In this special live episode from the 2025 North American Congress of Clinical Toxicology (NACCT), Ryan takes you inside the conference to hear directly from the researchers themselves. Covering 11 abstracts that span high-stakes management decisions, surprising case reports, and challenges to toxicology dogma, this year’s highlights feature everything from amlodipine overdoses to naturopathic misadventures, metformin-associated blindness, and more. The show kicks off with a foreword from Ryan and Dr. Jon Cole (abstract co-chair for AACT) discussing some of their favorite research from the conference.

If you couldn’t make it to NACCT or just want to catch up on some of the most impactful new research in our field, this episode will give you a front-row seat. Check below for links to the published abstracts, the full list of studies discussed, and timestamps for where you can hear each one.

Link to published abstract manuscript

10:43 #7. Is beta blocker toxicity associated with hypoglycemia?

• Lead author: Dr. Megan Audette, MD

18:17 #237. V-A ECMO as a treatment for vasoplegic shock in amlodipine poisoning: a comparison

• Lead author: Dr. Daniel Tirado, MD

27:59 #247. Blocked but not beaten: ECMO’s role in severe amlodipine toxicity – a poison center case series

• Lead author: Dr. Carlos Saldarriaga, MD

28:18 #26. Amlodipine double-dose therapeutic errors reported to Poison Centers

• Lead author: Johanne Freeman

30:38 #27. Dosing on the edge: unpacking inadvertent amlodipine ingestions reported to a single poison center

• Lead author: Dr. Tiana Patriarca, PharmD

34:03 #292. Intravenous administration of sodium zirconium cyclosilicate resulting in death

• Lead author: Dr. Stephen Thornton, MD

44:16 – #21. Quantitative analysis of amlodipine removal by plasmapheresis

• Guest: Dr. Keahi Horowitz, MD – Acute and Intensive Care Research Award winner

48:33– #23. Relationship between reported ingestion dose and outcome in amlodipine poisoning

• Guest: Dr. Colleen Cowdery, MD

51:37 – #24. Management of severe amlodipine toxicity with high-dose calcium alone

• Guest: Dr. Vincent Ma, MD
• High dose norepinephrine in amlodipine overdose
• Case report of calcium death

56:56– #70. Iatrogenic exposure to long-acting buprenorphine injectable in an opioid-naïve patient

• Guest: Dr. Conor Young, MD

01:00:11 – #182. Left in the dark: a case of blindness in the setting of metformin toxicity

• Guest: Dr. Madison Bombard, MD

01:12:11 – #169. Just because it’s natural doesn’t mean it’s safe: a case of pediatric toxicity from topical and herbal remedies

• Guest: Dr. Aria Darling, MD

01:04:31 – #203. Serotonin syndrome after vaping Moocah

• Guest: Dr. Connor Murphy, MD

01:07:06 – #307. Intravenous ozone autohemotherapy: a retrospective observational case series

• Guest: Nicole McLarty

01:11:25 – #134. Do they really need n-acetylcysteine? Exploratory analysis of outcomes in patients with elevated...

In this episode of The Poison Lab, host Ryan Feldman is joined by Dr. Joe Kennedy, medical toxicologist at the University of Vermont and consultant for the Northern New England Poison Center. Together they work through real poisoning cases to sharpen toxic differentials, sum up practical resuscitation priorities, and connect first-principles pharmacology to bedside decisions. They also answer listener questions on THAM vs bicarbonate, when to dialyze even with “normal” kidneys, and why rattlesnake antivenom costs so much—plus the real-world logistics of sourcing exotic antivenoms in the U.S.

Dr. Kennedy and Ryan discuss the topics below. Looking for timestamps? Join the subscribed feed!

• Case set #1: Shock with hyperglycemia, big pupils, and probably NOT what you think it is.
• Case set #2: Massive bleeding after gas-station “herbal” products
• Case set #3: Refractory wide-complex rhythms in a teen overdose
• Case set #4: Sudden collapse at a hog farm- (SPOLIER) Recent outbreak of deaths as related to case 4

Want the cases summarized and sent to you so you can come up with your differential before the show? SIGN UP FOR THE NEWS LETTER!

Listener Q&A

• THAM vs bicarbonate (closed vs open buffering; “breathe for bicarb, tinkle for THAM”)
• Why dialyze if the kidneys work? (EXTRIP-style thinking, gradients, and properties)
• Snake antivenom pricing & how zoos help hospitals obtain non-U.S. antivenoms

Call outs from the show

• NACCT Abstracts!
• Clover coagulopathy!
• THAM VS BICARB Electrolytes
• Potato quality video of dialysis from Ryan
• Article on snake antivenom costing >200,000 for one patient
• Article on exotic antivenom procurement
• Case report Ryan published on treating blue Indonesian pit viper

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

The GOTTA PICCEM Poisonous Mushroom Game!

