Should we Give Naloxone in Cardiac Arrest? Insights From the Authors of Three Key Studies

Finally, the journal club to rule ALL journal clubs. In this episode of The Poison Lab, we tackle one of the biggest topics in emergency medicine and toxicology: Should naloxone be given during opioid-associated cardiac arrest? With three fantastic studies published in 2024, we’re diving into the data and hearing directly from the authors themselves.Join host Ryan Feldman as he interviews Dr. Eric Quinn, Dr. Joshua Lupton, and Dr. David Dillon, some of the minds behind the latest research exploring the role of naloxone in out-of-hospital cardiac arrest (OHCA). With perspectives ranging from clinical outcomes to practical implementation, this episode offers a deep dive into what these studies tell us—and what remains unanswered.But that’s not all! Featuring special guests Spencer Oliver and Chris Pfingston from EMS 2020, this roundtable discussion incorporates the real-world insights of prehospital EMS professionals who face these decisions every day. Together, the panel unpacks:Conflicting evidence on naloxone’s impact on ROSC and survival.The challenges of interpreting retrospective studies in a high-stakes setting.Ethical dilemmas surrounding randomized trials for naloxone.Practical considerations for paramedics and emergency physicians in the field.Whether you’re a toxicologist, EMS professional, or just curious about the intersection of drugs, overdose, and resuscitation, this episode is packed with actionable insights, expert opinions, and engaging discussions.Tune in now to explore the science, controversy, and future directions for naloxone in cardiac arrest care!Studies discussed in the showOutcomes of Out-of-Hospital Cardiac Arrest Patients Who Receive Naloxone in an EMS System with a High Prevalence of Opioid Overdose – Dr. Eric Quinn.Association of Early Naloxone Use with Outcomes in Nonshockable Out-of-Hospital Cardiac Arrest – Dr. Joshua Lupton.Naloxone and Patient Outcomes in Out-of-Hospital Cardiac Arrest in Northern California – Dr. David Dillon.Studies and guidelines mentioned Editorial by Dr. Lavonas on Dr. Lupton's study AHA 2023 Guidelines for poisoning cardiac arrestAHA 2021 Position statement on opioid overdose out of hospital cardiac arrest Study of opioid overdose death after bystander naloxone training mentioned by ToxoShows mentionedChris and Spencer's excellent EMS showRyan's Interview on Poisoning Cardiac Arrest Guidelines with Dr. Eric LavonasJournal club with Ryan and Dr. Dillon Timestamps and chaptersIntroduction (0:00–12:25)Podcast

In this special holiday bonus episode, Ryan takes a look back at some of the most captivating episodes of The Poison Lab from 2022. Get ready for an ultimate test of your toxicology differential diagnosis skills as we compile all the "Stump the Toxicologist" segments into one streamlined, binge-worthy episode. Explore eight unique poisoning cases, be sure to check the show notes for a description of each case. time stamp of where it begins, and links to the original episodes, where you can dive deeper into the discussions and unravel the mysteries behind these intriguing cases! Case Teasers and Time StampsEpisode 13, March 2nd, 2022: Dr. Howard Greller0:06:19 Case 1: A 19-year-old male collapses at home and presents to the ED unresponsive, tachycardic, and hypotensive, with a wide QRS complex on EKG and a serum lactate of 20. 0:22:58 Case 2: A 16-year-old female presents to the ED 9 hours after ingesting 100 tablets of an unknown medication in a suicide attempt. She presents with vomiting, lethargy, bloody diarrhea, and a metabolic acidosis. An abdominal x-ray shows numerous radiopaque tablets in her GI tract. She is treated with a redacted antidote and whole bowel irrigation, but her condition worsens and she develops liver failure. She is transferred to a tertiary care center for a liver transplant, but recovers. On day 12, she develops a lower GI bleed and bowel perforation and dies. 0:34:42 Case 3: A seven-month-old child presents with crying, cough, vomiting, and respiratory distress. 0:37:42 Case 4: A 32-year-old male with a history of alcohol use and depression presents to the ED seven hours after ingesting two handfuls of an unknown medication and alcohol in a suicide attempt. He is initially anxious and tremulous, but has normal vital signs and labs, aside from an elevated ethanol level. He has a seizure nine hours after ingestion. His EKG shows a widened QRS, and he becomes hypotensive. He is intubated, placed on vasopressors, and undergoes extracorporeal membrane oxygenation (ECMO) and targeted temperature management (TTM), but dies three days later. Episode 15, July 6th, 2022: Dr. Josh Trebach0:46:11 Case 1: Two British medical students present to the ED after developing nausea, vomiting, paresthesias, myalgias, pruritus, and cold allodynia 12 hours after sharing a meal. Their neurological symptoms persisted for 4 weeks and the cold allodynia for 10 weeks.0:54:18 - 1:05:23 Case 2: A 16-year-old female presents to the ED unresponsive and cyanotic after intentionally ingesting a substance purchased online. Her oxygen saturation is in the 70s and a methemoglobin level is greater than 30%. 1:05:25 - 1:10:18 Case 3: A 48-year-old female, and co-author of the published case report, presents to the ED 10 minutes after eating a “peppery” tuna steak. She is tachycardic, hypotensive, flushed, and has conjunctival erythema. She also experiences abdominal pain, nausea, vomiting, diarrhea, headache, and chest pain. Her EKG shows tachycardia with ST depression. She requires phenylephrine to maintain her blood pressure. She is treated with famotidine and discharged from the hospital 43 hours later. 1:10:20 – 1:13:16 Case 4: A 63-year-old female presents to the ED 12 hours after ingesting five capsules of a weight loss product. She is bradycardic and has nausea, vomiting, and hyperkalemia.Episode 17, November 9th, 2022: Dr. Emily Kieran1:16:35 Case 1: A 34-year-old female presents to a clinic in West Bengal, India, with a three-year history of skin changes. She has hypo-pigmented macules on a background of hyperpigmentation, creating a “raindrop” like appearance on her...

