Medical Toxicology Rotation
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Drug Safety Oversight Board Members
April 29, 2021 Drug Safety Oversight Board (DSOB) Roster Chair • Douglas Throckmorton, M.D., Deputy Director for Regulatory Programs Center for Drug Evaluation and Research Executive Director • Terry Toigo, R.Ph, MBA Associate Director for Drug Safety Operations, Center for Drug Evaluation and Research Food and Drug Administration Center for Drug Evaluation and Research (CDER) Office of the Center Director (OCD) Primary Member: • Robert Temple, M.D., Deputy Director for Clinical Science Office of New Drugs (OND) Primary Member: • Mary Thanh Hai, M.D., Deputy Director, Office of New Drugs Alternate Members: • Peter Stein, M.D., Director, Office of New Drugs • Ellis Unger, M.D., Director, Office of Office of Cardiology, Hematology, Endocrinology, and Nephrology (OCHEN) Office of Medical Policy (OMP) Primary Member: • Jacqueline Corrigan-Curay, Director Alternate Member: • Leonard V. Sacks, Mgr. Supervisory Medical Officer Office of Generic Drugs (OGD) Primary Member: • Linda Forsyth, M.D., Division of Clinical Review Alternate Member: • Vacant Office of Surveillance and Epidemiology (OSE) Primary Members: • Mark I. Avigan, M.D., Associate Director for Critical Path Initiatives • Judy Zander, M.D., Director, Office of Pharmacoviligance and Epidemiology (OPE) Alternate Members: • Gerald DalPan, M.D., M.H.S., Director, OSE • S. Chris Jones, Deputy Director, Division of Pharmacovigilance (DPV) II • Judy Staffa, Ph.D., R.Ph., Associate Director for Public Health Initiatives -Page 1 of 4- April 29, 2021 • Cynthia LaCivita, R.Ph, Director, Division -
Medical Toxicology Milestone Project
The Medical Toxicology Milestone Project A Joint Initiative of The Accreditation Council for Graduate Medical Education and The American Board of Emergency Medicine July 2015 The Medical Toxicology Milestone Project The Milestones are designed only for use in evaluation of the fellow in the context of their participation in ACGME-accredited residency or fellowship programs. The Milestones provide a framework for assessment of the development of the fellow in key dimensions of the elements of physician competency in a specialty or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency, nor are they designed to be relevant in any other context. i Medical Toxicology Milestones Chair: Susanne White, MD Working Group Advisory Group Michele M. Burns, MD, MPH Timothy Brigham, MDiv, PhD Beth Baker, MD Wallace Carter, MD Laura Edgar, EdD, CAE William W. Greaves, MD, MSPH Lewis Nelson, MD Robert Johnson, MD Louis Ling, MD Earl Reisdorff, MD ii Milestone Reporting This document presents milestones designed for programs to use in semi-annual review of fellow performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. They are descriptors and targets for fellow performance as a fellow moves from entry into fellowship through graduation. In the initial years of implementation, the Review Committee will examine milestone performance data for each program’s fellows as one element in the Next Accreditation System (NAS) to determine whether fellows overall are progressing. For each period, review and reporting will involve selecting milestone levels that best describe a fellow’s current performance and attributes. -
Approach to the Poisoned Patient
PED-1407 Chocolate to Crystal Methamphetamine to the Cinnamon Challenge - Emergency Approach to the Intoxicated Child BLS 08 / ALS 75 / 1.5 CEU Target Audience: All Pediatric and adolescent ingestions are common reasons for 911 dispatches and emergency department visits. With greater availability of medications and drugs, healthcare professionals need to stay sharp on current trends in medical toxicology. This lecture examines mind altering substances, initial prehospital approach to toxicology and stabilization for transport, poison control center resources, and ultimate emergency department and intensive care management. Pediatric Toxicology Dr. James Burhop Pediatric Emergency Medicine Children’s Hospital of the Kings Daughters Objectives • Epidemiology • History of Poisoning • Review initial assessment of the child with a possible ingestion • General management principles for toxic exposures • Case Based (12 common pediatric cases) • Emerging drugs of abuse • Cathinones, Synthetics, Salvia, Maxy/MCAT, 25I, Kratom Epidemiology • 55 Poison Centers serving 295 million people • 2.3 million exposures in 2011 – 39% are children younger than 3 years – 52% in children younger than 6 years • 1-800-222-1222 2011 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System Introduction • 95% decline in the number of pediatric poisoning deaths since 1960 – child resistant packaging – heightened parental awareness – more sophisticated interventions – poison control centers Epidemiology • Unintentional (1-2 -
Severe Metabolic Acidosis in a Patient with an Extreme Hyperglycaemic Hyperosmolar State: How to Manage? Marloes B
