Dr. Mark Crouch on Ingestions 6/11/26

Speaker A: Flair or flavor? So the first global health flair or flavor is no laptops, no phones and a quiz. So we need six groups which is going to be about three people in a group I guess. So let's have these three. One, let's have uh, uh, let's see case two and then maybe. Oh um, man the two like faculty level folks. Case three, Case four for these three and then. Uh, it is 2:12 at 2:17 your group is going to present answers to three questions at the bottom. I'm not looking for open evidence or all the blah blahs, I mean just basics of um, what you would do with the case that's in front of you. So I think it was case one. Case two, three, four, five. I said six, but it's bonus case. So you guys are on the bonus case. So give yourself another 4 minutes and 40 seconds. I took some of your time. Sorry, sounds like American time standard. Huh? It sounds like an American time standard. We're not on island time. We got a limited amount. Uh, You are working overseas. Is this US or in Papua New Guinea? You'll see on your case it might be specific. Now it's not specific to Papua New Guinea. Okay. You might see overseas Mission Hospital. We are talking about toxic ingestions. Mhm, yeah, sorry. Poisoning and ingestions. That was on the. That was on the. That's it. Three minutes left. What are your initial stabilizing? And it also depends on like. Probably not. My truck. Okay, you got two minutes. Well, I guess that's not a st. Where do you get more? Mhm. I'm thinking of the sketchy right now. I don't think so. Hey, one more minute. I don't know what that is. I mean it does have that. Yeah, yeah, I just. You have 20 seconds to save a life. Hey, time's up in your orders. So group one, I'm gonna read the case and then we'll ask. Group one, a three year old comes to you at their urgent care with their family. The 10 year old sibling says that her little brother stole all of her gum. And the parents present an empty Mentos pure fresh bottle. The child admits to eating them thinking they were candy. This is a true story. My daughter Anna was furious at my son Gabriel. So what follow up information do you want? Any symptoms? Okay, all right. Symptoms. How long ago did. Okay, okay. Whether there's concern that 10 year old had something else. Ah, uh, okay. I like that. That's my yarda. All right. I like where we're going. Let's go to case Two. Group two, you're working overseas in a mission hospital. A young woman arrives, vomiting. She was upset with her family because of them not approving of her boyfriend and drank a weed killer about 45 minutes ago. What information, what follow up information do you want? They have the bottle. Can we see, like what is in the wheat killer? Um, did you take anything else? How much she ingested and then like her vitals and exam. Okay, good. Group three, A, uh, two year old child comes to the rural ER that you're moonlighting in, ingesting something from under the kitchen sink. The parents didn't bring the bottle with them, but say it was used to unclog toilets. What other info do you want to know? So, uh, we kind of said, uh, more information about what the liquid looked like, what it was, what did it, what it was. Uh, and then does John have any other symptoms like vomiting? Has their level of consciousness been normal? And then any chronic medical conditions that could interact or medications that they might be on? Who was present with the child at the time? What? Who was present with the child at the. Oh, I see now. There was a. There was a kicker in there. They live one minute away from the hospital. Yes. Can you go over and get it? Go get the bottle. Our other thing was. Can somebody else go and text it? Because we're. Right. Text the picture. Group four, you're working in a mission hospital in the OPD and a staff member comes to you about a medication error that occurred on the ward. Dull. Patient was inadvertently given a dose of sepa chlor, 500 milligrams twice. What other info do you want? Any allergies that the patient might have? What was the original indication for the antibiotic? Medical history. Okay, I like that. Group five, that's here, right? Hey. A, uh, mother brings a 20 month old child to the minor care of the ER after she found him with an empty bottle of naturopathic vitamins he had taken as a blood build that she had taken as a blood builder. She can't remember how many range. She switched to other remedies some months ago for the same condition. What other info do you want? Well, this is bottle, just iron B12. What the patient's doing? Is he vomiting? Is the timing of the ingestion known? Uh, yeah. Okay. All right, good group bonus. Two young men