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Okay, so let's get back into

how overdoses can occur. So accidental. I talked about my daughter, um my

best friend Carrie works for DCF in Palm Beach. She

investigates

Children's deaths. It is a difficult job.

I mean, unfortunately we do have to have people that do that.

But she goes into cases where a child has passed away and

she has to investigate the parents and look over the situation.

It really is tough.

So one of them was a parent who had given their child liquid albuterol and had

misread the dosage and overdosed their child on

the albuterol and the child unfortunately died.

So every time I verify that drug,

remember you're looking extra closely

when you're doing anything pediatric because

there's so much more sensitive to these type of medications,

also the over the counter Tylenol.

So there used to be a

infant concentration of Tylenol and Children's concentration

of Tylenol and what have I said

over and over and over again about having more than one concentration of the

of the same medication really increased risk for Madeira, that's very dangerous.

So, um,

they took them all off the market after

a lot of babies had overdosed because the parents

had given them the Children's concentration instead of

the infant concentration and they reformulated them all.

Um now I think it's like what?

1 64 5 or something, 160 mg per five mL, I think, don't quote me on it. Um,

but now the infant formulation is the same as the

pediatric formulation is the same as the prescription formulation.

Any liquid Tylenol is the same concentration.

So if you get the one that says infant Tylenol,

it's it's just a little rebuttal with like

a smaller syringe because you're gonna give smaller,

you'll get like

uh 1.25 millimeters or 2.5 mL or something.

So it just comes with a smaller syringe,

but the concentration is the same and that's for safety.

Um

Okay, suicide.

Unfortunately, this is um

on the rise here in the US and the rest of the world.

Um I've had a couple of suicides on my watch in the 19 year career

and it is just gut wrenching to know that you were a part of it.

Um I didn't get a call from the hospital saying,

how many clonazePAM did you give this patient yesterday?

They took all of them at once. Um I also had a teenager who had dental surgery. Um He

filled the prescription, then told the dentist that he had lost the prescription.

Um and just to get to give him some more and um he ended up taking

all of the Percocet from both scripts and

then um ended up shooting himself unfortunately.

So just having that on your heart that you were part of that situation,

even though there's nothing I could have known or done,

it's still it's really difficult part of medicine to be involved in.

Um So these do happen a lot of times by prescription medications.

Another reason why you need to have your medicine locked up.

Make sure you're only taking what's prescribed for you.

Um Because unfortunately this is a situation that does occur.

And then poisonings I always think of poisonings.

It's like back in the day that you know the

In like the Renaissance period somebody got poisoned.

But this stuff is still happening today.

I wanted to pull up just in 2020 there was a Russian former spy who was poisoned,

what's his name was?

If you want to look it up, it's Alexi A. L. X. I.

The last name is knave, a knave Alani and A. V. A. L. N. Y. This is just in 2020 guys.

So he was poisoned by the

Novick cock poisoning. It's N. O. V. I. C. K. Okay.

Um which is an irreversible irreversible acetylcholinesterase um inhibitor.

So we know about those. So instead of being like

a regular acetylcholinesterase inhibitor it forms

a covalin bond with acetylcholinesterase.

So you can't reverse it. This is like a nerve block.

You know it increases the acetylcholine because

it cannot convert to its inactive forms.

We know all about this. Um But it is a covalin bond so it is hard to reverse.

Uh this was just in 2020 guys.

Um This poor guy also in 2018 2 former Russian spies were killed with this agent.

And um in 2015 a Bulgarian arms dealer was also killed for this agent. Um

I thought this was interesting because the one that happened in 2020,

they put this nerve agent in his underwear, that's how they got it to him.

They put it in his underwear, he puts his underwear on and gets poisoned.

I mean how you can't make this stuff up.

This is like in the movies and it just happened in 2020. Um

What was I gonna say about that?

Okay so Russia has the Russian Academy for Chemical Defense.