Clinical Case Reports and Reviews Case Study ISSN: 2059-0393 Severe metabolic acidosis in a patient with an extreme hyperglycaemic hyperosmolar state: how to manage? Marloes B. Haak, Susanne van Santen and Johannes G. van der Hoeven* Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands Abstract Hyperglycaemic hyperosmolar state (HHS) and diabetic ketoacidosis (DKA) are often accompanied by severe metabolic and electrolyte disorders. Analysis and treatment of these disorders can be challenging for clinicians. In this paper, we aimed to discuss the most important steps and pitfalls in analyzing and treating a case with extreme metabolic disarrangements as a consequence of an HHS. Electrolyte disturbances due to fluid shifts and water deficits may result in potentially dangerous hypernatriema and hyperosmolality. In addition, acid-base disorders often co-occur and several approaches have been advocated to assess the acid-base disorder by integration of the principles of mass balance and electroneutrality. Based on the case vignette, four explanatory methods are discussed: the traditional bicarbonate-centered method of Henderson-Hasselbalch, the strong ion model of Stewart, and its modifications ‘Stewart at the bedside’ by Magder and the simplified Fencl-Stewart approach. The four methods were compared and tested for their bedside usefulness. All approaches gave good insight in the metabolic disarrangements of the presented case. However, we found the traditional method of Henderson-Hasselbalch and ‘Stewart at the bedside’ by Magder most explanatory and practical to guide treatment of the electrolyte disturbances and in exploring the acid-base disorder of the presented case. Introduction This is accompanied by changes in pCO2 and bicarbonate (HCO₃ ) levels, depending on the cause of the acid-base disorder. -
Toxicology and Environmental Teaching Tue 1St Oct 2019
TOXICOLOGY AND ENVIRONMENTAL TEACHING TUE 1ST OCT 2019 CASE ONE The ambulance bring in a 50 year old woman who has been found confused at her home by friends. There is no history available, but she was last seen well around dinner yesterday. She has no known past history and her medications are unknown. Initial Obs: - GCS M 5, E4, V4 pupils large and reactive - SBP 110 - HR 120 - Sats 99% o/a - Afebrile - BSL 8 1. She is confused and denies any ingestion or overdose. She dose state she only took some sleeping medication. What investigations would you do and how would you manage her presentation? Look up NHI: prior hx, community dispensing etc Investigations: Bloods, VBG, ECG Consider differential diagnoses : sepsis, trauma, metabolic 2. You note a community dispensing for 60 x 20mg amitriptyline tablets a few days ago. Her ECG and VBG are shown, please describe and discuss the findings: Potential toxic dose > 10mg/kg onset, toxicity usually rapid onset in 1- 2hrs VBG pH 7.35 PCO2 4.0 HCO3 15 Na 143 K 4.2 Lactate 3.5 - Sinus tachycardia with first-degree AV block (P waves hidden in the T waves, best seen in V1-2). - Broad QRS complexes. - Positive R’ wave in aVR. ECG Features of Sodium-Channel Blockade Interventricular conduction delay — QRS > 100 ms in lead II Right axis deviation of the terminal QRS: o Terminal R wave > 3 mm in aVR o R/S ratio > 0.7 in aVR Patients with tricyclic overdose will also usually demonstrate sinus tachycardia secondary to muscarinic (M1) receptor blockade. -
Medical Toxicology Education in US Emergency
YAJEM-57358; No of Pages 2 American Journal of Emergency Medicine xxx (2018) xxx–xxx Contents lists available at ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem Medical toxicology education in US emergency medicine residencies pursuing fellowship while programs with a rotation (elective or manda- tory) reported an average of 1.15 graduates (SD: 1.4; range: 0–7) (p = 0.015). Programs offering a rotation had a statistically significantly Keywords: higher number of TOX faculty than those without (p = 0.008). Emergency medicine Medical toxicology Amongst the 57 programs that did not respond to the survey re- Residency quest, 25 had neither a mandatory or elective rotation listed on their Education website. Only 5 of these programs had at least 1 board certified/eligible medical toxicology faculty. 8 programs offered an elective in medical toxicology and 24 offered a mandatory rotation. Programs with rotation had an average of 1.25 faculty (SD 1.22 and range 0–5). Duration of Medical toxicology (TOX), a core content area of the American Board rotations was: 4 weeks (n = 20; 63%), 3 weeks (n = 3; 9%), 2 weeks of Emergency Medicine [1] and an American Board of Medical Special- (n = 6; 19%), and 1 week (n = 3; 9%). ties (ABMS) recognized subspecialty of Emergency Medicine (EM), We describe the nature of TOX education amongst US-EM-residency Pediatrics, and Preventive Medicine [2] focuses on the “diagnosis, man- programs. agement, and prevention of poisoning and other adverse effects due to We demonstrate a statistically significant difference in the number medications, occupational and environmental toxicants and biological of board-certified TOX faculty and graduates pursuing TOX fellowship agents” [3] The importance of TOX training has long been recognized. -