come to the ER in a mission hospital, confused, agitated. They, uh, had dinner over a house cook fire a couple hours ago and prepared local produce. During your cultural orientation, you learned that those local foods include cassava and beans. What other info do you want? So we wanted to know if they were cooking inside or outside, what they were using as fuel for the fire. Was it wood? Was it charcoal? Was it plant fibers? What was the ventilation like, if it was inside? Um, were there any other toxins involved? Like, did they have alcohol while they were cooking? Uh, and then. Yeah. What are their symptoms that they have. Nice. I like all of that global health, public health lingo. Biofuel is the term for using grass or sticks or dung or anything else to make a fire that's not fully combustible. Kind of smoke and pollutants and stuff. So biofuel fires is what? That's. Okay, back to case one. What are your initial stabilizing steps for Gabriel? Whenever he popped these Mentos candies or Mentos gum? Uh, we're in a monitoring called poison control. Okay, we are poison control. Okay, you're in an urgent care. Anything else? Get some vitals. Okay. Do an exam. Okay. Like that. Okay, group two, you're in a mission hospital. Uh, what are your stabilizing steps for the young woman? Vomiting, ABCs, airy breathing, circulation and giving IV fluids for all the vomiting. Uh, like poison control or evaluating for need for maybe some reversing agents. All right, group three, two year old in the rural error. Also ABCs doing an IV. Is there IV medication they need to give? Poison control and wondering about whether activated charcoal is a good idea or not. Okay, good. Case four, the double dose of cefaclor. What are your steps? Monitor, get vitals exam. I'm not too worried. Okay, I can tell you said that without saying it. Page five. Uh, uh, the 20 month old with the vitamins stabilizing steps similarly, like assuming that the ABCs are. Okay, um, what avenue is just monitoring? Uh, sometimes vitamins are not in harmful. Other times, you know, you could get, um, like gastric lavage if it was really recent or if that's okay. And case bonus, the two young men start with our ABCs. They probably need oxygen since we're a little suspicious that this may be related to inhalational or carbon monoxide. Um, get their blood pressure, see if they need to, uh, have IV fluids, check their blood sugar if there are any co ingestions, and maybe send someone to see if we have any methylene blue in the pharmacy. Uh. Ah, methylene blue. I haven't taken a chemistry class in a long time. Bethlehem blue. Sounds important. All right, case one. Where do you get more info on this? Uh, yes, gin of Mentos, pure fresh. What the heck Manual brilliant to life, but also poison control. Uh, if we have access to up to date open evidence. Right. Uh, number two, where are you going? To get more info for the young, uh, woman vomiting. So labs like blood gas, uds to see like, what other things you may take. More information from family and that hopefully they've gotten the bottle to us by now. Okay. Three, A two year old Dreaux. Pretty similar. Yeah. Uh, we're also gonna look up the ingredients of Drano. Highly possible. That's what it is. Uh, I think it's Drano. Yeah, it's water and xanthan gum. That's all that's in it. Four, we're gonna get more information from the punk twice why they did it. Uh, and no, we're just gonna. Yeah. And yeah. Any other resources that we have access to just to double check. So it's not a templateborn. Uh, I'm very familiar with case five. Go get the ball. Okay. And case bonus. Um, more information, if we can, from whoever brought them or family that was around. Um, with someone who works locally. If there are any common toxidromes that they see in is if we have access. Getting an ABG and a vbg. Um, if we have more labs than that, a CBC and a CMP would be nice. EKG would be nice. Chest X ray would be nice. Okay, big hint. Case two, case four. And the bonus case. The answer is, ask someone who lives there and works there. Uh, there are lots and lots of poisons out there and they're not in msds. They're not always listed in poison control. Uh, especially the bonus case. Um, the things I heard that I really liked on the first one. Symptoms. Do they have them or do they not? An asymptomatic patient can be reassuring, but if you have a little time to figure out exactly what they ingested, you might know exactly how long you have to be reassured because they can crump very quickly. The timing of the ingestion, very important for multiple groups. Said timing. I'm pretty sure you guys mentioned timing. Why specifically? The location in the GI tract can