Cite this post as:
Scott Weingart, MD FCCM. EMCrit Podcast 215 – A Disagreement of Toxicologists with Dantastic Mr. Tox/&Howard. EMCrit Blog. Published on December 25, 2017. Accessed on March 24th 2023. Available at [https://emcrit.org/emcrit/disagreement-of-toxicologists/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: December 25, 2017
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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Great discussion! Some questions and points: 1) Is Dan and Howard’s reluctance to use lipids in CCB overdoses based on the availability of ECMO as an alternative? What if ECMO was not an option? 2) The discussion of decontamination in CCB overdose was a little vague. What would Dan and Howard suggest considering: multi-dose activated charcoal? whole bowel irrigation? gastric lavage????? Do they really believe that the potential (unproven) benefits are worth the risks. (I leave out single-dose charcoal with is probably safe in an alert cooperative patient.) 3) Do your guests see any role for bedside echo (LV squeeze,… Read more »
Leon, great questions (as always). My reluctance is based on my access to ECMO. Also, anecdotally, I have seen little benefit. The LogP’s of the three CCBs we are likely to see include Verapamil (5.4), Diltiazem (2.73) and Amlodipine (1.6). Based on this the most benefit would be expected in verapmil and the worst in amlodipine. I would consider it in a verapamil OD at an outside hospital. I am not opposed to trying it in the others but since we have ECMO would go to that sooner in these OD’s. For the second question on decontamination I suspect Howard… Read more »
Hi Leon! Thanks for the questions. My brief responses… I don’t have ECMO available in any form and would have to transfer a patient. I’m willing to try lipid, but don’t think that at least in the pig models (Bania and Chu) that it works so well. Plus the arguments made by Dr Weinberg in the podcast about timing and route. I’m a believer in decon and think that I give both charcoal and would WBI in bad cases. I know that there isn’t good data, but I think that some degree of common sense must prevail in serious poisoning.… Read more »
Howard: I think common sense could just as well argue against decontamination. If the patient is stable and not yet symptomatic, either they will deteriorate or they did not take a significant overdose. If the latter, they do not need decontamination. If the latter and they receive WBI, the treating physician might soon be faced with a hypotensive patient with a gut full of polyethylene glycol. It does not seem to me likely that one could often use WBI to transform a serious case into one that is benign. I’d have no problem with giving a stable cooperative patient a… Read more »
Hence the title of this episode. Can parse this in many ways. But I don’t think that we’ve ever been able to study this appropriately and would be very difficult to. To paraphrase one of my favorite mushroom sayings:
Falling in love is like eating a poisonous mushroom (a suspected CCB overdose). You never know it’s the real thing until it’s too late….