Holiday Special
Want to know about the dangers of mistletoe tea and snow flocking spray? What life-threatening complication alcohol can cause in a person who isn’t drunk?
This is the Pick Your Poison podcast. I’m your host Dr. JP and I’m here to share my passion for poisons in this interactive show. Will our patient survive this podcast? It’s up to you and the choices you make. Our episode today is the Winter Holiday Special, looking at holiday dangers, myths and misconceptions. Want to know about the dangers of mistletoe tea and snow flocking spray? What life-threatening complication alcohol can cause in a person who isn’t drunk? Listen to find out!
Today we're going to do something a little different with the format. Instead of one case, it’s a bunch of short, rapid-fire cases including some poisoning myths and misperceptions. Rapid fire cases mean rapid fire questions so I hope you're ready.
Case number 1 starts at the family holiday party. Your two-year-old nephew runs up to you holding a red leaf in his hand. Correction, part of a red leaf with a large bite taken out of it. The child is fine, in fact he's smiling with a smear of red on his teeth, and generally looks very pleased with himself. His mom, your sister-in-law, loves to decorate and this year filled the house with plants, including poinsettias. Obviously, he’s eating some.
Question 1. What now?
a. give syrup of ipecac to make him vomit up the leaf
b. call the Poison Center
C. Rush him to the emergency department
The answer is B call the Poison Center. Any poisoning concerns, always call the Poison Center Hotline at 1800-222-1222 for expert advice. If you’re in the medical field and you said no to all the options and elected to watch him for symptoms, full credit
Question 2. Poinsettias can cause life threatening toxicity. Fact or fiction?
a. fact
b. fiction
The answer is B. This is actually fiction. Very rarely, large ingestions cause mild nausea and vomiting. They can cause allergic reactions, more on this in a minute. The myth poinsettias are dangerously poisonous appears to be based on one death in Hawaii in 1919 of a 2-year-old attributed to, but never confirmed, to be due to poinsettias. Kind of amazing this myth persisted for more than 100 years.
Euphorbia is the Latin name for these plants. But what about pets, did I hear you say. that's question number 3. Poinsettias are poisonous to pets.
a. Fact
b. Fiction
Again, the answer is B fiction. In a rat study, researchers were unable to find any toxicity after feeding the rats large amounts of the plant. Cats occasionally vomit after exposure, like humans, but again other more serious complications aren't reported and in fact the ASPCA website reports that toxicity is generally overrated.
Moving right into question number four. I warned you at the beginning, when an ER doctor says rapid fire…” I mentioned earlier poinsettias can cause allergic reactions. There's a common cross-sensitivity with another type of allergy. What is it?
a. Latex
b. Seafood
C. bee stings
d. poison ivy
The answer is A. latex. This is really interesting and I had no idea about this before I started research for this episode. The Euphorbia family includes rubber trees which produce latex. Therefore, patients allergic to latex, might be allergic also to poinsettias because the plants have allergens in common.
Back to your nephew. If you called the poison center, they reassure you he’ll mostly likely be fine, at worst he’ll have some nausea and vomiting. You watch him closely for the remainder of the party. He’s perfectly fine and more in danger of vomiting from the large quaintly of desserts and candy he’s consumed than the few bites of the poinsettia plant.
Case 2
While you’re observing your nephew for symptoms, his twin, your two-year-old niece runs in from outside with a blast of cold air. She has red smeared on her hands and face. You go outside to check what’s she gotten into and discover the driveway is lined with bushes. The leaves are green and shiny with sharp spikes and the plant has pretty red berries. Holly bushes.
It looks like she might’ve eaten the holly berries. Question 5. What now?
a. give syrup of ipecac to make her vomit
b. call the Poison Center
C. Rush her to the emergency department
The answer is again B call the Poison center, who will recommend observation at home. Holly berries contain a toxin called saponin, once again the reputation of its toxicity outweighs its risk. If she only ate 1-2 berries, the most likely scenario, she’ll be fine. If she really ate a lot of berries, she might have nausea and vomiting. In one pediatric case, the patient became drowsy and lethargic.
