Poisoning and Herbs

Question 1

Random Poisoning Facts

Answer 1

55% of poisonings are from INCIDENTAL EXPOSURE; 9.6% actual suicides

Most common drugs that cause poisonings are ANALGESICS –> Sedative/Hypnotics (MOST FREQUENT and FASTEST RISING); Digoxin; Opioids

Most important issue is TIMING –> Isoniazid, TCAs, Antidepressants, Nictoine have RAPID effects

Acetaminophen, Hydrofluoric Acid, Ethylene Glycol have DELAYED onsets

WEIGHT of individual very very important

Question 2

Quick Poisoning Treatments

Answer 2

ACTIVATED CHARCOAL –> binds to the drug in the GI tract so that it can be expelled in the FECES

IPECAC SYRUP – not used much anymore; induces vomiting; empties only 30% of the stomach contents and its administration prevents the use of activated charcoal (will just throw up); can be abused

Question 3

KNOWN ANTIDOTES

Answer 3

Acetaminophen - N-ACETYL-CYSTEINE

Cyanide – HYDROXYCOBALAMINE

CO –> Oxygen

Digoxin –> FAD Fragment (immunologically sticks to it in the blood)

Ethylene Glycol/Methanol –> FOMEPAZOLE

Opioids –> NALOXONE

Organophosphates/Nerve Agents –> ATROPINE

Question 4

What do acids and bases do when ingested?

Answer 4

ACIDS –> exposure causes COAGULATION NECROSIS, an ESCHAR, MINIMAL TISSUE PENETRATION

BASES –> Exposure will cause LIQUEFACTIVE NECROSIS, SAPONIFICATION, DEEEEEEP TISSUE PENETRATION

Question 5

Hydrofluoric Acid

Answer 5

Used in glass etching, computers, automotive and air conditioner cleaners, etc

may not cause burning/itching, but can be a DELAYED PAIN REACTION

WEAKLY corrosive, but will cause injury by penetrating whatever tissue it contacts

If ingested, it can cause LOCAL and SYSTEMIC ABSORPTION OF CALCIUM

Binds Ca++ very strongly, can get into bones, and cause DEATH by binding up ALL the calcium in the body

TREATMENT? LOTS OF CALCIUM!!!!

Question 6

Cleaning Agent exposure

Answer 6

Lots of cleaning agents have chlorine, bleach, ammonia – VAPORS when MIXED

Vapors can be very irritative to the airways, and cause STATUS ASTHMATIUS (acute severe asthma) as well as DELAYED PULMONARY INJURY!!!

Question 7

CO Exposure

Answer 7

Binds Hb with much greater affinity than oxygen!

So no oxygen can bind at one site, and the other ones are too tightly held! NO RELEASE OF OXYGEN TO TISSUES

Also inhibits CELLULAR RESPIRATION

Formed by the incomplete combustion of carbon material (car exhaust, ventilation of a heater blocked, etc)

No O2 to tissues –> BRAIN and HEART most affected

Question 8

Symptoms of CO Exposure

Answer 8

Flu like illness with NO FEVER (mild)

Cherry Red appearance (high exposure)

DELAYED NEUROLOGICAL SEQUELAE and COGNITIVE EFFECTS

Those with higher metabolic rates (kids) are actually WORSE OFF

Question 9

Treatment of CO exposure

Answer 9

OXYGEN OXYGEN OXYGEN!!!!!!!

Hyperbaric O2 Chamber best

CO detectors are a must

Question 10

LEAD exposure

Answer 10

Pervasive toxin in the environment

Found in smelting, construction, demolition materials, folk medicines, cosmetics, bullets, etc etc etc

Most poisoning is ASYMPTOMATIC, but can have systemic effects at high doses

CNS effects –> hyperIRRITABILITY, intermittent LETHARGY, COGNITIVE IMPAIRMENT –> with several poisonings –> LEAD ENCEPHALOPATHY

PNS effects –> Peripheral NEUROPATHY; WRIST and FOOT DROP

N/V, abdominal pain, anorexia, microcytic anemia, possible impaired hearing/growth and IMPAIRED COGNITION and BEHAVIORAL CHANGES in KIDS –> BIGGEST CONCERN!!! Affects arborization of the brain neurons

