The Poison Lab

Clinical Toxicology LLC

Dive into the captivating world of poisons with The Poison Lab! Hosted by Clinical Toxicologist Ryan Feldman (@EMPoisonPharmD), and occasional co-host Toxo (@LabPoison). This show unpacks the fascinating history, cutting-edge science, and life-saving medical management of toxins from around the globe. From stories of those impacted to expert insights from pioneers in poisoning treatment, each episode brings you closer to understanding the poisons that lurk in plain sight. Explore episodes, med videos, games, and more at thepoisonlab.com—every poison has a story to tell!

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Top 10 The Poison Lab Episodes

Goodpods has curated a list of the 10 best The Poison Lab episodes, ranked by the number of listens and likes each episode have garnered from our listeners. If you are listening to The Poison Lab for the first time, there's no better place to start than with one of these standout episodes. If you are a fan of the show, vote for your favorite The Poison Lab episode by adding your comments to the episode page.

A very NACCT Holiday-2023 North American Congress of Clinical Toxicology High Yield Abstract Review

The Poison Lab

12/21/23 • 94 min

In this episode Ryan is joined by a guest panel (Dr. Grant Comstock MD, Dr. Joshua Trebach MD, Dr. Emily Kiernan DO, and Dr Frank Paloucek PharmD, DABAT) to review nine of the most interesting or clinically impactful research abstracts that were presented at the 2023 North American Congress of Clinical Toxicology (NACCT) in Montreal Canada. If you didn't get a chance to read all 363 research abstracts from some of Toxicology's best and brightest this year, tune in for a high yield review as well as clinical a break down of the studies and their relevance from the expert panel.

Check the show notes for a link to the published abstracts and the list of all studies discussed in the show

Abstracts available here

10:40- Abstract 1 (PDF #225) Methotrexate toxicity in the setting of therapeutic error, a multicenter retrospective review

Lead author: Andrew Chambers

24:12- Abstract #2 (PDF #251) Oleander seeds in candlenut weight loss product strike again

Lead author: Masha Yemets

31:16- Abstract #3 (PDF #2) Efficacy of sodium tetrathionate when administered intramuscularly for the treatment of acute oral cyanide toxicity in a swine model (Sus scrofa)

Lead author: Brooke Lajeunesse

39:45- Abstract #4 (PDF #10) Is HOUR enough after out-of hospital naloxone for opioid overdose? Prospective preliminary data from real-world implementation of the modified St. Paul’s early discharge rule

Lead author: Stephen Douglas

49:05- Abstract #5- Poster titles at NACCT 2013–2022: is NACCT experiencing a pun-demic?

Lead author: Dayne Laskey

52:40- Rivastigmine discussion

Lead author: none

58:40- Abstract #6 (PDF #5) Randomized controlled trial of ANEB-001 as an antidote for acute cannabinoid intoxication in healthy adults

Lead author: Andrew Monte

1:08:00- Abstract #7 (PDF#216) Successful use of expired physostigmine to treat anticholinergic delirium in a pediatric patient

Lead author: Bryan Hayes

01:20:00- Abstract #8 (PDF #202) Enough negativity? Clinically significant salicylism with first detectable concentration twelve hours )post-ingestion

Lead author: Stacey Bangh

01:25:24 - Abstract #9 (PDF #267) High sensitivity troponin is frequently elevated after carbon monoxide exposure

Lead author: Abdullatif Aloumi

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The Poison Lab Does Psilocybin- A Deep Dive with Psilocybin Research Pharmacist Dr. Paul Hutson

The Poison Lab

09/20/23 • 97 min

In this enlightening episode, Ryan engages in a deep conversation with Dr. Paul Hutson, PharmD, a renowned researcher in the field of psilocybin and director of the Transdisciplinary Center for Research in Psychoactive Substances at the University of Wisconsin Madison. Dr. Hutson shares his extensive knowledge and insights into the promising role of psilocybin in the treatment of depression and substance use disorder.

