California pharmacist first used this term in 1980 to describe the private synthesis of drugs different from the parent compound. This rendered the drugs immune from the DEA.  The loophole was that until a drug was isolated, studied, and scheduled, no laws could apply to it. Using well-known drugs such as fentanyl, mescaline, amphetamine, and meperidine, designer drugs such as MDMA, MPTP, and fentanyl derivatives were made.

Dec 2, 2002: Part IV – History of Drugs of Abuse

The mid 70s marked the second coming of cocaine.  It was the perfect drug for the “Me Generation.”  The new morality of young America was success, the high performance ethic.  Pot bred passivity.  Alcohol impaired performance and smelled.  People can tell when you’ve been drinking.  But cocaine fit the new value system-the tight line between high performance and self-indulgence.  Subsequent drugs have continued to provide a combination of “release” and the feeling of empowerment.  But the feelings are required at earlier and earlier ages. 

Nov 25, 2002: Part III – History of Drugs of Abuse

The baby boom generation knew little about drugs and therefore, offered the drug culture priests a slew of ready disciples.  When it was discovered that marijuana didn’t drive you mad, the government lost what little credibility it had.  In this age of youth rebellion, the fact that drugs shocked parents was all the more reason to use them.  Hollywood, ever sensitive to changing mores, romanticized the pot-smoking antiheroes in Easy Rider and “let it all hang out” hippies in Hair.

Nov 18, 2002: Part II – History of Drugs of Abuse

In the 1930s, cocaine and opium were driven underground.  Cocaine was the narcotic of choice among musicians, actors, and artists, but decent Americans didn’t use it.  It was Prohibition, after all, and most Americans were too busy finding bootleg gin to think about more exotic intoxicants. 

Nov 4, 2002: What is the history of drugs of abuse?

There have been a number of questions about drugs of abuse.  Therefore, I am going to do a series on drugs of abuse, starting with an overview of the history of drug abuse. Part I History offers ample evidence of drug abuse since early times.  Opium use can be traced back to Greece and Cyprus as early as 2000 BC.  Ancient Aztecs used LSD, peyote, and marijuana.  In more recent times, George Washington used marijuana to ease dental pain.  On the advice of Samuel Clemens, Ulysses Grant used cocaine while writing his memoirs.

Sept 23, 2002: How is the Poison Center funded?

During the United Way season, we are often asked how the Poison Center is funded. It is a common misconception that the Middle Tennessee Poison Center is totally funded by the state of Tennessee.  Although the majority of the poison control centers in the U.S. receive at least 50% of their operating budget from their state, our poison center and the Southern Poison Center in Memphis receive approximately 10% of their budgets from state dollars.

Sept 9, 2002: What is St. John’s Wort?

St. John’s Word is derived from the plant Hypericum perforatum. It has been used in Greece for various ailments since ancient times.  Currently sold as an antidepressant it has been called “herbal Prozac.”  The drug contains many active ingredients.  The drug inhibits the uptake of norepinephrine, dopamine, and serotonin, but only at blood levels not generally obtained with regular use.  In an recent trial where it was compared to Zoloft and placebo, St. John’s Wort did not proved efficacious in moderately severe depression.  There is little data on toxicity of this herb in overdose.

Aug 26, 2002: What is Gingko Biloba?

Gingko is derived from the world’s most ancient tree that is native to China and Japan. Traditional Chinese herbal medicine recommends gingko as an antimicrobial, anti-inflammatory, and vasodilatory remedy. A concentrated standardized gingko biloba extract was developed in Germany in 1965, where it is available over the counter and by prescription.  It is used in the US to enhance short-term memory, concentration, and alertness, particularly in the elderly. Earlier European and US studies indicated modest improvement in cognition of demented patients.

Aug 19, 2002: What is the toxicity of Pennyroyal?

I hope you enjoyed your time during the summer break and the hiatus from Question of the Week.  I spent one week at the beach, one week in Mexico building houses, and one weekend whitewater rafting with two adolescent males.  There was not one dull moment.

June 24, 2002: What are the Safety Issues with Herbal Products?

Currently, up to 50% of consumers use some type of herbal supplement.  Frequently, the consumer does not consider this to be medicine and the physician is unaware of the ingestion of these products.  For the next few weeks, I am going to review some of the more popular products.


Pokeweed is a perennial that grows wild throughout the eastern half of the United States.  It has a green or red center stalk with oblong leaves.  The small berries grow in “grape-like clusters” and ripen from green to purple in the summer. The juices of the ripe berries leave a purple stain when handled which may attract young children. The entire plant is potentially toxic.  The root is the most toxic and the ripe berries the least toxic.  Potentially toxic doses are as little as 0.5 teaspoonful of the root and 10 or more of the berries.

May 28, 2002: How does state funding for Tennessee’s poison control centers compare with other states in the South?

Most of the financially solvent poison control centers throughout the United States are funded by state government funds.  In Tennessee, the Department of Health allocates $100,000 each for Middle Tennessee Poison Center and Southern Poison Center in Memphis and pays for a toll-free inbound telephone line that is used by both centers.  In Tennessee the $220,000 annual support is the lowest amount among the Southeastern states (see table below) and represen

April 22, 2002: What is the toxicity of melatonin?

