Hello and welcome back to SAR! As a pharmacist my role comes after the diagnosis, you can’t have a drug prescribed without having a reason to have it. In one area pharmacists become detectives however: overdoses. While we tend to think of illicit substances being the only drugs that someone can take too much of and become medically unstable, any drug including herbals, supplements, and over the counter products can precipitate into a dangerous overdose. Today we explore the major Toxidromes or groups of symptoms that clue us in on the kind of overdose the patient is experiencing. Huge thank you to u/hey_buddyboy for writing the story at the end of post--can you stop the death of a small child?
Disclaimer: this post is not designed to be medical advice. It is merely a look at the chemistry of medications and their general effect on the body. Each person responds differently to therapy. Please talk to your doctor about starting, stopping, or changing medical treatment.

Overdose Bingo

Technically, everything is considered a drug and over ingestion could lead to an overdose. Even the most innocuous substances, like water, can be deadly. Infamously in 2007, a 28 year old woman died after drinking 2 gallons (7.6 liters) of water in a few hours during a radio contest called “Hold Your Wee for a Wii.” Contestants had to drink as much water without urinating which ultimately led to her death via blood dilution—her blood literally became too watery. With the multitude of drugs we have nowadays it would be easy to think that each drug would cause their own specific set of overdose symptoms but generally we can categorize drugs. These categories, called Toxidromes, allow us to guess what drug the person may have ingested and what we can do to support them through the medical emergency. Learning about toxidromes is an important aspect of medical training because it helps with getting care as quickly as possible. Most overdoses are accidental, whether by the over ingestion of drugs or accidental ingestion of harmful toxins, but there is still the possibility of intentional overdose such as with suicidal behavior. Complicating matters further if a person mixes substances which may potentiate the effects of the drugs.
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• Generally with overdoses we look to 8 domains that allows us to guess what’s going on:
  • 1) Heart Rate - the heart is responsible for moving oxygenated blood to the periphery and organs and creating pressure to bring deoxygenated blood back to the lungs. Likewise, blood flow due to the heart moves nutrients to cells and removes wastes intended for excretion. Heart rate is a closely controlled function—the heart can be sped up or slowed down depending on the needs of the situation. When you exercise, a faster heart beat allows for oxygen and carbohydrate distribution which supports your movement. During rest, a slower heart beat allows the cardiac muscle to rest thus preventing stressing it out.
    • During a drug overdose, heart rate can be pushed to the extreme in either condition. If slowed down too much, oxygen may not be provided to cells which starves them of life. If this is significant enough it may prevent the brain from getting enough oxygen which leads to a stroke. A too fast heart rate may tire out the heart prematurely leading to Heart Failure. Heart Failure should be thought of an old tired heart that wants to do the hard work but physically cannot beat fast enough or strong enough to do so.
  • 2) Blood Pressure - If the heart is controlling blood flow then the blood vessels help channel it where it needs to go. Just like a hose, the blood vessels are a web of tubes that guide the blood to each and every cell in our body. They can also flex, becoming wider to allow more blood to flow or thinner to restrict the blood flow. The sum of the blood flow is the pressure that we talk of and let’s us see how much strain there is on the blood vessels.
    • What happens when you overpressurize a tube? Well the liquid can back up and damage the origin point, it can split the tubing itself, or it can damage the destination point. Too high blood pressure is the same thing; when the blood vessels aren’t able to dilate enough, the extra pressure can damage the origin point (the heart), the tissue that carries the blood (the blood vessels), and put too much pressure on the delicate destination tissues (organs). While high blood pressure isn’t an immediate killer, it can cause irreparable damage over time or during hypertensive crisis (way too high blood pressure) it can literally tear organs in half.
    • Too low blood pressure prevents blood from flowing where it needs to go. It doesn’t matter how hard the heart pushes if the blood vessels are so dilated that they prevent blood from being delivered to the organs. This leads to hypotensive issues like syncope (fainting) or low organ perfusion (organs die due to no blood).
  • 3) Respiratory Rate - If you didn’t know, everyone needs to breathe (everyone also poops in case you forgot that too). The lungs are the site of gas exchange where oxygen is inhaled and carbon dioxide is exhaled. While it may be obvious that a drug overdose causing decreased breathing is dangerous, what about increased breathing? How could breathing too much be dangerous? When we exhale, we expel carbon dioxide which is normally dissolved in our blood as bicarbonate. Its the bicarbonate that controls our blood’s pH and large changes in pH can cause enzyme dysfunction, cellular dysfunction, and even tissue death. So yes, breathing too much can be just as dangerous as breathing too little.
  • 4) Temperature - the body’s temperature fluctuates over the course of day depending on the time, level of activity, and condition. Generally though most people stay between 97F and 99F (36.1-37.2C) which is the optimal temperature for enzyme and cell function. If someone becomes too hot, proteins and enzymes can start to break down which can lead to cell death (depending on how high, someone could literally cook). Likewise too low a temperature can make cells work too slowly which means they are unable to support themselves which also results in death.
  • 5) Mental Status - in this section we define four statuses: depressed, normal, agitated, and delirious (psychosis) which exist on a scale. Generally a person will be experiencing the extremes of these statuses and the kind of mood that they are can be obvious. If a person has ingested multiple substances they can swing between multiple statuses as certain drug leave their system or, in the case of extended release drugs, they suddenly hit. This domain can make treating overdoses a very scary thing because these patients are experiencing extreme trauma. It may also be a reason why the person doesn’t seek help or refuses it when its offered.