Now you have two kids to watch closely, it turns out to be a very difficult job, meaning they are running around like maniacs and both are fine. A quick aside about why I choose 2-year-olds for these fictional cases. Pediatric poisonings have two spikes, around the age of two and again in the teen years. Poisonings in toddlers are generally exploratory, meaning children who get into things they shouldn’t like the plants or cleaning products under the sink. They have to be ambulatory meaning walking or at least crawling and by the time they reach 3 or 4 they know better than to eat things they shouldn't. The second peak in the teenage years are intentional poisonings, often with suicidal intent.
And what about syrup of ipecac. Do you have some in your house? Should you have some in your house? No. The American Academy of Pediatrics used to recommend all households have some in case of emergency and it was so widely available you could get it at Toys R Us. What changed? There’s no data ipecac reduces toxicity from poisoning, and in fact vomiting, as we've discussed before, can lead to aspiration and other problems. So it’s no longer recommended and actually is no longer available in the United states. Another side note for today’s pop culture consult, chronic ipecac toxicity causes heart failure and was the cause of death of 32 year-old singer Karen Carpenter who struggled with anorexia and bulimia.
Anyway, On the topic of holiday plants, what about mistletoe. True or False mistletoe can be lethal?
a. True
b. False
Answer a. True, though it’s a bit of a trick question. Most patients do fine after exposure, like a child eating berries or leaves. They might have nausea and vomiting. Death has been reported after drinking mistletoe tea, presumably due to concentrated toxicity. I wouldn’t worry too much if my niece or nephew ate the mistletoe, I’d definitely pass on mistletoe tea.
Mistletoe is an ancient, interesting plant. Its parasitic, and has to grow on trees to survive. Question 6. In Norse mythology, which God is killed with a mistletoe arrow?
A. Odin
B. Loki
C. Baldor
Answer. C. Baldur son of Odin and Frigg, God of War. His mother’s tears at his death turn into white flowers, leading to speculation this story is the source of the association between mistletoe and love.
Case three
It’s 6 am the day after the family holiday party. Your phone rings multiple times. It’s your sister-in-law. Your nephew is unconscious, they’re on the way to the Emergency Department. In real life, taking care of family is frowned upon as a conflict of interest, but this is fiction so you’re the doctor. At the bedside, he’s unconscious and unarousable. His vital signs and physical exam are otherwise completely normal. He doesn’t even move as the nurse places an IV. Is this poinsettia poisoning, a delay reaction from yesterday? No, there’s no delayed onset and an altered mental status with no other symptoms doesn’t fit.
What's the first test to check?
a. blood sugar
b. an alcohol level
C. a sodium level
Answer A. Blood glucose or blood sugar. One of the first things we do in patients with an altered mental status, is check a fingerstick. If a patient comes in by ambulance, the medics usually check it enroute. It's a quick and easy test for a problem that’s quick and easy to treat. Are we worried about low or high blood sugar? Technically both cause an altered mental status but a sudden change in mental status without other symptoms first, can be caused by low blood sugar. Wait, did I just hear you say this child isn’t diabetic? The nurse looks up from the blood glucose monitor and says blood sugar 27mg/dL (or 1.5 mmol/L). Normal is 70-100 mg/dL (or 3.9-5.5 mmol/L). Meaning your nephew's blood sugar is low, life-threateningly so.
What causes hypoglycemia, or low blood sugar, in medical terms? Drugs for diabetes, like insulin, are a common culprit. Your brother and sister-in-law don't have diabetes and don’t have any of these medicines in the house. Infection can result in a low blood sugar, but he’d have to be very sick with other symptoms. Seizures are a possibility. Maybe he had an unwitnessed seizure. Not eating is a culprit, but you witnessed him eating plenty at the party yesterday. There are many rare diseases causing low blood sugar, like inborn errors of metabolism for example, but this isn’t an endocrine podcast, it's a toxicology podcast. There is a classic toxin causing low blood sugar especially in children.
