*NY Emergency Medicine Exclusive*
Congratulations to Helen - she is the first person to submit the correct answer to this week's VizD. Helen is the winner of $10
To view Helen's answer, click here
This week, Dr Lewis Nelson, Director of the Toxicology Fellowship at the New York City Poison Control Center will discuss the answer to this weeks VizD
NYEM: How frequent are diethylene glycol (DEG) poisonings?
LN: The DEG poisonings that make the news are the ones that occur in epidemics. It seems that every few years an epidemic DEG poisoning occurs somewhere in the world, and they are nearly always related to the use of DEG as a diluent/solvent for a medication. The first widely recognized epidemic occurred in the
NYEM: What makes diethylene glycol sweet in taste?
LN: Not only is DEG sweet, but so is ethylene glycol. DEG has even been purportedly used (illegally) in low quantities to sweeten wine. The reason for the sweet taste of these glycols (which are poly-ols) is likely related to the way these chemicals interact with our "sweet" taste receptors. Realize that sugars (such as glucose, which are receptors are likely supposed to sense) are also poly-ols, so this makes conceptual sense.
NYEM: It's interesting that the creation of the FDA was based on a poisonous elixir of diethylene glycol used in sulfanilamide, yet 70 years later we are still faced with this problem?
LN: This is likely due to the lack of sophistication and regulatory controls of these other nations. If you read the recent NY Times article on the path taken by the DEG to get from
NYEM: Have you recently seen a diethylene glycol poisoning in
LN: We have, though as mentioned above, it has been isolated in nature. Most cases have originated from the drinking of automotive or hydraulic fluid. In an odd case about two years ago, a young man was intentionally poisoned (in what I recall was a "joke") by the chemical used to make artificial fog, which contained DEG. Recently, a patient presented to her primary care physician with some vague complaints. On questioning she produced a bottle of Panamanian of "expectorante" purchased on a recent trip that that country. Although she did not have renal failure, her medication contained 8% DEG.
NYEM: If you were on a desert island and were poisoned with diethylene glycol but could only give yourself one of the following treatments – ethanol, fomepizol, or hemodialysis – which would it be?
LN: There is no know role for ethanol or fomepizole; in fact there is some weak suggestion that these may be harmful. The lack of insight stems from the fact that the parent compound, not the metabolite, may be the toxic component. This suggests that we need to be cautious making analogies between the various toxic alcohols. Hemodialysis is the treatment of choice as it clears both the parent compound (DEG) and any metabolites. However, if I was on a desert island I would go for the ethanol! (the thought of putting those catheters in my groin is pretty intimidating)
NYEM: Do you recommend a toxicology fellowship for Emergency Medicine Residents?
LN: Only for the motivated few, but this is a whole different discussion.
NYEM: What made you get so interested in toxicology?
LN: I understood pharmacology and physiology in med school.
NYEM: Do you have a favorite historical toxicologist?
LN: Lewis Goldfrank, although he may take offense to being labeled as historically important.
NYEM: How many editions are there of Goldfrank's Toxicology?
LN: Edition 8 is out, working on 9 already (only 4 years to go)
NYEM Are you working on any other books?
LN: Always! I, along with another like minded colleague and an ethnobotanist at the
NYEM: Thank you Dr Nelson
LN: Anytime!VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient. For more information please refer to the following link.