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• 6) Pupils - Ahh the eyes, the windows to the soul and overdoses. Pupil size is a big factor in determining what kind of overdose is happening since the eyes are 1) easily accessible and 2) controlled by both halves of the nervous system. The latter point also has an added point that changes in pupil size are fairly obvious—we can see what a pinpoint pupil looks like versus a fully dilated one. That being said the true measure comes when we test the pupillary response. If the doctor shines the light in a patients dilated eye and it doesn’t contract, there is a good indication that a drug is forcing it to be dilated. Likewise, a tiny pinpoint pupil shouldn’t exist indoors since there isn’t enough light to warrant such a small pupil size.
• 7) Skin - Like the eyes, the skin is also innervated by both halves of the nervous system which allows for us to see one of three states: normal, diaphoretic (sweaty), or dry skin. Now it can be hard to separate temperature and sweating such as when a feverish person sweats because their body is hot. But if a person is at normal temperature and their armpits are very moi—i mean wet, then there is a good indication of diaphoresis rather than a normal sweating response. Likewise someone that is feverish should be sweating and if they’re dry then there is another indication.
• 8) GI Tract - Finally we have the gastrointestinal tract which consists of the mouth, stomach, intestines, and rectum. In this regard we are listening for bowel sounds in a patient to see if their GI tract is acting normally. During an overdose, someone could be experiencing a “faster GI tract” that is moving feces faster than it should which results in diarrhea or a slowed down GI tract that is preventing the removal of fecal matter, such as constipation. Like the eyes and skin, the GI tract is innervated by both halves of the nervous system which allows for this duality of symptoms.

Pinpoint Pupils, Pinpoint the Issue

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Now that we have conquered the domains, we can start to look at some Toxidromes! Traditionally there are six sets of symptoms that are classically attributed to certain substances. The first one we will look at is the opiate toxidrome which is caused by, you guessed it, opiates! The opiates are a class of drugs derived from Morphine which is a polycyclic drug dubbed a morphinian (named after the drug). Overtime we learned how to modify the structure of Morphine to make the drug more potent (same effect with lower dose) or more efficacious (heightened effect at the same dose). Later developments allowed us to make semi-synthetic derivatives like Oxycodone (1916), Hydrocodone (1920), and Buprenorphine (1972). Heroin (used a Diamorphine in hospitals) was discovered in 1874 and is simply an acetylated form of morphine despite it being 3x as strong. Paul Janssen (yes that Janssen) developed Fentanyl in 1959 and its 50x more potent than Heroin and 100x more potent than Morphine.

• Since opioids have become more and more potent over time (smaller and smaller doses are needed to get the same effect), the risk of accidental overdose is incredibly higher. Pictured next to the penny is the lethal dose of Fentanyl, 2mg. Remember that opiates are depressants; their job is to inhibit the function of the nervous system and are extremely good at doing so. When someone takes prescription doses of opiates, they may feel CNS depression in the form of sleepiness or impaired thinking, which is why its important not to drive until you know how medications affect you. The problem with opiate prescriptions is that the dose is variable—someone gets their tooth pulled and are given 30 Oxycodone tablets to take every 4-6 hours as needed for pain. Well what happens if they take too much? Or a child in the house takes the medication thinking it's candy? That’s when an overdose can happen.