Question 7. What is it?
a. tobacco
b. Marijuana
c. alcohol
The answer is C. Alcohol is a classic cause of hypoglycemia in children. If a child eats a cigarette, or three cigarette butts, they are at risk for tobacco toxicity, however this causes flaccid paralysis, not low blood sugar. Marijuana causes the child to get high and have an altered mental status, again not low blood sugar.
We can discuss alcohol in a minute, but we need to treat him first, as this blood sugar is life-threateningly low. What’s the treatment? Simple. Sugar. Any sugar will do, in the hospital, we have dextrose. I’d give him an IV push of dextrose stat. Treating hypoglycemia is one of the satisfying things that never gets old no matter how many times you do it. Less than a minute after the medicine, he wakes up and is back to normal. Your brother and sister-in-law are relieved, but want to know what happened.
Alcohol is a classic cause of hypoglycemia. Chronic users often have low blood glucose, due to liver cirrhosis and failure. Unlike adults, in kids, hypoglycemia can develop with an acute, one-time exposure. Blood sugar regulation is complicated, but basically your liver is in charge of storing and releasing glucose if levels in the body get low. Glucose is stored in liver cells as glycogen. Children have small livers with small glycogen stores and are therefore more prone to hypoglycemia than adults. The liver of course is also responsible for metabolizing alcohol, doing so takes resources away from gluconeogenesis, ie making glucose. During a normal overnight fast, the body turns to glycogen stores to keep the blood glucose normal. In kids the small storage in the liver might not be enough in the setting of alcohol exposure.
Now that your nephew is awake the next step is to feed him a meal high in sugar and carbohydrates to make sure his blood sugar stays up. Do we need to call child protective services on your family? Did they give a two-year-old alcohol? No, it doesn’t take much alcohol to cause hypoglycemia in children. A few sips are enough. His parents say the party ended late, tired, they left the dirty dishes out to clean up this morning, including wine glasses. Your nephew probably drank a few sips, developed a low blood sugar overnight, becoming completely unconscious this morning. Good news he’ll be just fine. Important to remember even a few sips of alcohol are potentially dangerous in kids.
Case number four
Your sister-in-law calls you about your niece. These kids are having a rough holiday! She thinks the child ate a disc battery from the toy you brought to the party for them. Your sister-in-law says she had some gagging, but seems ok now.
Question 8. What next?
a. call the Poison Center
b. Rush her to the emergency department
C. give milk
The answer is B. Go directly to the emergency department. If you called the poison center first, that's also correct and they’ll tell you to go to the ED. I have no idea where giving milk as an antidote came from, but it’s not an antidote and won’t help. I’m glad she’s asymptomatic, nevertheless this is an emergency. Why? Button battery ingestion can cause life-threatening complications. The timer starts now because they happen in as little as 2 hours.
Once again, you’re the emergency medicine physician. Question 9. What do you do first?
a pump her stomach
b. get an x-ray
c. call the pediatric gastroenterologist
The answer B. The first step is an x-ray. We rarely pump stomachs anymore, given little proven benefit. Even if we did, it won’t help remove a battery. We may need a pediatric gastroenterologist, but they will want to know if we see a battery and if we do, it’s location. A missing battery doesn’t always mean the child ate it.
You order x-rays of the neck, the chest and down through the abdomen. If there’s no foreign body on x-ray, there’s no problem. She can go home.
Question 10. Which location is more worrisome?
A. A battery in the esophagus
B. A battery in the stomach
c. a battery in the small intestine
The answer is A. The esophagus is where injuries are most likely to occur if the button becomes lodged and requires emergent removal. If it’s in the stomach, you can observe to see if it passes.
The radiologist calls, telling you the button battery is stuck in your niece’s esophagus. Just the news you didn’t want to hear. Why are we so worried about these batteries? Why is the esophagus an emergency but not the stomach?