That's like a thing you can go to school for to the

Russian Academy for Chemical Defense to learn about creating chemical defenses.

So that's a little bit scary. Um But something I want you to be aware of that.

This is a thing and we are experts now

and a cyclical industries inhibitor um blocking agents.

Now we can totally figure this out. So um

let's see what else is that for the next one.

Oh so we can talk about the treatment now or we can talk about it later,

but they gave what they called sympathetic treatment.

So anti coal energy with anticonvulsants.

So um because we're gonna have such a build up of acetylcholine because

it's not going to break down because we're blocking the settler colonist race.

Um you're gonna have an increase of acetylcholine in the synapse.

So we're gonna give anti Colonna rejects and then we want to prevent the seizures.

So they also give anti

convulsants and what they called bio scavengers,

which is beautiful colonist raise.

So basically it looks for any sort of colon Esther

and hydra light's is it the reason why these bio

scavengers are good is because they're kind of non specific.

So any sort of toxic nerve agent, it can help with any of them.

It's kind of non specific for all of them.

So they can create all these new ones in the lab and you

can give these and they sort of are broad spectrum helpful of these.

So that's what they gave him. He I think survived and his

hiding out in Germany recovering but he started to become ill on a three

hour flight and the emergency landed the plane and he was able to get treatment

very quickly. Um He would have died for sure like the other ones.

But I think that he actually lived through this

one but it's just crazy to think about these um

like a pseudo colon related nerve

poisonings that are happening right now. 2020. Um Okay so then you also can.

Okay so that's like

a primary toxicity. A secondary toxicity is a drug drug interaction. So we give

and

we give an inducer to something who has a active metabolites.

So we give an inducer to a pro drug we're

going to induce it to have more active metabolite.

It's gonna have higher blood levels that we were not expecting.

So we didn't realize this drug interaction happens or um we are on Lipitor

and we give

close erythromycin and clindamycin is a set of from three p 4 50 A

three A four inhibitor and Lipitor is metabolized by 3842 it's inactive compound.

So we're on Lipitor. We give

Chloroform is because for a short course because we're a dentist and we didn't

uh look at these drug interactions and we didn't ask the patient what they were

on and all of a sudden there literature levels because they're already on 80

mg even though they shouldn't shoots up and then they get wrapped up dialysis.

So these secondary toxicities due to

drug drug interactions or inappropriate drug therapy

because we just gave too much or they had some sort of um

genetic reason of why they're either not breaking it down or they're you know,

something like that and those are much more common.

So the secondary toxicities are much more common.

That's what the pharmacist is for to look at those drug interactions,

make sure that we're being safe,

make sure that we're not using a major drug interactions together.

The biggest thing in looking at these is that

we are treating the patient not the toxin.

A lot of these um antidotes are toxic and it's great that we have

them but a lot of times the research like in theory they should work.

But then in research,

I mean in clinical practice they're not as effective as we would hope they would be.

So number one we're gonna do palliative care we're gonna make

sure that they their organ systems stay functioning until that drug

naturally gets out of the body.

Um But then if we have the antidote that's an added benefit

but don't let the antidote distract you from

A. B. CS

get their area under control.

Um

You know make sure that their blood is flowing. Check their E. C. G.

Let's just do normal keep them alive

until they the drug gets out of their body.

So antidotes can work on both kinetics or dynamics.

So remember add me absorption, metabolism, distribution elimination.

They can work on any of those factors by like finding it up in

absorption um working on the metabolism by the enzymes um that sort of thing.

Or they can you can optimize the urine let's get it excreted faster.

Or it can work on the dynamics by binding to the receptor

sites making like blocking the receptor sites so it doesn't activate them.

That sort of thing. Um You know I hate these terms but I'm gonna throw them in there. Um

E. D. Is the effective dose.

So that's the dose where you are going to

have your clinical effect or your therapeutic effect.