Throughout the discussion, they delve into the research that supports the use of psilocybin in medical therapy, shedding light on the rigorous processes involved in conducting such studies. Dr. Hutson elucidates the efficacy and safety findings that have emerged from his and others research, offering listeners a glimpse into the potential future of psilocybin in mainstream medical practices. Listeners will gain a deeper understanding of the meticulous approach to research that ensures both safety and effectiveness. Dr. Hutson shares firsthand experiences and observations, providing a rich and detailed perspective on the current state of psilocybin research. Moreover, the conversation ventures into the practical aspects of integrating psilocybin into contemporary medical practices, discussing the potential frameworks and guidelines that would govern its use. They explore what the future might hold for patients and practitioners alike as they stand on the cusp of a revolutionary shift in mental health treatment.

Whether you're a healthcare professional keen on the latest developments in medical research or someone interested in the evolving landscape of mental health treatment, this episode promises to be a rich source of information and insight. Tune in to be informed and to foster a deeper understanding of the promising horizon that psilocybin research is unveiling in the medical community.

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Toxicologists vs the Internet (#8) With Guest Dr Adam Blumenberg MD

The Poison Lab

04/12/23 • 90 min

Dr. Adam Blumenberg, MD (@ABlumenbergMD) Join's the show. He is an emergency medicine physician, medical toxicologist, and Assistant Professor at Columbia University Medical Center in New York City. He hosts his own toxicology youtube series (www.ToxicHistory.com) and has developed multiple free medical education software programs in toxicology (www.toxicrunner.net) and medical simulation (www.medsimstudio.com). Most impressively, he has produced his own free base lidocaine crystals on a stove top, if you ask nicely he might just loan you one. He joins the show to sleuth the cause of fatal poisoning cases and tackle internet questions from reddit.com/r/askdrugs

Dr. Blumenberg' s projects
www.ToxicHistory.com
www.medsimstudio.com (medical vital/imaging simulator)
www.toxrunner.net (toxicology question bank)
Things discussed in the intro
Mithradata
Ohio vinyl chloride disaster
Arizona nitric acid spill
Ohio metal factory explosion

Cases

Case 1

Case 2

Full text

Case 3

Case 4

Full text

Case 5

Not the actual case from the show but close enough

Questions

BHO explosions

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High yield highlight- Managing a Bupropion overdose

The Poison Lab

02/27/23 • 7 min

Ready for a high-octane dose of knowledge? 🔥🧠 Ryan's got you covered with this electrifying mini-episode on managing a bupropion overdose! 💊💥 Beware - there are plenty of pitfalls you'll want to avoid. Check out the full episode and other mini-episodes for even more tips and tricks! 🎧👀

Bupropion is the #1 antidepressant cause of major (life threatening) reported to U.S. Poison Centers
It is difficult to manage due to
Potential for delayed seizures
Unique cardiogenic shock in overdose
Potential wide complex arrhythmia refractory to Sodium Bicarbonate
Potential interference with brain death testing
Treatment
Decontamination
Aggressive whole bowel irrigation or charcoal may be indicated if large ingestion
Supportive care
Intubation if airway compromised
Benzodiazepine for agitation
Benzodiazepines and GABA-ergic AED's for status epileptics
Tachycardia, tremor, and agitation are risk factor for seizures
Tachycardia may be masked by alpha 2 agonist co ingestions
Seizures may occur 24 hour out
Sodium bicarbonate for wide QRS (it may be refractory)
Inodilators and vasopressors for cardiogenic shock
ECMO for refractory shock or arrhythmia
Awareness that severe bupropion toxicity can mimic brain death
send analytical confirmation of bupropion if possible to rule out confounding
Enhanced elimination
limited options due to protein binding, not routine
Focused antidote
Consider IV fat emulsion if the patient is peri arrest
Observation times
Talk to a toxicolleague about observation times, decontamination, and use of invasive therapies to avoid falling into a trap

Toxicologists vs the Internet (#7) With Guest Dr Emily Kiernan DO

The Poison Lab

11/09/22 • 85 min

Dr. Emily Kiernan, DO (@em2kiernan) an emergency medicine physician and medical toxicologist with Emory university school of medicine joins the show to solve toxic cases, opine on recent healthcare related poisoning, and dive head first into the bongwater on this episode. (Remember friends, don't drink the bong water).

