12-03-18 Bits and Pieces

Toxicology Question of the Week

December 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.

The Poison Center has received some interesting calls over the last couple of months.  We continue to have more than the usual number of exposures to Carbon Monoxide.  The main question continues to be why patients should remain on normobaric oxygen after there is no longer carbon monoxide on the hemoglobin molecule. (see Question of the Week from 11/5/2018) Cytochrome oxidase in the mitochondria may malfunction as long as three days following CO exposure. Data indicates prolonged normobaric oxygen may prevent delayed or persistent neuropsychological sequelae.  Please call the poison center for recommendations regarding length of time oxygen may be indicated in patients exposed to carbon monoxide.

We also received calls regarding clenbuterol,  a beta agonist with anabolic properties.   It is administered to animals to increase lean muscle and decrease fat deposition.  In humans, clenbuterol is ingested for weight loss and body building and may be a contaminant of heroin.  It is unique among beta agonists in that it is well absorbed orally.  Stimulation of beta-3 receptors in skeletal muscle is thought to account for the anabolic properties.  The patient with toxicity may present with sympathomimetic symptoms, hypokalemia, and hypoglycemia.  Chronic use can cause cardiomyopathy (due to increased myocardial oxygen demands) and cardiac hypertrophy (rats). 

We recommended GI decontamination with whole bowel irrigation (WBI) a few times in the last month.  This entails placing an NG tube in a patient and administering Golytely at a rate of 1-2 liters/ hour (adult).  The procedure was developed by a pediatric toxicologist in Winnipeg to remove iron tablets in the GIT.  The theory is that the faster you can administer Golytely, the greater number of pills/pill fragments you can mechanically remove.  Because one can sometimes see pills in the rectal effluent, it is thought to decrease absorption.  (Patients CAN NOT drink  Golytely-it defeats the purpose).  It does not cause electrolyte abnormalities.  Historically, it was used for iron and lithium (ions which have no method of GI decontamination), sustained release preparation (due to delayed absorption) and mules (ingesting packets of cocaine with constipating agent-not single packet swallowed when being chased by law enforcement). We recommended WBI in a teenager who ingested a large number of antihypertensives 30 minutes prior to arrival.  We also recommended it in a patient with an acute on chronic lithium ingestion that arrived within 2 hours of ingestion.  Call the poison center if you have questions regarding the indications for this procedure.

Our next Questions of the Week will address unique exposures during Christmas that can lead to toxicity.  Stay tuned. 

I am interested in any questions you would like answered in the Question of the Week.  Please email me with any suggestion at donna.seger@vanderbilt.edu

Donna Seger, MD

Medical Director

Tennessee Poison Center

www.tnpoisoncenter.org

Poison Help Hotline: 1-800-222-1222

The Question of the Week is available on our website: www.tnpoisoncenter.org