In this episode of The Poison Lab, host Ryan Feldman is joined by Dr. Amy Zosel, a medical toxicologist, emergency physician, and educator. Together, they use real poisoning cases to practice identifying toxins and flexing their toxic differential The conversation dives into intriguing and challenging toxicology cases, with a focus on educating listeners about real-world poisoning scenarios, myth-busting internet misinformation, and providing practical clinical insights.

Mini episode with Dr. Robert Bassett on Remembering Poisonous Mushrooms

Dr. Zosel and Ryan discuss:

14:15 Case 1

33:04 Case 2

• News story

37:00 Case 3

• New story

48:00 Case 4

• News story
• US outbreak

"Robocough"

Study about Naloxone in Clonidine overdose

Below this will be key takeaways regarding managing the poisonings discussed, it may ruin your experience if you are guessing the poisons

Key Takeaways:

• Amatoxin Mushroom Poisoning: The classic delayed onset of severe GI symptoms, followed by a latent phase, can mask progressive liver damage. Early recognition and treatment with hydration, silibinin, and possible liver transplant are critical.
• Tetramine Toxicity: Known for causing refractory seizures, tetramine is a rare but serious poisoning often requiring aggressive supportive care and anticonvulsants.

A Lethal mushroom hiding in edible mushrooms

Mushroom foraging danger

Resources Mentioned:

• National Poison Control Hotline: 1-800-222-1222
• National Suicide Prevention Lifeline: 1-800-273-8255
• SAMHSA Free Helpline: 1-800-662-HELP (4357)

Follow The Poison Lab:

• Twitter: @LabPoison
• Instagram: @tox_talk
• Website: www.ThePoisonLab.com

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If you are looking for links to Dr. Basset's initiatives check back later, they are not fully launched yet!

Check it out on Dr. Hamilton's website as well

Poison Mushrooms! Got’a Pic’em (GOTAAPPICEM) A mnemonic device to sort through mushroom ingestions – The Hot Stove League of EM/Tox

The GOTAA PPICCEM Mnemonic

Late-Onset (Severe) Toxic Mushrooms ("GOTA")

These mushrooms have delayed symptoms (>6 hours) and are associated with significant toxicity:

G – Gyromitrin (Gyromitra esculenta) – False morels; inhibits GABA, leading to seizures.

O – Orellanine (Cortinarius spp.) – Causes renal failure; famously poisoned The Horse Whisperer author.

T – Tricholoma equestre (Man on Horseback) – Leads to rhabdomyolysis.

A – Amatoxin (Amanita phalloides, Galerina spp.) – Causes liver failure; the most lethal mushroom toxicity.

Early Onset Nausea, Late Toxicity Mushrooms ("A²P²")

A² – Allenic norleucine (Amanita smithiana) – Found in the Pacific Northwest; early GI symptoms followed by renal failure.

These may present early but still cause significant toxicity.

P² – Paxillus spp. – Can cause hemolytic anemia and multi-organ injury.

Early-Onset Nausea Mushrooms ("PICCEM")

P– Psilocybin (Psilocybe spp.) – Hallucinogenic, similar to LSD, typically low toxicity but may cause hyperthermia or seizures.

Symptoms appear within 6 hours and are usually self-limited.

I – Ibotenic Acid & Muscimol (Amanita muscaria, Amanita pantherina) – Acts like a “mushroom speedball”, causing both stimulant and sedative effects.

C – Coprine (Coprinus spp., Inky Caps) – Induces disulfiram-like reaction with alcohol.

E – Emetic Mushrooms (LBMs: Little Brown Mushrooms) – Various species that cause self-limited vomiting and diarrhea.

M – Muscarine...

In this special collaboration with NephMadness, we're diving into the world of nephrotoxins with an expert panel from Virginia Commonwealth University. NephMadness is an educational competition modeled after March Madness, and this year, one of the featured regions focuses on plant-based nephrotoxins. Together, with our expert panel we break down the competing nephrotoxin teams: Tubular Toxins vs. Oxalate Offenders.

Joining us are Dr. Anna Vinnokova (Nephrologist), Dr. Rachel Khan PharmD (Neph pharmacist), Dr. Ethan Downes (Nephrology fellow), and the legendary nephrotoxicologist, Dr. Josh King (Board certified Nephrologist and Toxicologist). We ALMOST named this episode "Getting Downe with the Mad Neph King and the Bean Queens"... but we didn't, your welcome.

After the show, go to the blog and vote for your favorite!

Expect irreverent musings, deep dives into toxic plant exposures, and a mystery case reveal that will leave you questioning your diet.

Topics and Timeline of Episode:

Intro

Listener Guesses With Josh and Ryan– 8:30

Listener Winner – 25:42

NephMadness and Guest Introductions – 28:07

Toxin Reveal – 33:41

• NEJM Case report

Tubular Toxins – 35:46

• Aristolochic Acid & the Belgian Weight-Loss Clinic Outbreak – 40:30
• Black Licorice & Its Surprising Toxic Effects – 47:16

The Oxalate Offenders Team: How Dietary Oxalates Harm the Kidneys – 52:00

• Historical Context: First recognized through sheep die-offs when herds grazed on Halogeton glomeratus, a high-oxalate plant, leading to fatal poisoning.
• Oxalate in Plants: Functions to bind excess calcium in the soil.
• Impact on the Body: Plants high in oxalate but low in calcium can contribute to oxalate accumulation, this leads to binding calcium in the blood, creating calcium oxalate crystals and acute renal calculi. Chronic inflammation from excess oxalate deposition leads to CKD progression.
• High-Oxalate Foods: Spinach, Swiss chard, rhubarb, cashews. Everything in moderation!

Practical Advice for Clinicians & Patients on Herbal Medicine Use – 1:00:00

• Resources for identifying nephrotoxic herbal products
• Talk to your patients non judgmentally, open conversations, discuss efficacy (or lack there of, see resources below) and safety
• Herbal medicines are not FDA approved and may not contain what they claim to

Herbals may not all be safe: Josh King Discovering Contaminants– 1:01:11

Wrap up– 1:08

Key Takeaways:

• Aristolochic acid is a direct nephrotoxin, associated with progressive kidney damage and urothelial cancers.
• Black licorice toxicity results from...

Do you think you know the cause of these symptoms? Send your guesses to toxtalk1@gmail.com to take part in the next episode

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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...

Ryan on others shows

• Ryan on "22 at the Lips"
• Ryan on "Continuing Studies"

Review the show where ever your listening

Join as a donating member

• Ad free episodes
• Bonus content and early access
• Discounts and give aways on GOTA PICCEM Mushroom card game

The GOTTA PICCEM Poisonous Mushroom Game Landing Page!

• Email: Toxtalk1@gmail.com

More Show Resources

• Get Messages from Toxo (Newsletter)
• Ryan's Medical Games and Resources
• Show Website