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• Luckily the signs and symptoms of opiate overdose are pretty specific and are dubbed the Opioid Triad: CNS depression, respiratory depression, and pinpoint pupils. By the time an overdose is happening, the brain is being turned off and the person will probably fall unconscious and may be unrousable. Likewise the person’s respiratory center is impaired and doesn’t accurately send the signal to breathe. This means that they could have shallow breaths or stop breathing entirely leading to hypoxia and likely death. If they are able to get resuscitated, the likelihood of permanent brain or spinal cord damage is high. The last triad sign is pinpoint pupils which is a useful diagnostic symptom that is easy to determine. If you were to lift the eyelid of a person suspected of an opiate overdose, their pupil would be tiny and wouldn’t respond to dark environments. Generally the eye dilates when the eyes are closed but if you lifted the eyelid during an overdose, it would still be tiny.
  • In addition to the opiate triad the other signs are decreased, decreased, and decreased. Opiates are inhibitory so many of the functions in the body will slow down too. Heart rate will go down which will also cause the blood pressure to go down. Since the body is moving less, temperature will also be decreased. Opiates have a direct effect on the GI tract to stop peristalsis or the movement of food/feces along the intestines (which is why opiates cause constipation).
• One of the big things to remember with overdoses is the circumstances that lead to them. A child that accidentally ingests opiates to the point of overdose will present slower than an older adult due to many drugs requiring liver activation. LIkewise, many opiates are formulated in extended release tablets and capsules. So what happens when someone takes a few tablets, doesn’t have much effect after an hour and takes more? This extended release problem is also a big issue for when Naloxone (NarCan) is used. Naloxone is an opioid receptor antagonist and prevents the binding of the opiate to the receptor thus swiftly reversing the overdose. Using NarCan can help stop an overdose before it gets bad but it’s important to always send the person to the hospital following NarCan use. Why? Because the NarCan will dissipate faster than the extended release opiate will and so the person may have a follow up overdose. Another issue with opiate overdoses is the rate of co-ingestion. Opiates are often taken with other depressants like benzodiazepines or alcohol which can potentiate the CNS depression or respiratory depression. Opioid overdose is the most common cause of death in adults younger than 50 years old.

Over the Counter doesn’t mean completely safe

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Let’s imagine a scenario: you are eating a beautifully crafted salad that you spent over an hour preparing because you wanted to get the perfect Instagram snap. As you are enjoying your kale, quinoa, and shrimp salad you start to feel your tongue tingle and your throat is scratchy. Uh oh, you are having an allergic reaction to the shrimp despite not having one previously! In your panic, you decide to take some children’s strength Benadryl to stop the allergic reaction. 10 minutes later the drug isn’t helping and your throat is tighter so you take more Benadryl. Then you take more. And more. And more. Until you’ve finished the bottle. Nothing is helping so you then drive to the hospital where they stick you with an EpiPen and then you tell the doctor how much Benadryl you took. He says “you took how much?!?!” and then calls Poison Control because you have overdosed on the anti-histamine. Not only did you overdose yourself, you took 750% the recommended dose.

• As unbelievable as that story sounds, Poison Control gets countless calls each day about people who have taken more of a medication than they should have because they didn’t understand the risk. In fact, that story above is a true one! That person is my mother, hi mom! Public shaming aside, her tale is a cautionary one because the medications that we take over the counter can be just as dangerous as the ones that we are prescribed. Let’s look at some examples:
  • Diphenhydramine (Benadryl) belongs to a class of drugs called the anti-histamines, which as the name suggests, counteract the action of Histamine in the body to prevent allergic reactions. Anti-histamines also have anti-cholinergic activity which block the action of acetylcholine used by the parasympathetic nervous system. The PSNS is responsible for the rest and digest state of the body and controls many of the processes that happen when we aren’t up to much such as tissue repair and digestion. Anti-cholinergic activity isn’t unique to just anti-histamines; there are drugs that are used specifically for that purpose like Atropine, Dimenhydrinate (Dramamine), Hydroxyzine (Atarax, Vistaril), Ipratropium (Atrovent), Tiotropium (Spiriva), Tolterodine (Detrol); or drugs with anti-cholinergic side effects: tricyclic antidepressants (Amitriptyline, Nortriptyline, Doxepin), Antipsychotics (Olanzapine, Clozapine, Quetiapine, Promethazine), and so much more. For a complete list, click here.