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Fast and Fatalurious

The Poison Lab

05/04/22 • 41 min

In this episode Ryan and Toxo dive into a widely available prescription poison with a frightening ability to cause rapid neurologic and cardiovascular decline, and the best part, it looks like candy!

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Toddler Time Bombs (Poison Center Triage)

The Poison Lab

07/22/20 • 67 min

Ryan and Toxo cover some topics off the "one pill can kill" list, try breaking down the toxic mechanism of opioid induced respiratory depression in a simplistic way (but maybe fail), and walk through the triage and management of poison center case where a child was "potentially" exposed to a lethal toxin at home.

Case Report

Pediatric ingestion case study discussed at the beginning of the episode: https://pediatrics.aappublications.org/content/130/6/e1700

"One Pill Can Kill" Resources

Missouri Poison Center resource guide:http://missouripoisoncenter.org/wp-content/uploads/2015/02/2011-One-Pill-Can-Kill.pdf
Pediatric poison prevention article:https://pubmed.ncbi.nlm.nih.gov/16419734/
HealthyChildren.org guide on medication safety:https://www.healthychildren.org/English/safety-prevention/at-home/medication-safety/Pages/Poison-Prevention-One-Pill-Can-Kill.aspx

Respiratory Centers and Drug Effects

Detailed overview of the impact of drugs on respiratory centers:
https://www.ncbi.nlm.nih.gov/books/NBK482414

Buprenorphine Studies

Epidemiology

AAPCC Annual Report on poisoning trends:https://pubmed.ncbi.nlm.nih.gov/31752545/
Trends in pediatric opioid exposures:https://pubmed.ncbi.nlm.nih.gov/32178937/
Trends in ED visits for unsupervised medication exposures:https://pubmed.ncbi.nlm.nih.gov/26347435/

Exposure Studies

U.S. Poison Center data on buprenorphine: https://pubmed.ncbi.nlm.nih.gov/29941678/
Harvard Emergency Medicine group analysis: https://pubmed.ncbi.nlm.nih.gov/27756148/
Maryland Poison Center/RADARS data:https://pubmed.ncbi.nlm.nih.gov/18381506/
ICU exposures in children:https://pubmed.ncbi.nlm.nih.gov/20921918/

Triage Considerations for Pediatric Exposures

Symptoms: What are the current symptoms and their severity?
Causative Agent & Exposure Characteristics: What substance was ingested, and in what quantity? What’s the context of the exposure?
History: Includes past medical history, patient weight, and the time elapsed since exposure.
Onset: When are symptoms expected to appear?
Labs: Perform toxin-specific assessments where applicable.
Aggravating/Remitting Factors: What interventions have already been performed, and how have they affected the patient?

If you have questions about these studies or poisoning scenarios, consult your local poison center or toxicologist. Thank you for tuning in!

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LIVE from Denver: 2024 NACCT Research Review – Insights from the North American Congress of Clinical Toxicology

The Poison Lab

10/04/24 • 82 min

In this exciting live episode from the 2024 North American Congress of Clinical Toxicology (NACCT) in Denver, Ryan dives into 12 of the most impactful research abstracts presented at the conference directly with the authors themselves. Covering a wide range of toxicology topics—from the NACSTOP2 trial on acetaminophen overdose, ECG intervals, cannabis toxicity in young children, and more—each guest breaks down their study’s findings and clinical relevance. If you missed the conference or want a deeper understanding of the year's most important toxicology research, this episode is for you. Check the show notes for links to the published abstracts, the full list of studies discussed, and time stamps for where you can find those studies.

Link to published abstract manuscript

Abstracts

07:48-Abstract #1. The NACSTOP2 trial: a multi-center randomized controlled trial investigating the early cessation of n-acetylcysteine in acetaminophen overdose

Guest- Dr. Anslem Wong, MD, PhD

21:33- Abstract #36. ECG intervals: does one size really fit all?

Guest- Dr. Caitlin Roake, MD, PhD

25:41- Abstract #85. Do abnormal electrocardiographic intervals predict death in poisoned patients older than 65 years?