Medical Toxicology Core Content Task Force for the Medical Toxicology Subboard & Julia N
J. Med. Toxicol. (2012) 8:183–191 DOI 10.1007/s13181-012-0223-5 SPECIAL ARTICLE The 2012 Core Content of Medical Toxicology Lewis S. Nelson & Beth A. Baker & Kevin C. Osterhoudt & Curtis P. Snook & The Medical Toxicology Core Content Task Force for the Medical Toxicology Subboard & Julia N. Keehbauch & for the American Board of Emergency Medicine Published online: 30 May 2012 # This article is being published without copyright 2012 Keywords Core content . Medical toxicology. Curriculum Medical Toxicology. The Core Content encompasses the spe- cialty of medical toxicology and outlines the areas of knowl- edge considered essential for the practice of medical toxicology. Functionally, the Core Content provides the orga- Preamble nizational framework for the development of the medical toxicology certification and cognitive expertise examinations, In December 2011, the Medical Toxicology Subboard, com- and details the knowledge to be tested on those examinations, posed of representatives from emergency medicine, pediatrics, beginning with the 2014 examinations. In addition, the Core and preventive medicine, approved a revised Core Content of Content may serve as a template for the development of medical toxicology fellowship curricula. The previous version, 1 Medical Toxicology Subboard Members: Frederick Fung, M.D., initiated in 2000, approved in 2002, and published in 2004, Daniel A. Goldstein, M.D., Rama B. Rao, M.D., Anne-Michelle Ruha, will be retired and replaced by this new version. M.D., and Saralyn R. Williams, M.D. The first Medical Toxicology Core Content was devel- James H. Jones, M.D. (American Board of Emergency Medicine Board oped to assist in the construction of the first examination in Liaison), Julia N. -
Reporting Terminology and Codes Chemical Pathology (V3.0)
Standards for Pathology Informatics in Australia (SPIA) Reporting Terminology and Codes Chemical Pathology (v3.0) Superseding and incorporating the Australian Pathology Units and Terminology Standards and Guidelines (APUTS) ISBN: Pending State Health Publication Number (SHPN): Pending Online copyright © RCPA 2017 This work (Standards and Guidelines) is copyright. You may download, display, print and reproduce the Standards and Guidelines for your personal, non- commercial use or use within your organisation subject to the following terms and conditions: 1. The Standards and Guidelines may not be copied, reproduced, communicated or displayed, in whole or in part, for profit or commercial gain. 2. Any copy, reproduction or communication must include this RCPA copyright notice in full. 3. No changes may be made to the wording of the Standards and Guidelines including commentary, tables or diagrams. Excerpts from the Standards and Guidelines may be used. References and acknowledgments must be maintained in any reproduction or copy in full or part of the Standards and Guidelines. Apart from any use as permitted under the Copyright Act 1968 or as set out above, all other rights are reserved. Requests and inquiries concerning reproduction and rights should be addressed to RCPA, 207 Albion St, Surry Hills, NSW 2010, Australia. This material contains content from LOINC® (http://loinc.org). The LOINC table, LOINC codes, LOINC panels and forms file, LOINC linguistic variants file, LOINC/RSNA Radiology Playbook, and LOINC/IEEE Medical Device Code Mapping Table are copyright © 1995-2016, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license at http://loinc.org/terms-of-use.” This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO®). -
Lecture Notes on Toxicology
LECTURE NOTES For Medical Laboratory Science Students Toxicology Dr. Biruh Alemu (MD), Ato Mistire Wolde (MSC, MSC) Hawassa University In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education May 2007 Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00. Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Important Guidelines for Printing and Photocopying Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty. All copies must retain all author credits and copyright notices included in the original document. Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication. ©2007 by Dr. Biruh Alemu, Ato Misire Wolde All rights reserved. Except as expressly provided above, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission of the author or authors. This material is intended for educational use only by practicing health care workers or students and faculty in a health care field. PREFACE The scope of toxicology widened tremendously during the last few years. An important development in this discipline is mandatory because of the expansion of different industrial, medical, environmental, animal and plant noxious substances. -
American College of Medical Toxicology Interim Guidance for The