affect your intervention and the degree of absorption that's been, you know, already into the patient's bloodstream or something. Okay. Yeah. Anyone else have thoughts about timing on ingestions? Some charcoal. Yeah, Jeremiah mentioned charcoal. I think we used to use something called Fuller's Earth. It's probably out of vogue now. Uh, it's actually very helpful in case number two. Um, but, yeah. So activated charcoal timing is good. Uh, quantity. Yeah. So how might you Find out in the case number one, how might you find out how much, uh, pure fresh Mentos were ingested? Let's know the size of the container. Okay. After the 10 year old, a 10 year old knows exactly how much gum was in. She did 21 pieces. Oh, my gosh, it was a bunch. Uh, yeah. And then, uh, the thing I heard the most that was very, very encouraging was get the bottle. Because at least in this country, uh, the bottle has a lot of useful information. Unfortunately, half of the bottles will say if ingested, call a physician, medical attention. The best ones say all poison control. So what's the number for poison control? No phones, no laptops. 100 222-822-1222. Yep. But there's a bottle of cleaner down under the table over there. So without going on the Internet or without using my phone in this room, I was able to go find the number for poison control because. So go ahead and pick up the blue bottle that's under the table there and look at the directions for if ingested or harmful if swallowed or whatever it is. Yeah, so it says tall poison control. And the other thing that every one of these bottles will say is keep out of the reach of children. So in this country, you are very, very blessed in that anybody who brings anything that they've ingested, you can go, oh. Now, uniquely, the 500 milligram, uh, dose of cefaclor is already a higher dose of Cefaclor. Um, we use it for pneumonia rather than skin infections at that dose. If you give it twice, then one thing I will tell you, if you are working overseas in a place that has medicines you've never been able to pronounce before. Heard of, they're all made in Jaguar, India. Like, there's nothing. Open the box and look at the package insert. Because global manufacturers that get approval to distribute to WHO member states have to put package inserts in those. I don't know how many times we've gotten a donation of, uh, seven crates of fill in the blank. And I'm looking in up to date or whatever, and they're like, yeah, nobody uses this. It's not even allowed in the United States. Thank you very much. And then I just open up the package insert and there's two pages of very helpful information, including on cifaclor, unless you take five times the recommended oral dose. So I look at that and I say, oh, we took twice the recommended amount. I'm fine. I still watch and monitor and that kind of thing. Uh, question two. Initial stabilizing steps. I heard ABCs a lot. Ah. In BLS. Now they say cab. Or did they go back to abc? Depends if they're bleeding. Oh, is that what it is? Good. So, yeah, think of the ABCs, um, and then IV fluids. So establishing an IV. If you're at an urgent care in ER, you can probably get an IV hep lock in. Uh, big hint. Do that before circulatory collapse. Because after circulatory collapse, it sucks. And this is true for postpartum hemorrhage or anything else. Anytime you're thinking you're in a situation, you're like, I might have to recess. I need ABCs. Put the IVN immediately. You can always take it out and you don't have to give anything through it. But if they have no blood pressure and then you're trying to find a vein and they're unconscious, that sucks. So anytime you're thinking ABCs, you're like, Nurse, will you please start an IV? What am I getting started? Just get the access early. Uh, I love that somebody said, check a sugar. Uh, because, yeah, hypoglycemia, um, not necessarily from the ingestion, but somebody comes in and the parents are like, oh, yeah, we're pretty sure they got into something. Oh, but also they haven't eaten all day and they were roofing and, you know, whatever. So, yeah, check the sugars. Uh, where do you get more information from? The emergency manual is good. Calling Poison Control. So true. Uh, story. When I was. Well, yeah, seven years ago, when my son was very young, he got into my daughter's, um, Mentos. Uh, she was so excited. Somebody sent a care package from the States. Like, awesome. This is my, you know, my prized possession right now is this package of gum. And her two year old brother goes in and, like, eats the rest of it. She was so mad. And we were having company over for dinner. One of m. My colleagues, another doctor, we have no idea what to do. So