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• When someone overdoses on an anticholinergic drug they fall into the anticholinergic toxidrome which I dub the analogy man due to the five common symptoms:
  • Hot as a Desert - because the body is sensing something is wrong, it is trying to push the nervous system into fight or flight which causes an increase in heart rate. This increased heart rate and muscle shaking leads to heat generation and a spike in temperature.
  • Dry as a Bone - during rest and digest, the person isn’t sweating because they shouldn’t be exerting any action. As such, during anticholinergic overdose the person isn’t able to produce any sweat despite a rise in temperature.
  • Red as a Beet - due to the dilation of blood vessels close to the surface of the skin in order to release the heat the person isn’t able to via sweating.
  • Blind as a Bat - anticholinergic drugs cause the eyes to dilate which makes them unable to accommodate correctly for the amount of light in the room. This means a person is unable to focus the lens correctly making them effectively blind. Likewise, they are unable to constrict the pupil in bright light which may lead to retinal damage. You can see how dilated the patients pupils in the photo above.
  • Mad as a Hatter - one of the major complications of anticholinergics is their ability to block acetylcholine inside the brain. During an overdose, this leads to an agitated (hyperactive) delirium in which the person can be confused, restless, and picking at imaginary objects. Interestingly this mimics Alzheimer’s symptoms which is thought to be due to the degradation of cholinergic neurons thus resulting in a hypo-cholinergic state.
• Anticholinergics aren’t only found in drugs. There are hundreds of Poison Control reports of people ingesting plants from their garden such as Belladonna and Jimsonweed which contain anticholinergic alkaloids like Atropine and Scopolamine and end up poisoning themselves. One such case is when a family of six ingested Jimsonweed in a stew thinking that it was another plant from their garden. At 9pm the six family members were enjoying the stew and by the time an additional family member arrived at 10pm, the entire family was laughing, confused, and hallucinating. After one person vomited, the unaffected family member calls 911 and all six people were transported to the hospital. Physical examinations revealed tachycardia and dilated, sluggishly reactive pupils in five of the six patients. “Temperatures ranged from 98.0ºF (36.7ºC) to 99.4ºF (37.4ºC). Respirations ranged from 17 to 22 breaths per minute.During the next 6 hours in the emergency department, the six patients continued to experience tachycardia (fast heart beat), mydriasis (dilated pupils), and altered mental status. One remained unconscious. The others demonstrated confusion, aggression, agitation, disorganized speech, incoherence, and hallucinations. All six were admitted to the hospital, five to the intensive-care unit. The unaffected relative reported to providers that pesticides had been sprayed on mint leaves that might have been incorporated into the stew. However, a treating physician consulted the poison control center hotline and established that the illnesses were not consistent with cholinergic poisoning, as would be expected with ingestion of organophosphate pesticides, but were consistent with anticholinergic poisoning.” Luckily all six people recovered without complications and everyone was discharged by the fifth day.

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• Another medication that people often overdose on is Acetaminophen/Paracetamol (Tylenol) but not for the reason you might think. Most people who take APAP only ingest one to two tablets/capsules when they need relief without thinking much of it. And that would be fine if that’s where it stayed. Acetaminophen is an extremely common co-ingredient in many over the counter formulations. In fact there are over 600 different over the counter products that contain acetaminophen in them. This makes it extremely dangerous if someone takes their two tablets of Tylenol for their arthritis, then takes some Excedrin for their headache, and then some Mucinex for their cold symptoms. All three products contains Acetaminophen and each time the person takes a product that contains it, they are at risk of overdosing.
  • The max 24-hr period dose of APAP is 4000mg or 4g and this is a firm number—do not go over it unless your doctor gives it the go ahead. The reason is because Acetaminophen is extremely heavy on the liver to process. Luckily the minimum toxic dose to do significant harm is 7500mg or 7.5g of Acetaminophen in a 24 hours period which gives you a little more wiggle room in case you take too much. So why is APAP so toxic? It all has to do with metabolism!