Melatonin is currently being administered to children as a potential sleep aid.  Although the drug appears to be relatively safe in therapeutic doses as well as in overdose, there are still many unanswered questions regarding this drug.

April 8, 2002: What is the toxicity of muscle relaxants?

The group of drugs that are classified as muscle relaxants differ greatly in pharmacologic and toxicologic properties.  Most of the skeletal muscle relaxants depress the CNS.  Some of the drugs have anticholinergic (thus the hallucinations) and antihistaminic properties.  Presentation of a child that has ingested a muscle relaxant includes CNS and respiratory depression, muscle flaccidity, and possibly anticholinergic effects i.e.

Feb 19, 2002: What is the analytic Accuracy of Toxicology Screens? (Part II)

For the average analytic laboratory, confirmed false negatives occur at a rate of 10-30% and confirmed false positives occur at  a rate of 0 – 10%.  The most common reason for an analytic false negative is ordering a drug screen which does not test for the suspected drug.  False positives are low due to high concentrations of the detected drug and confirmation of the presumptiv

Jan 28, 2002: What is the clinical Presentation and treatment of Benzodiazepine Overdose?

Benzodiazepine (BZDP) overdose (OD) most frequently presents with sedation and CNS depression.  Coma may occur.  Cardiovascular stability usually does not occur with a pure BZDP OD. One of the more frequent complications of a pure BZDP OD is aspiration pneumonia, which probably occurs prior to airway protection.  The morbidity and mortality is much higher if BZDPs are ingested in combination with alcohol or other sedative-hypnotic drugs.

Jan 21, 2002: What is the clinical significance of therapeutic ingestion of BZDP?

Benzodiazepines (BZDP)  potentiate the activity of GABA, a major inhibitory neurtransmitter in the CNS.  The drugs cause sedative-hyponotic, muscle relaxant, anxiolytic and anticonvulsant effects. Clinically one may see sedation, impaired psychomotor skills, cognitive dysfunction, and short-term memory impairment. Rarely, BZDP may cause paradoxical effects.  Tolerance to the sedative effects occurs over days, possibly over periods as short as hours.

Nov 19, 2001: What is the toxicity of serotonin reuptake inhibitors?

Serotonin Selective Reuptake Inhibitors (SSRI) and Serotonin Reuptake Inhibitors (SRI) were developed because the tricyclic antidepressants (TCAs) had significant sedative and anticholinergic side effects. SSRIs inhibit the synaptic reuptake of serotonin.  In addition to affecting synaptic serotonin levels, the SRIs  have variable effects on the synaptic levels of epinephrine and norepinephrine.

Nov 12, 2001: Answers to submitted questions

A number of subscribers have asked about IV NAC (N-acetylcysteine). IV NAC is not FDA approved. It has been shown to reduce morbidity and mortality in acetaminophen-induced hepatic failure (note-this is only in hepatic failure caused by acetaminophen overdose). I would certainly administer IV NAC in this setting.

Oct 29, 2001: How Toxic are Detergents and Soaps?

Soaps are the product of a reaction between  alkali and fats or oils.  Detergents are a bit more toxic as they contain combinations of surfactants which lower the surface tension of water and allow it to remove dirt more efficiently.

Oct 22, 2001: What is the toxicity of household cleaning products? —Part II

The Middle Tennessee Poison Center received many questions regarding household cleaning products.  One of the most frequent calls occurs when bleach (hypochlorite) and ammonia are mixed to use as a cleaning solution (most frequently for bathroom fixtures).  The combination of these products forms the noxious chloramines gas.

Oct 1, 2001: What is the pathophysiology of salicylate toxicity?

Salicylate toxicity seems to be increasing.  We are receiving an increased number of calls at the Poison Center.  I addressed the treatment of salicylate toxicity last week.  This week and next week we will address other aspects of salicylate toxicity.

Sept 24, 2001: What is the treatment of the patient with salicylate toxicity?

As previously discussed, Ipecac administration and gastric lavage are not recommended in children.  Salicylates are absorbed by activated charcoal, so early administration of charcoal should be considered.  Furthermore, multiple-dose activated charcoal causes gastric dialysis, i.e., the drug is actually pulled from the blood int

Sept 10, 2001: What is the treatment of mothball ingestion?

Mothballs are either napthalene (which can be toxic) or paradichlorobenzene (ingestion usually inconsequential). One can determine which ingredient is in the mothballs by placing the mothball in 4 ounces of tepid water in which 3 heaping tablespoonsfuls of salt have been dissolved. A napthalene mothball will float whereas a paradichlorobenzene mothball will sink.

Aug 8, 2001: What are the indications for naloxone administration?

Naloxone, an opioid antagonist, cannot be administered orally because the liver metabolizes the first dose and there is little drug that reaches the circulation (first-pass effect).  Naloxone is well absorbed IM, SQ, and endotracheally.  The onset of action is one-two minutes following IV administration.  Duration of action is 20-90 minutes.