we get into, like, the Skype. Like, put some credits on Skype real quick. And we just call Poison Control in the United States. Oh, where are you calling from? Uh, Oklahoma. What happened? Oh, and then we explained it, and they said, okay, well, this is what you look for and all that stuff. So even from Papua New Guinea, I just called Obama poison. Watch him, keep an eye on him. Things get crazy, let us know. It's like, yeah, we'll do that. But the. The topic of poisoning and ingestion, uh, you guys aced this quiz, which is nice because we still have, like, 30 minutes where we can kind of chat a little more. And I have a few other points to make. Um, but we're going to step into the global health side of things. Uh, I mentioned one story from where my kids got into trouble. Uh, another time was one of my very, very early experiences in our emergency room. And it was case number two. Uh, I had never seen this is kind of a case before. Uh, the girl in question was actually the teenage daughter of our groundskeeper. And Noli is amazing. He's worked for our hospital, keeping that place in shape for almost 20 years. Uh, like a lot of families in Papua New guinea, they run into challenges and obstacles, sometimes of their own choices and sometimes of the circumstances around them. And his daughter was in one of those and drank weed killer. The weed killer that she drank is banned in about 130 countries. And it's called paraquat or gramoxin. Uh, it has a nasty habit of creating oxygen super radicals that attack the alveoli and the lungs. Drinking more than 30 mils, which is three 10cc syringes, is universally fatal. So it is one of the most poisonous and toxic substances that mankind has ever created, which is why several countries have banned it now. But, uh, Papua New guinea is not one of those. So Noli and his family endured probably one of the worst couple, ah, of weeks that I've ever seen while they watch their teenage daughters succumb to poisoning. Um, the other one from our neck of the woods, the bonus case. If you don't prepare fava beans properly and you ingest them, does anybody know what it metabolizes into G6PD? Huh? Uh, G6PD is one. And then I threw in cassava as well. Because these wild fava beans and cassava can both do this if you don't prepare them properly. So you can get a hemolytic crisis with G6PD deficiencies in fava bean ingestion. And then there's one other thing I just don't remember. Metabolizes to cyanide, so you can. And actually, purple lima beans will do this too. So in Papua New guinea, these beans are still out there. The locals try to rip them out and burn them every time they find them, but it's like a weed. I mean, it's. The whole island is jungle, so you can't get rid of all of it. And so people will harvest them, mistaking them for one of the more customary local produce or something, and then they'll cook them, and it almost always comes in as two or three Guys. And so these two guys came in and I was, I had no clue what was going on. They were combative. They were shouting. Uh, they like, I just need them to get sedatives because they're driving me crazy. And they're big guys and so, you know, they're, they're kind of, you know, throwing their, their buddies off all their watchmen, and everybody's running for the hills and stuff. And we finally, you know, get them tranquilized with some promazine Largactyl. It's like super old version of Haldoline. Um, and then I call Bill McCoy, who was kind of backing me up, and he says, oh, yeah, in the top drawer of the ultrasound room, there's a box and it says Nathiodote. You'll open that, take 10 mils out of that ampoule and push it through a 16 gauge IV. It's like, okay. So we go and we get these guys cannulated, starting to run some Hartman's, um, uh, lactated ringers to keep their blood pressure up and stuff. And I hit one guy, and I hit one guy. And from absolute extremists, about 20 minutes later, they're both sitting up like, hey, can we go home? It is amazing. Uh, so that is a poisoning that's. So cyanide poisoning has an antidote. Uh, and I think it's in the slides later we'll talk about it. Um, but that was some of my first experiences. M in Papua New guinea with poisoning and ingestions. Now, the setting is wildly different. If you look at info in the States, um, a lot of the challenge here is medications, uh, sometimes intentional and sometimes unintentional, and especially with the opioid crisis. And I think probably five years ago is when I first started seeing naloxone advertised at, like, bus stops, where pretty much anybody now can just get naloxone. I think that's right. You don't need a prescription. I do. Yeah. Go to, like, County