BASOPHILIC STIPPLING = DIAGNOSTIC

Question 11

Treating Lead Poisoning

Answer 11

Oral Succimer Therapy
Calcium Disodium EDTA
BAL (Dimercaprol)
PENICILLAMINE (side effects in 1/3)

Life threatening encephalopathy? BAL and THEN Calcium EDTA (in that order)

Calcium alone or before is so effective that it will literally pull our calcium out of us –> bone and brain too –> SEIZURES –> Give BAL first and this will be prevented

Question 12

Alcohol Poisoning

Answer 12

Main concern is the MAINTENANCE OF AN AIRWAY

Alcohol Depresses respiratory function - patient may either stop breathing or aspirate vomit while passed out

CHILDREN CAN BECOME SEVERELY HYPOGLYCEMIC REALLY FAST FROM ALCOHOL POISONING because of decreased GLYCOGEN stored in the liver

Question 13

Problem with weed/bug killers?

Answer 13

Most contain ORGANOPHOSPHATES –> these are ACETYLCHOLINESTERASE INHIBITORS –> poisoning with these guys will send a person into CHOLINERGIC OVERDRIVE –> “Wet Symptoms” –> Salivation, lacrimation, urination, GI upset, Diarrhea, Emesis, Fluid in the lungs

TREATMENT with ATROPINE!!!!! Then we can use PRALIDOXIME which will regenerate AChE

Question 14

First symptoms of IRON TOXICITY?

Answer 14

BLOODY VOMIT, BLOODY DIARRHEA

Iron destroys the intestinal barrier that keeps it from crossing into the bloodstream

Question 15

TCA Poisoning

Answer 15

Manifests as CV TOXICITY (Na channel block –> widening of QRS –> unremitting v tach, Torsades, V fib, death)

ANTICHOLINERGIC side effects (DRY symptoms – mydriasis, tachycardia, urinary RETENTION, decreased GI, dry mouth, etc

NEURO SYMPTOMS –> Seizures

Question 16

Treating TCA Overdose?

Answer 16

NO GOOD ANTIDOTE!!!!

Main treatment is AGGRESSIVE decontamination with ACTIVATED CHARCOAL

If CV symptoms have started, give Sodium Bicarb to compete with Na Channel Block

Question 17

Problem with VERAPAMIL?

Answer 17

Calcium Channel Blocker –> VERY dangerous in OD –> once it is absorbed, the constellation of symptoms include BRADYCARDIA, HYPOTENSION, MENTAL STATUS CHANGES

Treatment? No good treatment!! Can give calcium!

Question 18

Snake Bites?

Answer 18

Not all are poisonous, but if one is, expect to see the area as SWOLLEN, DISCOLORED, OOZING

Treat with CROFAB –> antibody that binds the venom in the blood and stops the progression of symptoms from that point on

Question 19

Drugs made from HERBS

Answer 19

• Opiates –> come from Papaver Somniferum
• Digoxin –> from D. lanta
• Lidocaine –> from Erythroxylum coca
• Warfarin –> from Melilotus officinalis
o Discovered when cows suddenly began dying due to hemorrhagic disease (bleeding from the ears/nose)
o Warfarin can be reversed by VITAMIN K since it is a Vitamin K antagonist and the newer drugs from anticoagulants cannot be reversed
• Progestin –> from Diascorea villosa
• Cromolyn –> from Ammi visnaga
• Cancer Drugs
o Etoposide and Tenoposide –> from Podophyllum peltatum (poisonous) o Vincristine and vinblastine –>from Catharanthus roseus
o Paclitaxel –> from Taxus brevifolia

Question 20

Aconite

Answer 20

Can cause arrhythmias, muscle paralysis

Used for treatment of CV conditions, also a sedative

Question 21

Pyrrolizidine Alkaloids

Answer 21

SATURATED PAs are NOT TOXIC

UNSATURATED ARE TOXIC!!!!!! Specifically harmful to LIVER and LUNGS –> found it COLTSFOOT (for cough), BORAGE and COMFREY, which is found in some teas

Question 22

Rue and Pennyroyal

Answer 22

Abortificants

Can cause MULTI-ORGAN FAILURE

Penny can also cause coagulopathy, metabolic acidosis, seizures

Question 23

HERB most involved in DRUG interactions?