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• Acetaminophen is metabolized by the liver via two pathways: the glucuronidation pathway (blue) and the cysteine conjugation (yellow). The majority of Acetaminophen is sent through glucuronidation but a little bit of it is sent through the CYP2E1 enzyme which produces the toxic metabolite, NAPQI. When NAPQI exists, it causes cells to literally explode which is no good for the liver. Luckily the body is able to use a molecule called Glutathione to swiftly mop up the NAPQI before it’s able to much (or any) damage. That is unless you take a lot of Acetaminophen—as someone takes more than 4000mg of APAP, the reserves of detoxifying Glutathione starts to go down and eventually depletes completely. This leads to a build up of NAPQI which eventually causes acute liver damage.
• I can already hear some of you saying, “well can’t you just take some glutathione to stop the liver damage?” You could but glutathione is very poorly absorbed by the body, only about 17% makes it to the blood and only about 3% stays in the liver.
• The first signs of Acetaminophen overdose are pretty non-specific. The person will generally appear pale and have intense nausea and vomiting or could be completely without symptoms for the first 24 hours. Eventually as the damage to the liver continues, they experience intense right-sided stomach pain where their liver is and it may even progress into acute kidney failure. Fortunately we do have a couple of things we can do to support them:
  • If we know the person ingested too much Acetaminophen, such as a child discovered to swallow tablets thinking their candy, we can administer activated charcoal to try to bind to the drug before its absorbed. This remedy only works if the person catches the overdose within 4 hours of ingestion. After four hours we use the antidote N-Acetylcysteine (NAC) which is the precursor to glutathione. By giving the precursor we can help the body produce more glutathione and help the liver process the Acetaminophen. [I know some people will think of gastric lavage (a.k.a stomach pumping) but that technique isn’t used much anymore. Unlike activated charcoal which can travel into the intestines, the gastric lavage really only sucks up contents in the stomach and beginning of the intestines. This means that anything that progressed further than what we can suck up won’t be extracted and will still cause overdose. There is a lack of evidence and multiple complications associated with stomach pumping.]
• A helpful tip from u/Bubzoluck! Let’s say that you are indulging in some nice cold drinks and then whacked stubbed your toe on the corner of a coffee table. What over the counter pain med should you take: acetaminophen, ibuprofen, or either? The right answer is… ibuprofen! Remember that alcohol is taxing on the liver because it also uses Glutathione for its metabolism. Taking APAP while drinking means two toxic molecules are competing for the same resource thus depleting it faster. Ibuprofen does not utilize Glutathione for its metabolism and is the safer option if you’ve been drinking. (It may cause more heartburn though. Can't have it all :P)

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Yeah, but your face is turning blue! Violet, you're turning Violet, Violet!

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Hopefully by now you have gotten a sense that overdoses do not need to be from just illicit substances—any chemical can be overdosed on. One last condition that I want to take a look at is Methemoglobinemia which is when there is an elevated level of methemoglobin in the body. (By the way, methemoglobin would be an awesome name for a dog or kid.) Our red blood cells are made up of four clusters of Hemoglobin, the globular protein that binds oxygen, transports it around the body, and then releases it where it needs to go. The pertinent atom in Hemoglobin is the iron ion which has an oxidation state of Fe+2 (Fe is the symbol for iron). It is only Fe+2 (a.k.a ferrous iron) that is able to correctly bind and release oxygen is a controlled manner. Sometimes through natural processes that Ferrous iron (Fe+2) is converted into Ferric iron (Fe+3) through an irreversible oxidative process in which that iron atom is now unable to bind oxygen correctly. The result is the creation of Methemoglobin which is blue in color unlike the normal red of Ferrous iron.