Health or anywhere else, uh, pharmacy and just carry around naloxone because we realize there are like 10 times as many opioid pills in this country as. Ah. And people are just sometimes inadvertently way overdosing. Having naloxone in the community is kind of like having defibrillators in the community. It's also relevant. Thank you for the topic. Uh, there's been one fentanyl overdose in a baby already this summer in Tulsa. Um, and then there was a party. There were a whole bunch of people got Narcan and they didn't die because of something they took. Elephant nose being laced in something then you're stepping into unfortunately to your ER shifts. When they get the coffee mates and they decide to free base everything that they, you know, we're doing recreationally then they realize they can add some to it. Yeah. Uh, so we'll go through a little bit more on that. I'm going to go through. Uh, this is our hospital. This is Nazarene Hospital. It's been around for about 70 years. That river is called Water Ka, not the artist of the river. Uh, we dammed it up about 10 years ago and put a hydroelectric dam there. Um, so we power our emission station with hydro and then we put up with solar onto the generators. It's very green, it's about a mile high. Most of the highlands of Papua New guinea look exactly like this but with less buildings. It is gorgeous. There are a lot of hard things about living there. The climate and the scenery is not. That's my family at ah, the PNG Independence Day celebration this past September. That's a QR code that links to that blog. Tell some of our stories. Uh, PNG has about 9 million people. It's mostly rural. Most of them live in areas like this. Capital city, port Moresby has 250 to 300,000 people. The next biggest city lay has about 100,000. The third biggest, Mount Hagen has about 70,000 and the rest are out in the bush. Um, we are hospital there. We have about a thousand people on the station. Of them are Pompano Union. There's probably about 40 there. Uh, and that's the biggest thing. Lots of languages are just battle syncretism is an ongoing process where we kind of stamp some Christian flavors onto the animism of the country and then carried on. We are dealing with some of that. Tribalism is huge. Uh, tribal warfare comes off all the time and that is one of the biggest things that we deal with in our lives. The fight of women and children is pretty awful. Uh, in terms of basic services and especially for women. Violence against women, including rape and assault is fairly rampant. Uh, the Human development index we are 155 just below Syria and Pakistan. There is our hospital, the front gate so to speak, getting queued up, ready to come in. They will wait a long time. Some of them. It's the first time they've seen a permanent building. It's a very rural. Here's what we do. About 60,000 visits, about 7,8000 admits. More like 3000 deliveries. Uh,000 to 1500 surgeries a few more minor ones. Uh, I don't know why nutritional feeds is on there. We have a uh, huge primary health department but that's the one that they choose to put on the website for some reason. Uh, the one thing I would like to bring to bear on this and this is more a global health for those of you who are interested in overseas missions, national health or even at times here in the States. I think as clinicians I uh, have an MD and an MPH and so at times I have to wear different hats. I think as clinicians we sometimes, especially during residency get very focused on our clinical acumen, uh, diagnostics investigations, management strategies and that kind of thing. If you are considering working in an under resourced area or a cross cultural setting or both, that bit of up to date that you just skip over, stop skipping that. Because sometimes the only clue I have to diagnose my patient is not a lab test or anything else. It is what is the epidemiology of where common or is it not? If it is common, what's the percentage? If there's something on my differential and I look at the epidemiology and it's like one in a hundred thousand, it needs to move way down. Now if the guy says yeah, I just ate these beans I'm like okay, uh, but this is something I'll go through kind of briefly. There's this interesting project called the Global Health uh, disease Burden and it's hosted at uh, the Institute for Health Metrics in the world. Male and female and 2023 or the deaths from the whole world. I'd say that global health is the health of um, population and your population is Earth. You can see this blue area is heaps of non communicable diseases and that kind of thing. Uh, that top right is kind of what we associate more with low middle income