Join host Ryan Feldman in an insightful episode of "The Poison Lab" as he sits down with Dr. John Downs, Director of the Virginia Poison Center, and one of the leading experts on per- and polyfluoroalkyl substances (PFAS), commonly known as "forever chemicals." Known for their persistence in the environment and human body, PFAS have raised significant public health concerns over the past few decades. Dr. Downs shares his journey through occupational medicine, toxicology, and public health, which uniquely positioned him to provide expertise on PFAS exposure, health risks, and ongoing regulatory efforts. Together, they delve into the origins, uses, and potential health effects of these ubiquitous compounds, while examining government policies, environmental impact, and strategies to reduce exposure. A must-listen for anyone interested in the intersection of environmental health and toxicology! Episode Breakdown:2:42 – What Are Forever Chemicals?8:01 – History of PFAS and Associated Health Concerns15:41 – Government Regulation of PFAS20:42 – Shortcomings in PFAS Regulation25:20 – How Individuals Can Mitigate Risk31:15 – Testing for PFAS Levels and Exploring Treatment Options41:14 – Future Directions and Research Needs for PFAS45:29 – Conclusion and OutroKey Topics Discussed2:42 – What Are Forever Chemicals?PFAS are a large group of man-made chemicals that are persistent in the environment and human body.The podcast focuses primarily on PFOA (perfluorooctanoic acid) and PFOS (perfluorooctanoic sulfonic acid), as these were the first compounds identified as having very long elimination half-lives, measured in years, and not undergoing significant human metabolismThe podcast mentions that there are potentially thousands of different PFAS compounds and that more research is needed to determine if they all induce the same health effects as PFOA and PFOSCommonly used for their water- and oil-resistant properties in nonstick cookware, fast food wrappers, firefighting foams, and more.8:01 – History of PFAS and Associated Health ConcernsFirst created by Dupont chemical, used widely in 1940's in TeflonLarge contamination of water by PFAS identified in West Virginia townLed to landmark study in West Virginia (the C8 study) on epidemiological data of PFAS-related health risks.Effects noted: High cholesterol, thyroid dysfunction, ulcerative colitis, hypertension in pregnancy, decreased immune response to vaccine, and certain cancers (testicular and kidney cancer).PFAS in the EnvironmentPFAS are not easily degraded, leading to bioaccumulation in humans and animals.Non-stick cookware: Teflon, the trade name for non-stick cookware, was one of the earliest applications of PFAS, utilizing PFOA.Firefighting foam: PFAS was used in firefighting foams, particularly for aviation fuel fires. This has led to contamination of groundwater around military installations and airports.Fast food wrappers and other consumer products: PFAS are used to make products water and oil resistant, including fast food wrappers, clothing, upholstery, and popcorn bags.Biosolids: The nitrogenous waste produced after wastewater treatment, have been found to contain concentrated PFAS. These biosolids are sometimes sold to farms as fertilizer, potentially contaminating water and crops.Ski wax: Ski waxers have been found to have a high degree of PFAS...