• Now the creation of Methemoglobin is a natural process that our body anticipates and about 3% of Hemoglobin is in this bad Methemoglobin state. That being said, there are conditions in which we can start to convert more and more Hemoglobin to the bad kind which impairs our ability to transport oxygen—this is where Methemoglobinemia starts. As levels rise above 3%, the person becomes Cyanotic (cyan is Greek for blue) and their skin and fleshy membranes start to take on a brownish-blue or gray hue. By this time the person is experience shortness of breath (feel like they can’t breathe, not because their lungs aren’t working but because their blood isn’t), and their brain starts being deprived of oxygen which causes confusion. As levels rise further, above 20% Methemoglobin the blood starts to take on a chocolate brown color as more and more of the blood is deprived of the ability to transport oxygen. By this point the person is experiencing extreme headaches and dizziness as their brain is starving for oxygen and may even fall unconscious. Coma and seizures also start to pop up at this time. Finally if levels rise above 70%, the person will almost certainly die.

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• As lovely as that experience sounds, luckily Methemoglobinemia is pretty rare. There are some co-morbid conditions that put people at higher risk of Methemoglobinemia such as anemia, lung disease, and disease with abnormal Hemoglobin structures (Sickle cell disease) but the majority of people should not experience it. One population is at higher risk is infants since they lack the robust levels of Methemoglobin reductase (CYPB5R) enzyme which helps convert the bad Fe+3 back to Fe+2.
  • Issues arrive when we take drugs or substances that inflate levels of Methemoglobin above what the body is able to handle. One such common source is the over-indulgence in Nitrate/Nitrile containing foods like contaminated drinking water, cured meats and cheeses, spinach, and arugula. When nitrates are ingested, they oxidize the Fe+2 to the bad Fe+3 form which can precipitate acute Methemoglobinemia. Now before you start throwing out all your pepperoni and parmesan, know that you have to eat a LOT of these foods for many days in a row to push your body into danger territory. Likewise nitrates are an essential nutrient that we need to absorb for healthy gut function. So y’know, moderation.

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• Another source of Methemoglobinemia is in drugs that contain Aniline derivatives. Aniline (shown as the top right compound) is a Benzene ring with a primary amine stuck on the side. During metabolism, drugs that contain this group can be oxidized into Methemoglobin-producing metabolites which may precipitate the condition. Now, if these drugs are being used correctly and as prescribed, the risk is exceptionally low, so if you take one please do not worry. But I also believe in patients knowing as much about their medications, so please be aware that if you are turning blue and take one of these medications, please go to the hospital. That being said, I will offer a word of warning about Benzocaine:

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• Benzocaine is an old drug—it was first discovered in 1890 and has been used as a topical anesthetic for a century. You may have heard of its brothers, Cocaine, Lidocaine, and Novocaine (which you can read a post about here!) When Benzocaine became over the counter in the 90s, it became a go to for patients to grab when they had aches or pains that pain medications wouldn’t solve. One such application was to put it on the gums of babies who are teething to provide relief. Unless a doctor has told you specifically otherwise, do not give infants Benzocaine. Adults are able to detoxify Benzocaine due to our heightened liver capacity but infants are unable to do so, the result is extreme methemoglobinemia in which 81% of the time there is serious injury and a 1.5% fatality rate. If a child is having teething discomfort, a cold towel or teething ring and/or rubbing children’s Tylenol on the gums is a much safer option than Benzocaine. And yes, there are products marketed towards infants that contain Benzocaine. Be very careful about getting products that are Benzocaine free. Read more on the FDA’s warning about Benzocaine.

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• Alright so we talked about causes, what about treatments for Methemoglobinemia? Well interestingly since our patients are blue, we will give them blue! Specifically, Methylene Blue, a synthetic dye that started off as a way of dying clothes a very deep blue. Kinda pretty, eh? The history of how a dye became a medication is an interesting one: In 1876, Methylene Blue was first synthesized by German chemist Heinrich Caro for industry purposes. With the colonial expansion of Europeans into places like Africa and India, the need to find effective anti-Malaria treatment guaranteed instant fame. During this time dyes were being used to dye microorganisms under microscopes so they could be viewed easier and it was discovered that unlike other thiazine dyes, Methylene Blue kills parasites in addition to dying them.

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• During WW1 two scientists Paul Guttmann and Paul Ehrich discovered that Methylene Blue was an effective treatment against the parasite that causes Malaria by messing with the iron the parasite uses, but not the humans. When the US was pulled into WW2 and the Pacific Theater began, the Navy used Methylene Blue regularly to treat sailors infected with Malaria. This sparked a mantra among sailors of “Even at the loo, we see, we pee, navy blue.” In 1943 it was disocvered that Methylene Blue could reverse carbon monoxide poisoning which produces a different kind of bad Hemoglobin in which the carbon monoxide is stapled onto the iron atom. With this discovery it was determined that Methylene Blue can be used to treat other kinds of bad hemoglins like in Methemoglobinemia and the rest is history.