Guest- Dr. Michael Chary, MD

30:06- Abstract #61. Minimum tetrahydrocannabinol dose that produces severe symptoms in children <6 years old with cannabis edible ingestions

Guest- Dr. Keahi Horowitz, MD

36:25- Abstract #114. Frequency and severity of cannabis toxicity before and after legislative change to increase cannabis edible package size

Guest- Dr. Robert Hendrickson, MD

38:24- Abstract #101. Quantification of acetaminophen line-crossers in the setting o f overdose with delayed gastric absorption

Guest- Dr. Jamie Sterr, PharmD

41:41- Abstract #175. Cause for pause: bradycardia induced by transdermal rivastigmine in anticholinergic delirium

Guest- Dr. Santiago Batista Minaya, MD

46:21- Abstract #199. Cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) Syndrome with poor neurological outcome in the setting of suspected opioid use

Guest- Jack Yang and Dr. Avery Michienzi, DO

49:49- 191. Severity scores for caustic injury: Zargar they even used?

Guest- Dr. Amar Chakrabortya, MD

53:!2- Abstract #9. Disparity in immune-mediated reactions to Crotalidae polyvalent immune fab (ovine) and Crotalidae immune F(ab’)2 [equine] in alpha-gal endemic regions and alpha-gal sensitized adults

Guest- Dr. Ari Filip, MD

59:10- Abstract # 26. Acute propranolol overdose and dose thresholds of severe toxicity

Guest- Dr. Katherine Isoardi, MBBS

1:06:05- 28. Risk of serotonin toxicity following acute lamotrigine overdose

Guest- Dr. Angela Chiew, MBBS, PhD (Introduction at 1:00:00)

1:12:36- Interview with AACT President Elect

Guest- Dr. Jillian Theobald, MD, PhD

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A Prescription for Heartache (& Seizures) (Bupropion)

The Poison Lab

02/15/23 • 90 min

What Do Bath Salts, Face-Eating Zombies, and Antidepressants Have in Common?

In this episode of The Poison Lab, Ryan is joined by Dr. Filip, Dr. Olives, and Dr. Reyes to discuss a unique and heartbreaking poisoning scenario involving an antidepressant now recognized as the #1 cause of major life-threatening effects in antidepressant overdoses in the U.S. Check out the mini-episodes for more details!

Key Highlights

This Antidepressant:

#1 Cause of Major (Life-Threatening) Effects in overdoses reported to U.S. Poison Centers.
Difficult to manage due to:
Delayed seizures.
Unique cardiogenic shock in overdose.
Wide complex arrhythmia refractory to sodium bicarbonate.
Potential interference with brain death testing.

Mechanism of Toxicity

Increases dopamine and norepinephrine.
Blocks gap junctions in cardiac myocytes:
Rohr 2004: Gap junction blockade causes a wide QRS.
Vink 2004: Connexin 43 is critical for cardiac signal transmission.
Callier 2012: Similar effects on cardiac action potential as other gap junction blockers.
Burnham 2014: Bupropion's IC50 for connexin 43 is >50 μM, higher than fluoxetine and lamotrigine.
Shaikh Quereshi 2014: Bupropion interferes with connexin 43 production/localization in chicken cardiac myocytes at >50 μM.

Clinical Effects

Sympathetic Toxidrome

Seizures: Delayed, typically occurring 8–24 hours post-ingestion.
Tachycardia: May precede seizures but could be masked by co-ingestions.

Takeaway (TL;DR):

Patients often present with neurologic symptoms and tachycardia before seizures.
Do not discharge patients without consulting a toxicologist or poison center regarding observation time.
Avoid dismissing tachycardia and anxiety as situational in bupropion overdose cases.

Key Literature Insights

Shepherd 2004: Seizures primarily associated with sustained-release products; often preceded by neuropsychiatric symptoms.
Starr 2009:
XL products linked to seizures.
Tachycardia, tremor, and agitation are predictors.
Seizures occurred as late as 24 hours; 25% occurred after 8 hours.
Offerman 2020:
Tachycardia >120 bpm predicts seizures.
Late seizures occurred only in symptomatic patients.
Prehospital seizure correlated with cardiac arrest.
Rianprakaisang 2021:
QTc and HR >140 bpm predict seizures.
ToxIC review confirmed tachycardia as a risk factor.

Treatment Overview

Decontamination

Whole bowel irrigation or activated charcoal may be needed for large ingestions.