Ryan on others showsRyan on "22 at the Lips"Ryan on  "Continuing Studies"Support the showTox Trinkets (Rep the show at home!) Support Toxo's repairs Review the show ON YOUR APPReach the showEmail: [email protected] Show ResourcesGet Messages from Toxo (Newsletter)Ryan's Medical Games and ResourcesShow Website

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 manuscriptAbstracts07:48-Abstract #1. The NACSTOP2 trial: a multi-center randomized controlled trial investigating the early cessation of n-acetylcysteine in acetaminophen overdoseGuest- Dr. Anslem Wong, MD, PhD21:33- Abstract  #36. ECG intervals: does one size really fit all?Guest- Dr. Caitlin Roake, MD, PhD25:41- Abstract #85. Do abnormal electrocardiographic intervals predict death in poisoned patients older than 65 years?Guest- Dr. Michael Chary, MD30:06- Abstract #61. Minimum tetrahydrocannabinol dose that produces severe symptoms in children <6 years old with cannabis edible ingestionsGuest- Dr. Keahi Horowitz, MD36:25- Abstract #114. Frequency and severity of cannabis toxicity before and after legislative change to increase cannabis edible package sizeGuest- Dr. Robert Hendrickson, MD38:24- Abstract #101. Quantification of acetaminophen line-crossers in the setting o f overdose with delayed gastric absorptionGuest- Dr. Jamie Sterr, PharmD41:41- Abstract #175. Cause for pause: bradycardia induced by transdermal rivastigmine in anticholinergic deliriumGuest- Dr. Santiago Batista Minaya, MD46:21- Abstract #199. Cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) Syndrome with poor neurological outcome in the setting of suspected opioid useGuest- Jack Yang and Dr. Avery Michienzi, DO49:49- 191. Severity scores for caustic injury: Zargar they even used?Guest- Dr. Amar Chakrabortya, MD53:!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 adultsGuest- Dr. Ari Filip, MD59:10- Abstract # 26. Acute propranolol overdose and dose thresholds of severe toxicityGuest- Dr. Katherine Isoardi, MBBS1:06:05- 28. Risk of serotonin toxicity following acute lamotrigine overdoseGuest- Dr. Angela Chiew, MBBS, PhD (Introduction at 1:00:00)1:12:36- Interview with AACT President ElectGuest- Dr. Jillian Theobald, MD, PhDSupport the showTox Trinkets (Rep the show at home!) Support Toxo's repairs Review the show ON YOUR APPReach the showEmail: [email protected] Show ResourcesGet Messages from Toxo...

In this episode the poison lab hosts scientific discourse . Three listeners (Dr. Michael Mullins, Dr. Donna Seger, and Dr. Leon Gussow) write in their critiques surrounding specific recommendations and language used with the AHA 2023 Management of Poisoning Cardiac Arrest or Life-Threatening Toxicity guidelines. Lead author of the guidelines Dr. Eric Lavonas then responds to and addresses their points with counterpoints or appraisals. Tune in and draw your own conclusions!Link to guidelinesLink to high yield review Support the showTox Trinkets (Rep the show at home!) Support Toxo's repairs Review the show ON YOUR APPReach the showEmail: [email protected] Show ResourcesGet Messages from Toxo (Newsletter)Ryan's Medical Games and ResourcesShow Website

Have a burning question you have always wanted to ask a toxicologist? What are tips for managing an anticholinergic overdose? What is the deadliest poison? Why are they called lead pencils if there is no lead?! Send your questions in to [email protected] to take part in a future episode! (If you would like to be anonymous simply state it in the email)Support the showTox Trinkets (Rep the show at home!) Support Toxo's repairs Review the show ON YOUR APPReach the showEmail: [email protected] Show ResourcesGet Messages from Toxo (Newsletter)Ryan's Medical Games and ResourcesShow Website

In this episode Ryan is joined by two expert guests to help read listener guesses for the cause of this poisoning murder and shed light on the toxin involved in the case, which puzzled medicolegal investigators. Ryan is joined by Dr. Dan McCabe, MD (emergency medicine physician, medical toxicologist, medical director of Iowa poison center) and Dr. Crissy Lawson PharmD (emergency medicine pharmacist). SPOLIER ALERT Mystery case from the showReview Paper from Dr's  Lawson, McCabe, and Feldman (PMID: 38613376)Toxo's show note referencesTV special about Mary Yoder colchicine murderColchicine potential arrhythmic effectsGo fund me for Dr. Betty Bowman Support the showTox Trinkets (Rep the show at home!) Support Toxo's repairs Review the show ON YOUR APPReach the showEmail: [email protected] Show ResourcesGet Messages from Toxo (Newsletter)Ryan's Medical Games and ResourcesShow Website

In this bonus episode Ryan highlights some of the great episodes done in 2023 and compiles ALL of the stump the toxicologist segments from 2023 into one easy to consume episode. Test your toxicology differential skills with more than six poisoning cases. Check out the actual episodes for more information in the show notes on each of the poisonings. Frank Paloucek EpisodeAdam Blumenberg EpisodeSupport the showTox Trinkets (Rep the show at home!) Support Toxo's repairs Review the show ON YOUR APPReach the showEmail: [email protected] Show ResourcesGet Messages from Toxo (Newsletter)Ryan's Medical Games and ResourcesShow Website

Do you think you know the cause of these symptoms? Send your guesses to [email protected] to take part in the next episode Support the show!Rep the show!Show website