Tox trinkets (Rep the show at home!)

• Email: Toxtalk1@gmail.com

More Show Resources

• Ryan's Medical Games and Resources

GOTTA PICCEM: The Poisonous Mushroom Card Game

👉 Order now right here OR go to www.gottapiccem.com and click "Buy GOTTA PICCEM"

What started as a nerdy teaching tool made to teach mushroom poisoning by folks who treat mushroom poisoning is now a full-fledged card game—equally great for Friday game night and the classroom.

• 58 Poisonous Mushroom Cards
• Full-color pictures, toxin info, clinical syndromes, key anatomy, U.S. + global distribution, and spore print colors.
• 88 Play Cards + 30 Bonus Cards
• Collect mushrooms, play antidotes and modifiers, stack combos, and score big.
• Toxin-Based Scoring
• Point systems reflect real-world toxicity—every round plays differently based on your hand and bonus cards.
• Endless Replayability
• Rule variants at gottapiccem.com keep things fresh.

Dive into the companion blog at www.gottapiccem.com for:

• Deep-dive toxin explainers for each mushroom
• Case reports & real-world clinical notes
• Controversies and mysteries in mushroom poisoning

📖 Start here: gottapiccem.com (Companion Blog → “Learn the Mushrooms”)

👉 Order now right here OR go to www.gottapiccem.com and click "Buy GOTTA PICCEM"

• Multiple box options (pick your fancy)
• Ships direct from our manufacturer in South Korea
• 🌍 Global availability (shipping costs + tariffs may apply)

P.S. We’re exploring U.S. manufacturing to lower costs and expand distribution—timeline TBD—so we made the game available now.

If you grab a copy:

📸 Snap a photo of your first round

✉️ Send it to toxtalk1@gmail.com or tag @LabPoison / @tox_talk

Nothing would make Ryan happier than seeing the community play!

Listen here (https://www.wpr.org/shows/larry-meiller-show) to hear Ryan Live on AIR for the Larry Meiller show, Thursday July 17th 11:45AM-12:30 PM CST.

Check this "Listen Live" link if your having trouble!

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• Discounts and give aways on GOTA PICCEM Mushroom card game

The GOTTA PICCEM Poisonous Mushroom Game!

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• Email: Toxtalk1@gmail.com

More Show Resources

• Ryan's Medical Games and Resources
• Show Website

On August 29, 2022, twelve diners at a Markham, Ontario restaurant fell critically ill with vomiting, numbness, and life-threatening arrhythmias. The culprit? A deadly plant toxin: aconite.

In this episode—the first of a new Poison Lab Outbreak series—we go inside the Markham mass poisoning case. Join host Ryan Feldman, clinical toxicologist and emergency medicine pharmacist, as he investigates how a rare and lethal toxin ended up in a restaurant spice jar and nearly cost lives.

You’ll hear firsthand from the experts who responded to the outbreak:

• Dr. Jessica Kent, toxicology fellow at the time at the University of Toronto
• Dr. Abinhay Sathya, intensivist at Markham Stouffville Hospital
• Dr. Margaret Thompson, toxicologist and on-call consultant for the Ontario Poison Centre
• Dr. Randy Purves, research scientist at the Canadian Food Inspection Agency (CFIA)
• Bryn Shurmer, MS- analytical chemist at the Canadian Food Inspection Agency (CFIA)

Together, they walk us through the outbreak timeline—from the first patients in VT to the public health investigation that uncovered a mislabeled spice bag full of pure aconite root.

Looking for timestamps?

A fully timestamped version of the episode—so you can jump to any topic—is available to our supporting members.

💡 Key topics:

• Clinical presentation and toxic effects of aconite
• Challenges in mass poisoning recognition and coordination
• The crucial role of poison centers in outbreak response
• Public health trace-back to contaminated galangal powder
• Lessons for emergency departments and toxicologists

📍 Resources & Mentions:

• Case series about the incident written by Dr. Kent, Sathya, and Thompson
• Twitter/X post by Dr. David Juurlink that helped disseminate early info
• The Poison Lab previous aconite episode: Open and shut (Mystery Case #31)
• Paper written by Ryan, Dan McCabe, and Crissy Lawson

🎧 Listen now at:

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

Subscribe and Review:

Love what you're hearing? Help us reach more toxicology enthusiasts by leaving a review on Apple Podcasts, Spotify, or wherever you listen. Don’t forget to share this episode with...

Review the show where ever your listening

Get Messages from Toxo (Join the Newsletter!)

Join as a supporting 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!

Tox trinkets (Rep the show at home!)

• Email: Toxtalk1@gmail.com

More Show Resources

• Ryan's Medical Games and Resources
• Show Website

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 (Clitocybe, Inocybe spp.) – Cholinergic...