countries, neonatal maternal infections and that kind of thing. And the bottom right is like accidents and injuries in 2023 in the whole world the number of deaths attributable to poisonings was 0.12% of total deaths. That's what's highlighted there in that green box. But let's just focus on that since that's our topic for today. And let's explore this idea of global health. Now if you go to same but people less than five years old, the change from the blue to the red, go somewhere and you're going to open up a clinic and the biggest need in your area is women and children's health. This is what we've Been trained in. This is what the American medical system trains doctors to address. But you might end up like this. That's the whole point of this slide. Look how much it changes. Just when you change one thing, the age you're looking at. Let's change a little more. Here's the U.S. right? Here's the globe. Lots of red. Here's the U.S. all right. We already won the red fight. Now we're dealing with the blue fight. So for you guys, this is what you're getting trained in. M. Here's the U.S. less than five. Okay. We've. We've restored the red, but it's all where, right? Neonatal. Why? Have a hazard to guess why. It's all in neonatal. Our NICU suck a lot better than mine, I promise. Genital. Okay. It's a good thought. Infectious disease, huh? Huh? Could it be? Where do we define viability in this country? Where do we draw the line between stillbirth and neonatal death? We draw it about three weeks younger than the rest of the world. Mhm. So if you say that 22 weeks is viable. And all of the 22 to 24 week deaths in children less than five get classified as a neonatal death instead of a stillbirth, that creates this picture. Fix the world or even help the world if we don't understand it. Here's Oklahoma. All ages, both sexes. Looks a lot like the US graph to me. Here's Oklahoma at less than five years. Yeah, kind of tracking. Here's Papua New Guinea. All ages, both sexes. We are still fighting that red fight. And poisonings make uh, up 0.088% of the total deaths. It looks really different too. It does. Uh, how so? Like sir, I don't, I don't think I saw cervical cancer. On the other you see cervix. A percentage is. Yeah. Rheumatic heart disease. Yeah, Rheumatic heart disease is in there. Dr. Mark, what's IHD like? Dales? Ischemic heart disease. Yeah. So CAD. Coronary artery disease. The rest of the world calls it ihd. Mhm. Genital is there. Yeah, genital shows up. But Malaria, tb, measles, had two measles outbreak. Sign there. Those suck, uh, HIV and climbing. Here's Papua New guinea for the kids. Wow. Right. How does this, uh, compare to the United States? Depending on where you go in the world, your, your fight is going to look different. And this kind of stuff is worth not skipping when you are tempted. Uh, cares about epidemiology. Most people do. Uh, the clinician at the bedside, dealing with one patient. No, that's not the time to start talking to your patient about. Well, actually, you're not very likely to have this. No, that's not what I'm talking about. But as you think about if I want to do low resource setting, cross cultural setting, or another country, you need to understand that I've been very well trained in this burden of disease. But the other burdens of disease are going to be a little bit different. Uh, I picked Cambodia just because that's another place that image has a good number of folks. Good number of good folks. Yeah. But there's there less than five. Okay. So kind of briefly go through these, uh, when you have poisoning and ingestion, the things that we went through, some of these will have direct caustic injury paraquat. Gramoxin causes the worst esophagitis I've ever seen in my life. If you don't die from the pulmonary fibrosis, you might die from the esophagitis. So there's direct caustic injury. That's also why it says if it gets in your eyes, if it gets on your skin and that kind of thing. Do this flush with water. Never a bad idea to flush with water. And then there's the systemic injury side. So, uh, from this group, acetaminophen. What organ system are you okay in the back? Opioids and benzos. Respiratory center, back group here. Beta blockers, calcium channel blockers or digoxin, heart arrhythmia, that kind of thing. Good. Warfarin, Circulatory. Yeah. Bleeding circulatory. Good. Cyanide, Neuro, Neuro. Everything. Neuro and everything else. Yeah. And then based on the story I just said heraclad or gramoxin. Pulmonary. So the caustic is the gi. So a lot of these. If it's an ingestion, the caustic injury is the gi. Okay. Try some magnesium, aluminum. Give them a ppi, like whatever to reduce the GI