American College of Medical Toxicology Interim Guidance for the Use of Lipid Resuscitation Therapy Lipid resuscitation therapy (LRT) refers to the administration of a lipid emulsion with the intent of reducing the clinical manifestations of toxicity from excessive doses of certain medications. This therapy has shown very promising results in experimental (animal) models of poisoning by lipid-soluble cardiotoxic medications. 1,2 The data deriving from experience with similarly poisoned humans is highly anecdotal, although they do suggest that LRT may be beneficial. 1,2 The choice of if, and when, to initiate LRT is one that is solely discretionary and is based on the clinical judgement of the treating physician. Given the uncertainty of its beneficial effect in human poisonings, it is the opinion of the American College of Medical Toxicology that there are no standard of care requirements to use, or to choose not to use, LRT. However, in circumstances where there is serious hemodynamic, or other, instability from a xenobiotic with a high degree of lipid solubility, LRT is viewed as a reasonable consideration for therapy, even if the patient is not in cardiac arrest. The purpose of this document is to propose a treatment guideline if LRT is used as a component of the treatment of poisoned patients. If LRT is used, it should be instituted for patients with hemodynamically instability, not responsive to standard resuscitation measures, such as fluid replacement, inotropes, and pressors, where appropriate. The decision to use LRT instead of, or in conjunction with, other therapies that have been anecdotally reported to be effective, such as euglycemic-insulin therapy, is to be based on the clinical judgement of the treating physician. -
Medical Toxicology: a Distinct Medical Subspecialty Sprouting from Ancient Roots
Toxicology Medical Toxicology: A Distinct Medical Subspecialty Sprouting from Ancient Roots Yedidia Bentur MD Israel Poison Information Center, Rambam Health Care Campus, and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Key words: toxicology, poisoning, toxin, intoxication IMAJ 2008;10:747–748 The term "toxicology" is derived from the Greek words toxikos non-medicinal products in the home, workplace and environment or toxa ("bow") and toxicon ("the poison in which the arrows has led to increasing numbers of exposures and poisonings. At were dipped"). Today this term is used to define the science of the same time, suicide has been recognized as a leading cause of poisons – their source, chemical composition, effects, tests and death, including by poisoning. Clearly, despite the ever-expanding antidotes. Recognition of the potential toxic effects of various information on poisons and poisonings, a serious medical prob- substances is probably as old as mankind, dating back 18,000 lem has been created due to the lack of awareness to potential years to the prehistoric Masai hunters of Kenya who used poison hazards on the part of the public, as well as physicians' inability arrows. The historic poisons were plant extracts, animal venoms to keep pace with the growing amount of information and their and minerals. They were used for hunting, in wars, for executions limited training in toxicology. All these factors prompted the and in religious rituals. Currently abused agents were also known medical community to establish poison information (or control) in antiquity: cannabis in China (2200 B.C.), the hallucinogenic centers, first in the Netherlands in the late 1940s and in 1953 mushroom Amanita muscaria – "soma" in India (2000 B.C.), opium in the United States (Chicago). -
IFCC Curriculum
The IFCC Curriculum AUTHORS: R. Greaves, J. M. Smith SECTION AUTHORS: R. Greaves, C Florkowski, L. Langman, J. Sheldon The IFCC Curriculum was developed as part of the IFCC eAcademy project by the Committee for Distance Learning. Authors: Janet M Smith [email protected] Ronda Greaves School of Health and Biomedical Sciences - RMIT University, PO Box 71, Bundoora, Victoria 3083 Australia [email protected] Section authors: Evidence Based Laboratory Medicine Section Chris Florkowski Clinical Biochemistry Unit, Canterbury Health Laboratories, PO Box 151, Christchurch, New Zealand [email protected] Immunology Section Jo Sheldon Protein Reference Unit, St. George's Hospital, Blackshaw Road, London SW17 0NH - UK [email protected] Mass Spectrometry Section Ronda Greaves School of Health and Biomedical Sciences - RMIT University, PO Box 71, Bundoora, Victoria 3083 Australia [email protected] Loralie Langman Department of Laboratory Medicine and Pathology Mayo Clinic 200 2nd Street SW Rochester, MN 55905 USA [email protected] Contacts: [email protected] _________________________________________ The IFCC Curriculum - Rev 0 - December 2017 (effective until further revision) 1 Contents INTRODUCTION .................................................................................................................................. 4 SECTION A: Laboratory Organisation and Management .......................................................... 9 Section A1: Laboratory Principles and Procedures: Learning Objectives ......................