Supportive Care

Airway Management: Intubate if compromised.
Benzodiazepines for agitation or seizures.
Use GABA-ergic AEDs for status epilepticus.

Cardiogenic Shock

Sodium bicarbonate for wide QRS (though may be refractory).
Inodilators/Vasopressors for shock.
ECMO for refractory shock or arrhythmias.

Observation Times

Late seizures can occur up to 24 hours post-ingestion.
Discuss observation times with a toxicologist.

Additional Considerations

Severe toxicity can mimic brain death—send for analytical confirmation if possible.
Limited enhanced elimination options due to high protein binding.
Consider IV lipid emulsion if the patient is peri-arrest.

Don't Fall into Traps:

All ingestions are unique. Collaborate with a toxicologist to guide management and avoid pitfalls.

Rohr 2004: "Role of gap junctions in the propagation of the cardiac action potential"

PubMed Link

Vink 2004: "Connexin 43 is the most important protein for connexon formation and cardiac signal transmission"

APAPalooza. A North American Congress of Clinical Toxicology 2023 Acetaminophen Research Highlight

The Poison Lab

11/19/23 • 51 min

In this episode, Ryan dives into cutting-edge research on the treatment of acetaminophen (APAP) overdose, featuring interviews with authors of several key abstracts from the North American Congress of Clinical Toxicology (NACCT) in Montreal Canada (Abstracts and posters available in the show notes). We get first looks insights into research evaluating the impact of fomepizole high risk acetaminophen overdose, as well as who gets fomepizole for acetaminophen overdose and dies. Then we evaluate the effectiveness of standard N-acetylcysteine (NAC) treatment in high risk patients and high dose NAC in high risk patients. Join us for an insightful discussion on these advancements that are reshaping the management of APAP toxicity. Guests include Dr. Masha Yemets PharmD, Dr. Molly Stott PharmD, Dr. Alexandru Ulici PharmD, and Dr. Michael Moss MD.

Link to published abstracts
(First guest) Abstract #126 Characterizing fomepizole use in acetaminophen deaths reported to US poison centers- Dr. Yemets
(Second guest) Abstract #125 Clinical impact of fomepizole as an adjunct therapy in massive acetaminophen overdose- Dr. Stott
(Third guest) Abstract #131 Comparison of low-risk and high risk acetaminophen ingestions using the standard prescott protocol of intravenous N-acetylcysteine- Dr. Ulici
(Fourth guest) Abstract #130 High-risk acetaminophen overdose outcomes after treatment with standard dose vs. increased dose N-acetylcysteine- Dr. Moss
Other studies discussed regarding NAC dosing
ATOM 2 Angela Chiew
Outcomes of massive APAP treated with regular NAC (Virginia group, lead author Dr. Downes)

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FAQ

How many episodes does The Poison Lab have?

The Poison Lab currently has 58 episodes available.

What topics does The Poison Lab cover?

The podcast is about Life Sciences, Podcasts, Education and Science.

What is the most popular episode on The Poison Lab?

The episode title 'Where is Episode #31 and Bonus Episodes- Ryan Joins "The Larry Meiller Radio Show" and The "EMS2020" Podcast' is the most popular.

What is the average episode length on The Poison Lab?

The average episode length on The Poison Lab is 46 minutes.

How often are episodes of The Poison Lab released?

Episodes of The Poison Lab are typically released every 28 days.

When was the first episode of The Poison Lab?

The first episode of The Poison Lab was released on May 23, 2020.

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The Poison Lab

Clinical Toxicology LLC

Top 10 The Poison Lab Episodes

Case Report

"One Pill Can Kill" Resources

Respiratory Centers and Drug Effects

Buprenorphine Studies

Triage Considerations for Pediatric Exposures

What Do Bath Salts, Face-Eating Zombies, and Antidepressants Have in Common?

Key Highlights

Mechanism of Toxicity

Clinical Effects

Key Literature Insights

Treatment Overview

Additional Considerations

FAQ

How many episodes does The Poison Lab have?

What topics does The Poison Lab cover?

What is the most popular episode on The Poison Lab?

What is the average episode length on The Poison Lab?

How often are episodes of The Poison Lab released?

When was the first episode of The Poison Lab?

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