We need your help!!

It’s been a slow day at the Poison Control Center so far, a day that has so far been filled with a smattering of calls here and there, where you answer people’s questions when it comes to how to properly take their medications and non-serious issues of accidental ingestions or skin contact with hazardous chemicals. You love your job, and greatly enjoy being helpful by teaching people how to keep themselves safe and healthy. For a long time now, you’ve taken pride in your work and love answering questions for people, whatever they might be. On busier days, the phone is often ringing with people having questions about their medications or certain symptoms they might be experiencing, and as usual, you take the calls with grace and expertise, as you are very knowledgeable on the topics of which you speak. But today, you receive a very different, much more serious call that has your blood racing; you almost feel bad for wanting something exciting to happen, since “exciting” in the medical field is often the last thing a person wants to hear, especially a patient. You pick up the phone, and a doctor by the name of Dr. Stephens, from the local hospital answers, asking for a specialist on call for the Poison Control Center hotline. “That’s me,” You answer, “What can I do for you?”
“We have a patient that came in today and we need some advice on how to proceed,” The doctor responds, her voice stern and serious to the point that you can practically see her face in your mind, and how red her face must be since she sounds a bit out of breath from running around. “We had a child come in, about two years old, male, and this is something I’ve never seen, but… He’s blue. I mean, his skin is just blue, he’s cyanotic and no one can figure out why, the parents aren’t able to tell me anything. But, that’s not the worst of it,” She sounds young, as though this might be one of the first times she’s handled an actual emergency room case on her own, and you feel sympathy for her, while at the same time you’re scrambling to grab a notepad and a pen to be able to scribble these symptoms down that she’s describing to you, so you can do your best to help. “The child is having trouble breathing, he’s stopped and had to be brought back a few times, he’s barely even reacting to stimuli and his eyes keep rolling in the back of his head, and his heart rate is off the charts… He’s had a seizure too before he even arrived in the ER to begin with. Are you getting all this down?”
“Y-Yeah, of course,” You stammer back, your mouth a bit agape from the seriousness of the situation, and despite all the training you’ve had for cases like these, suddenly having this case thrust upon you like this is making you start to sweat. “Anything else? Do you know what he was given to cause this?”
“The parents say they have no clue. Grandma was watching him, but she’s a little scattered, and the kid wandered into his older brother’s room, and apparently got into something under his bed, and the next thing the parents know, they’re getting a call from the grandma that she’s bringing the kid into the ER, since he ingested some drugs from under the older brother’s bed. Some kind of white, powdery substance, but we can’t figure out what it is since the brother won’t talk, and at this rate we’re about to lose the kid to a coma. I know this kind of thing is rare, so it’s just shocking to me that it’s happening here and now… Do you have any answers?” Her voice seems to snap at you as you jolt from the desk you’re hunched over, feeling as though she might as well be yelling at you from two inches in front of you.
“I… I don’t know, it could be a lot of different things, I-,” You start, and Dr. Stephens cuts you short.
“We don’t have time for I don’t know, this baby is dying and I need to figure out what caused it. The cops think it might have been cocaine and he might have mistook it for sugar, but what did they put in this guy’s cocaine to make someone’s skin turn blue?” She’s certainly not helping to lessen any of this newfound pressure with the way she’s barking at you, but you can understand her concern and the amount of pressure on her to get this right, as a child’s life currently hangs in the balance. You tell her you’ll figure it out right away and get back to her, to which she says, “I hope so, I’ll be waiting; we’re counting on this.”
You begin to wrack your brain, wondering what on earth this could be, the term that belonged to the toxidrome associated with someone turning blue from an overdose, and the antidote to save this child’s life. You know you don’t have much time, but you also believe in yourself, and your intelligence; you’re in this career for a reason, and it’s time to put your knowledge to the test!
What is the condition causing the child to turn blue and experience the aforementioned symptoms, and what found in the cocaine could have caused this condition to occur?
And that’s our story!. If you have any questions, please let me know! Want to read more? Go to the table of contents!
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