T. D. Is the toxic dose.

This is when we start to get not side effects but we've

given too much and we're having these um effects from it.

Remember a side effect is when we are in the

the effective dose and were expected these to occur a

toxic

um

you know a toxicity is when we're in a toxic dose,

we've given too much and these these side effects

would not occur in a normal range of dozing.

And then of course we have L. D.

Which is the lethal dose and they find this out in mice or whatever.

Okay um There's two variables route of administration and lag time.

So in a case of an accidental overdose um You know like

my daughter I was able to immediately call the poison control and um

be like what do I do?

So we could go to the hospital right away if we realize that it happens right away.

But in the case of like a suicide they may be in a

place where they are not expecting to get help for a while.

They put themselves in that situation where they

hope they don't get found for several hours.

And in that case we may be like we couldn't give a

like a like activated charcoal because at that point it's too late.

We have to use some sort of other method of um

Of neutralizing the toxin. Um so the time does matter.

I mean if they take it you know like a dog eats a bunch of raisins.

Like my sister's dog got into the um she had this really expensive yogurt,

she was really excited about it, she left it on the counter overnight.

She was really mad that she left her $4 yogurt on the counter and it was wasted.

Come to find out the dog eats it.

Dogs cannot eat raisins and messes with their kidneys

and it ended up costing her like a $400 vet

bill for this $4 yogurt that she was mad about because

she left it out but they gave him if a cat if a cat is a nausea vomiting inducing drug.

So we saw the dog eat the raisins, we know that that was right away, we rushed him to the

er and they gave him the cat to make him throw up immediately.

So if this happened later if there was more of a

lag time we wouldn't be able to give the Epa cac

cac used to be over the counter but we realized that

interesting kids vomiting it's kind of dangerous.

So we um it's only in the er now you can only get it in the er

okay so we went over these four mechanisms but we can go

over again um decrease the active

metabolites so what what's available circulating

in the bloodstream right now we can bind up the drug so

that it is um there's not as much active in the blood,

we can use like lipid therapy to kind of bind it up there or um

you know other other mechanisms of doing that we can block the

action of the medication so we can block the receptors so we can

take naloxone which blocks the opiate receptors so

that the opiates cannot bind to them.

We can decrease its toxic metabolites. For example Tylenol has a toxic metabolite.

We can stop the conversion to that toxic metabolite or we can just counteract the

effects if you have a full histamine

reaction because you're having an anaphylactic shock,

we're going to give epinephrine.

Epinephrine is not an

is not a histamine blocker,

it works on the alpha and beta receptors but

it counteracts the effects of that histamine overflow.

Okay so this is a big chart I'm gonna I'm trying to see here if I can look at this.

I don't know if we have time but we can get started on this.

Uh you're gonna have your toxin intake that um it's going to go

to the receptor or it's going to get metabolized by an enzyme.

Some of them get

metabolizes toxic metabolites which could cause these bad effects.

So we can work on each of these steps in order to uh kind of

stop this toxicity from happening.

So the first one is a direct action on the toxin. Sochi lading agents.

We don't have a lot of time here but I want to talk quickly about collecting agents.

These are heavy metals.

Um Iron magnesium, you can throw calcium in this group when we talk about

besides the antibiotics they are what we call the sweeter ions.

I don't know if you remember twitter ions from your chemistry class,

but they have a polar side and a non polar side.

These cat ions will bind up the the positive cat ions will bind to the

negative part of the ion and will render them not able to get absorbed.

So um they affect their absorption, they can't get into the bloodstream.

So uh as I told you guys before, I had a patient who um

was taken in an antibiotic and he wasn't getting any better come to find out.

He was drinking a gallon of milk a day.

The calcium was binding up the antibiotic and he just wasn't absorbing it.

So a calculating agent is like iron or magnesium that

binds up the drugs so that you don't absorb it.

Okay, we're about out of time for this one.

So we will start back with this gigantic picture in just a minute.

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