Finally, the journal club to rule ALL journal clubs.

In this episode of The Poison Lab, we tackle one of the biggest topics in emergency medicine and toxicology: Should naloxone be given during opioid-associated cardiac arrest? With three fantastic studies published in 2024, we’re diving into the data and hearing directly from the authors themselves.

Join host Ryan Feldman as he interviews Dr. Eric Quinn, Dr. Joshua Lupton, and Dr. David Dillon, some of the minds behind the latest research exploring the role of naloxone in out-of-hospital cardiac arrest (OHCA). With perspectives ranging from clinical outcomes to practical implementation, this episode offers a deep dive into what these studies tell us—and what remains unanswered.

But that’s not all! Featuring special guests Spencer Oliver and Chris Pfingston from EMS 2020, this roundtable discussion incorporates the real-world insights of prehospital EMS professionals who face these decisions every day. Together, the panel unpacks:

• Conflicting evidence on naloxone’s impact on ROSC and survival.
• The challenges of interpreting retrospective studies in a high-stakes setting.
• Ethical dilemmas surrounding randomized trials for naloxone.
• Practical considerations for paramedics and emergency physicians in the field.

Whether you’re a toxicologist, EMS professional, or just curious about the intersection of drugs, overdose, and resuscitation, this episode is packed with actionable insights, expert opinions, and engaging discussions.

Tune in now to explore the science, controversy, and future directions for naloxone in cardiac arrest care!

Studies discussed in the show

• Outcomes of Out-of-Hospital Cardiac Arrest Patients Who Receive Naloxone in an EMS System with a High Prevalence of Opioid Overdose – Dr. Eric Quinn.
• Association of Early Naloxone Use with Outcomes in Nonshockable Out-of-Hospital Cardiac Arrest – Dr. Joshua Lupton.
• Naloxone and Patient Outcomes in Out-of-Hospital Cardiac Arrest in Northern California – Dr. David Dillon.

Studies and guidelines mentioned

• Editorial by Dr. Lavonas on Dr. Lupton's study
• AHA 2023 Guidelines for poisoning cardiac arrest
• AHA 2021 Position statement on opioid overdose out of hospital cardiac arrest
• Study of opioid overdose death after bystander naloxone training mentioned by Toxo

Shows mentioned

• Chris and Spencer's excellent EMS show
• Ryan's Interview on Poisoning Cardiac Arrest Guidelines with Dr. Eric Lavonas
• Journal club with Ryan and Dr. Dillon

• Podcast

In this special holiday bonus episode, Ryan takes a look back at some of the most captivating episodes of The Poison Lab from 2022. Get ready for an ultimate test of your toxicology differential diagnosis skills as we compile all the "Stump the Toxicologist" segments into one streamlined, binge-worthy episode. Explore eight unique poisoning cases, be sure to check the show notes for a description of each case. time stamp of where it begins, and links to the original episodes, where you can dive deeper into the discussions and unravel the mysteries behind these intriguing cases!

Case Teasers and Time Stamps

Episode 13, March 2nd, 2022: Dr. Howard Greller

• 0:06:19 Case 1: A 19-year-old male collapses at home and presents to the ED unresponsive, tachycardic, and hypotensive, with a wide QRS complex on EKG and a serum lactate of 20.
• 0:22:58 Case 2: A 16-year-old female presents to the ED 9 hours after ingesting 100 tablets of an unknown medication in a suicide attempt. She presents with vomiting, lethargy, bloody diarrhea, and a metabolic acidosis. An abdominal x-ray shows numerous radiopaque tablets in her GI tract. She is treated with a redacted antidote and whole bowel irrigation, but her condition worsens and she develops liver failure. She is transferred to a tertiary care center for a liver transplant, but recovers. On day 12, she develops a lower GI bleed and bowel perforation and dies.
• 0:34:42 Case 3: A seven-month-old child presents with crying, cough, vomiting, and respiratory distress.
• 0:37:42 Case 4: A 32-year-old male with a history of alcohol use and depression presents to the ED seven hours after ingesting two handfuls of an unknown medication and alcohol in a suicide attempt. He is initially anxious and tremulous, but has normal vital signs and labs, aside from an elevated ethanol level. He has a seizure nine hours after ingestion. His EKG shows a widened QRS, and he becomes hypotensive. He is intubated, placed on vasopressors, and undergoes extracorporeal membrane oxygenation (ECMO) and targeted temperature management (TTM), but dies three days later.