irritation. But the ramoxan, it's that pulmonary fibrosis which you'll get them prevention. This is a site that's, uh, worth knowing about Clintox.org especially if you're going to moonlight somewhere. They teamed up with the Choosing Wisely campaign. I'll just send these around. You can glance at them along, uh, to talk about what are the best ways to try and prevent, uh, accidental poisoning and ingestion. What's on every bottle label besides poison control number. It is, uh, out of reach of children. Cabinet locks and put Things up on shelves. Yeah. The fact that we predominantly do that in this country is impressive. I have seen several kids who were out playing in the garden and one of the people was working there. And because these bottles are hard to come by, this little water bottle right here, once they finish it, they say, oh, my buddy has weed killer. Let me put it in there. And then they set it in the garden and they're going and they're doing all their gardening stuff. They come back, the bottle's empty, and their 3 year old is laying the garden unconscious. So prevention worth a pound of poor treatment. We talked about stabilization. A lot of it is supportive. Keep their circulation up, keep, uh, them breathing. I mean, you get bad poisonings during an icu. That's still the goal. It's just we have a lot more bells and whistles in an icu. We have pressers and ventilators rather than an oxygen cannula and an IV can. Some of them have antidotes. So we'll go back around this way. So from, um, Isaac over here, Eucamus. The antidote for what? Phone a room if you want in. Acetylcysteine is the other name for it. Yes. Cetaminophen. Insulin. Used to counteract the effects of. Beta blockers and calcium channel blockers. The third one on this list. You can give insulin for flumazenil back to this group over here. Antidote. Yep. Benzos. Naloxone? Um, yep. Vitamin K. Okay. Did you fab. And who was on? Uh, two was over there. Thiodote or sodium thiosil? Very quiet. Yes. Good. And sorbents. I'm going to touch on this. Cyanide. Sorry, Is that cyanide? Yeah, yeah, sorry, that's the cyanide. Uh, paraquat doesn't have one. Uh, Jeremiah. Sorry. Does atropine work for paraquat? Uh, I haven't seen that. Uh, this is now coming back. These adsorbents Jeremiah mentioned. Activated charcoal? Yes. Case two. Is that an organophosphate? No, not specifically. Uh, it's kind of its own class. Uh, it's a class of herbicide that kind of fell out of favor. There's probably overlap with organophosphates, but it's not in that. Like, um, pot as a. Whatever, pistol. And you know, I forget how we remember the anticholinergic effects or that kind of thing. It's just an evil poison. It's. It's a rotten. It is what it is. Yeah. Adsorbents. When I was, um, in residency, activated charcoal was Kind of going, going out. We weren't super impressed. And that Clintox group that I mentioned was kind of saying, well, if you get it within an hour, great. Otherwise, don't waste your time. Um, I'm reading now up to six hours. There was a. This is a pretty good, um, AFP article that still talks about the one hour mark. But actually this year that Clintox uh, group came up with a revised recommendation. They said up to six hours. You think that the substance is absorbed by charcoal, Go ahead and give it up to six hours post ingestion. Now, there's a contraindication to giving activated charcoal. Anyone? Basic A, uh, perforation. I would be high. Be very hesitant to. The only one I read about. It's mentioned in there. Sorry. If it's a basic substance, acid acidic condition because you can. It could cause vomiting. Yeah, it's related to vomiting. Bowel obstruction. So the contraindication is inability to protect the airway. The patient is unconscious, cannot protect their airway. Don't put an NG and give it. Unless you're also willing to intubate to protect the airway, you're committing that person to two procedures that are not your risk. So you need to be pretty convinced that the poison you're dealing with is going to activate charcoal is going to help. Um, but up to six hours in a person who has an airway, you can give it. Vomiting was mentioned, I think by Jeremiah. Uh, what's the worry about vomiting caustic. It's going to come back up again. And yeah, this kind of double burn effect, if you have a really nasty substance that's already made one pass through the esophagus and then you give it a second crack at eroding all of the cell layers, that's probably not great. Um, so if you're going to do that, you can pretreat with ondansetron phenergan metaclopramide is what we have. Um, that is, Uh, I'll walk you through some of these pictures. I put some dates there. We. I.