Notice to NC Emergency Physicians from NC Poison Center
CLENBUTEROL POISONING CASES REPORTED IN WAKE COUNTY - July 23, 2008
Clenbuterol is a veterinary drug similar to albuterol. It is a beta-2 adrenergic agonist. There was an outbreak along the Eastern seaboard (or the I-95 route) three years ago, we had two of the cases reported in the attached MMWR report.
The clenbuterol may be adulterated with cocaine or heroin. Two of the known four cases in Wake had UDS positive for cocaine. This may pose a dilemma if you are considering use of propanolol, as discussed below.
Last night the poison center was called about another two cases, so the poison center now knows about four cases in the Raleigh area.
REQUEST FOR ALL EMERGENCY PHYSICIANS: if you see a patient(s) fitting the clinical picture below, Please report the case(s) to the poison center at 800-222-1222, so we can get a handle on the magnitude of this problem in NC--is it confined to Raleigh or is it spreading. Please obtain urine and have your lab hold it for further testing.
Clinical Picture
HISTORY - patient thinks he has purchased cocaine or heroin. TThe cocaine patient will likely tell you that she became suspicious when she snorted the drug and didn’t experience any oral numbness (like Michael’s patient).
CLINICAL EFFECTS - can see some or all of: tachycardia, palpitations, hypotension, chest pain, shortness of breath, nausea, agitation, tremor, hypokalemia, hyperglycemia.
The hypokalemia is profound, with K+s around 2.0 - 2.2 mmol/L.
The hypotension is characterized by systolics in the 80s or high 70s, or by normal/elevated systolic with a WIDE pulse pressure.
Management
Supportive therapy and admission. These patients do not go home from the ED.
HYPOKALEMIA - with K+s so low, you will need to give them K+, just remember that the patient has normal body stores of K+, the K+ is just sitting inside the cell. As the patient gets better or if you give propanolol, the K+ will increase, perhaps significantly after propanolol.
HYPOTENSION - most patients do not require therapy other than IV NS boluses to assure normal intravascular volume. As long as the patient is perfusing - normal mentation, good cap refill, normal urine output, no symptoms d/t hypotension - this probably will be sufficient.
If you feel you need to treat the hypotension, you can give IV propanolol judiciously. So far, we’ve not seen the need to use this.
WHY propanolol in a hypotensive patient - Because it will block beta-2 receptors, where the drug is having its effect. DO NOT USE a beta-blocker that is more specific for beta-1 receptors--the hypotension will worsen. Consider benefit vs. risk if the patient’s UDS is positive for cocaine.
AGITATION - benzodiazepines, e.g., lorazepam
We have alerted state public health, who is alerting Wake public health and law enforcement. Investigation is ongoing- I’m working on testing the urine from the currently hospitalized patients, so we can gold-seal the diagnosis.
Marsha Ford, MD, FACEP
Director, NC Poison Center
marsha.ford@carolinashealthcare.org, mford6@carolina.rr.com