Episode 15, July 6th, 2022: Dr. Josh Trebach

• 0:46:11 Case 1: Two British medical students present to the ED after developing nausea, vomiting, paresthesias, myalgias, pruritus, and cold allodynia 12 hours after sharing a meal. Their neurological symptoms persisted for 4 weeks and the cold allodynia for 10 weeks.
• 0:54:18 - 1:05:23 Case 2: A 16-year-old female presents to the ED unresponsive and cyanotic after intentionally ingesting a substance purchased online. Her oxygen saturation is in the 70s and a methemoglobin level is greater than 30%.
• 1:05:25 - 1:10:18 Case 3: A 48-year-old female, and co-author of the published case report, presents to the ED 10 minutes after eating a “peppery” tuna steak. She is tachycardic, hypotensive, flushed, and has conjunctival erythema. She also experiences abdominal pain, nausea, vomiting, diarrhea, headache, and chest pain. Her EKG shows tachycardia with ST depression. She requires phenylephrine to maintain her blood pressure. She is treated with famotidine and discharged from the hospital 43 hours later.
• 1:10:20 – 1:13:16 Case 4: A 63-year-old female presents to the ED 12 hours after ingesting five capsules of a weight loss product. She is bradycardic and has nausea, vomiting, and hyperkalemia.

Episode 17, November 9th, 2022: Dr. Emily Kieran

• 1:16:35 Case 1: A 34-year-old female presents to a clinic in West Bengal, India, with a three-year history of skin changes. She has hypo-pigmented macules on a background of hyperpigmentation, creating a “raindrop” like appearance on her...

Join host Ryan Feldman in an insightful episode of "The Poison Lab" as he sits down with Dr. John Downs, Director of the Virginia Poison Center, and one of the leading experts on per- and polyfluoroalkyl substances (PFAS), commonly known as "forever chemicals." Known for their persistence in the environment and human body, PFAS have raised significant public health concerns over the past few decades. Dr. Downs shares his journey through occupational medicine, toxicology, and public health, which uniquely positioned him to provide expertise on PFAS exposure, health risks, and ongoing regulatory efforts. Together, they delve into the origins, uses, and potential health effects of these ubiquitous compounds, while examining government policies, environmental impact, and strategies to reduce exposure. A must-listen for anyone interested in the intersection of environmental health and toxicology!

Episode Breakdown:

• 2:42 – What Are Forever Chemicals?
• 8:01 – History of PFAS and Associated Health Concerns
• 15:41 – Government Regulation of PFAS
• 20:42 – Shortcomings in PFAS Regulation
• 25:20 – How Individuals Can Mitigate Risk
• 31:15 – Testing for PFAS Levels and Exploring Treatment Options
• 41:14 – Future Directions and Research Needs for PFAS
• 45:29 – Conclusion and Outro

Key Topics Discussed

2:42 – What Are Forever Chemicals?

• PFAS are a large group of man-made chemicals that are persistent in the environment and human body.
• The podcast focuses primarily on PFOA (perfluorooctanoic acid) and PFOS (perfluorooctanoic sulfonic acid), as these were the first compounds identified as having very long elimination half-lives, measured in years, and not undergoing significant human metabolism
• The podcast mentions that there are potentially thousands of different PFAS compounds and that more research is needed to determine if they all induce the same health effects as PFOA and PFOS
• Commonly used for their water- and oil-resistant properties in nonstick cookware, fast food wrappers, firefighting foams, and more.

8:01 – History of PFAS and Associated Health Concerns

• First created by Dupont chemical, used widely in 1940's in Teflon
• Large contamination of water by PFAS identified in West Virginia town
• Led to landmark study in West Virginia (the C8 study) on epidemiological data of PFAS-related health risks.
• Effects noted: High cholesterol, thyroid dysfunction, ulcerative colitis, hypertension in pregnancy, decreased immune response to vaccine, and certain cancers (testicular and kidney cancer).

PFAS in the Environment

• PFAS are not easily degraded, leading to bioaccumulation in humans and animals.
• Non-stick cookware: Teflon, the trade name for non-stick cookware, was one of the earliest applications of PFAS, utilizing PFOA.
• Firefighting foam: PFAS was used in firefighting foams, particularly for aviation fuel fires. This has led to contamination of groundwater around military installations and airports.
• Fast food wrappers and other consumer products: PFAS are used to make products water and oil resistant, including fast food wrappers, clothing, upholstery, and popcorn bags.
• Biosolids: The nitrogenous waste produced after wastewater treatment, have been found to contain concentrated PFAS. These biosolids are sometimes sold to farms as fertilizer, potentially contaminating water and crops.
• Ski wax: Ski waxers have been found to have a high degree of PFAS...