Answer 23

ST. JOHN WORT

Question 24

Most common DRUG in Herb-Drug interactions?

Answer 24

WARFARIN!!!!!!

Question 25

St. Johns WORT

Answer 25

Most HERB-drug interactions

Has 3 COMPOUNDS IN IT –> Hyperforin, Hypericin, Flavinoids –> All of these are effective for DEPRESSION (but on study found it to be not that effective compared to placebo – controverisal)

SJW INHIBITS UPTAKE OF 5HT, NE, DA but ONLY AT VERY HIGH DOSES

Inhibits MAO in VITRO, but NOT IN VIVO

Interacts with about 1/4 of ALL PRESCRIPTION DRUGS!!!! Lots of CYP450 interactions (Specifically CYP3A4). ALso interferes with P-GLYCOPROTEIN

Question 26

CHONDROITON SULFATE + GLUCOSAMINE

Answer 26

Chondroitin = Glycosaminoglycan found in JOINT CARTILAGE and other tissue, commercially derived from COW TRACHEA

Has inflammatory effects

GLUCOSAMINE = Major substituent of Glycosaminoglycan chains, including AGGRECAN, which is a proteoglycan that helps enhance cartilage resilience

Commercially from CHITIN from the shells of ARTHROPODS

Can actually increase glycosaminoglycan in the cartilage after joint injury

CHONDROITIN + GLUCOSAMINE = Good for MODERATE JOINT PAIN; NO BLEEDING RISK, so good alternative to NSAIDS

Question 27

S-Adenosyl Methionine (SAME-e)

Answer 27

A methylated version of methionine –> Prescribed as a DIETARY SUPPLEMENT –> said to treat:

DEPRESSION
ARTHRITIS
CHOLESTASIS during Pregnancy

Nice alternative to NSAIDs

ELEVATES HOMOCYSTEINE, which can potentially increase CV events –> Add vitamin B to lower homocysteine!

Question 28

ALOE VERA

Answer 28

Plant with MULTIPLE MEDICINAL PARTS

Leaf and Gel both have properties

GEL DECREASES healing time in wounds (abrasions, burns), but actually INHIBITS healing of DEEP SURGICAL WOUNDS, because of its mechanism of increasing re-epithelialization –> encourages skin cell growth, don’t want for deep wounds

Gel internally can help for ULCERATIVE COLITIS

Leaves are used as LAXATIVES and also has other pro-healing components –> Potentially for PSORIASIS

Question 29

GINGER

Answer 29

Used to treat GI conditions, Arthritis

GINGEROLS are the main compound –> AGONISTS of the CAPSAICIN receptor –> Both are used to treat pain, but GINGER itself is LESS potent

Great for N/V post-op, motion sickness, morning sickness

Mechanism –> Restores the normal rhythm in the muscles of the GI tract, promotes gastric emptying into the intestines

NO INCREASED BLEEDING RISK!

Question 30

CAPSAICIN

Answer 30

From chili peppers, used for PAIN

Depletes SUBSTANCE P, and chronic use can DESENSITIZE sensory neurons through a calcium channel blocking effect

Also used for OSTEOARTHRITIS, DIABETIC NEUROPATHY, PRURITIS, PSORIASIS, POST-MASTECTOMY PAIN SYNDROME, FIBROMYALGIA, CLUSTER HEADACHES snort for headaches

Always wash hands after using!

Question 31

PSYLLIUM

Answer 31

Used for CONSTIPATION

Cholesterol lowering effects as well! 1/4 to 1/2 teaspoon per day, up to 2 teaspoons to prevent bloating/gas when using for cholesterol

Question 32

PEPPERMINT

Answer 32

Essential oils are very potent SPASMODIC AGENTS –> great for gastric problems or irritable bowel syndrome

It is a problem for GERD patients –> it will RELAX THE LES, which makes reflux WORSE

Peppermint oil can ALSO RELIEVE HEADACHES

Cheap, no synthetics needed –> candy itself is pretty potent!