Over 3,000 battery ingestions are reported to poison centers each year in the United States. In the past ten years, mortality has increased sevenfold, despite the incidence of battery exposure remaining the same. Why? Because batteries have become stronger and more powerful. The reason why kid’s toys have those maddening tiny screws to change the batteries. It’s an attempt to reduce the risk of exposure.
Batteries in the esophagus can complete an electrical circuit inside the body, yikes, leading to electrolysis and liquefactive necrosis. This is much less likely to happen with batteries in the stomach. If it’s in the stomach, we typically give it 4 days to leave the stomach and 2 weeks to pass out of the GI tract, confirming with x-ray. If it doesn’t pass, rare, then it might have to be removed.
Back to our niece. This is a true emergency, as I said injury can occur in as little as 2 hours. You call the pediatric gastroenterologist. He’s at home, but leaves immediately to come in. While waiting, let's talk about the potential complications. Liquefactive necrosis is about as bad as it sounds, basically the esophagus turns into liquid and disintegrates. This in turn, means all sorts of other bad things can happen including esophageal perforation, pneumonia, a lung abscess, and mediastinitis, infection in the mediastinum around your big important blood vessels and your trachea. Also, fistulas, ie abnormal connections between the esophagus and other body parts like the mediastinum or the aorta. Exsanguination from perforation into a large blood vessel is possible. I could go on, but the pediatric gastroenterologist arrives. He sedates your niece with anesthesia and passes an endoscope, a camera down into her esophagus. Fortunately, he’s able to pull the battery out and reports no evidence of esophageal injury thanks to his quick intervention. This is a huge relief.
Case 5
Arriving home with your niece and sister-in-law, you notice someone laying in the holly bushes. Your sister-in-law says it's their 17-year-old neighbor. You tell her to get your niece inside and situated as she's still a little sleepy from the sedation, and you go to check on the teenager.
He opens his eyes when you speak to him, but they appear glassy and unfocused. White powder dots his face, especially around his mouth and nose. You notice a brown paper bag. You reach under the bushes and pull it out, scratching up your arm on the sharp leaves as you pull it out. Inside the bag is a spray can labeled Snow. You spray some into the air, dusting the holly bush with artificial snow. It’s snow flocking spray to decorate for the holidays. He sits up and reaches toward you, saying something unintelligible in garbled, slurred speech. He looks like he’s drunk. Is he intoxicated? Yes, but not with alcohol. In addition to fake snow, this can contains propellant, often a hydrocarbon. The snow flocking on his face is a sign he’s been huffing from the spray can to get high.
Question 11. If he continues to misuse inhalants, what complication is he at risk for?
A. lung damage
B. brain tumor
C. sudden death
D. low blood sugar
The door on the house next door bangs open. “Not again,” his mother yells. She grabs him around the waist and hauls him toward their house. He seems overall ok, no sign of sudden death, so you leave him to his mother and go inside to check on your niece. Listen to the sudden death = deadly breath episode for more about hydrocarbon exposure and risks.
These cases are fictional, as are all our cases, to protect the innocent. But they are based on real poisonings.
What’s the most dangerous pediatric exposure during the holidays? Grandma and Grandpa's pill bottle. Myself, I think it's safe to say every EM physician and toxicologist, has taken care of a child who's gotten into a grandparent’s medications. The classic story is grandma comes to visit, leaves her suitcase on the floor, and unknowingly her pills within reach of the toddler. A public service announcement and a holiday message from me Dr JP, if you’re expecting visitors this season, please, please make sure that their medicines are as securely stored as those in your own house if you have children or pets.
Last question in todays podcast. We talked about snow flocking spray. What was tinsel made out of before the 1970s?
A. Silver
B. Mercury
C. Iron
D. Lead
Follow the Twitter and Instagram feeds both @pickpoison1 and you’ll see the answer when I post it. Remember, never try anything on this podcast at home or anywhere else.
Thanks so much for your attention. It helps if you subscribe, leave reviews and/or tell your friends. Transcripts are available on the website at pickpoison.com.
While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Thank you. This holiday season, take care and stay safe.