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Case Studies in Toxicology
Case studies are impartial and objective summaries of toxicological matters wherein TCAS was retained for the purpose of assessing toxicological factors. In many cases the assessment led to a determination of impairment, disease, death causation or no causation. It is our hope that these case studies will familiarize and educate readers with basic concepts in forensic toxicology.
Each case is unique and the toxicologist must always consider the context and circumstances in a toxicological assessment or forensic investigation. What may hold true for one case may be completely different for another, even if the same substances or circumstances are present. For example, dosage, exposure characteristics, duration and additive effects of a particular substance are likely to be different in every case. Additionally, federal and state regulatory guidance varies widely by region, by substance and with respect to toxicity standards. Thus, the outcome of one case history in no way implies a similar outcome in other cases. Indeed, in some cases the claims were shown to be scientifically invalid with successful defense verdicts resulting from TCAS assessments.
This page presents a series of toxic exposure studies for selected substances. Toxic exposure studies provide descriptive and instructional information pertaining to some of the toxic agents for which TCAS has been retained on numerous occasions.
Toxic Exposure Case Study Archives
Toxicology case studies provide historical overviews of past cases, typically involving application of multiple disciplines. Each study outlines facts, events and circumstances surrounding the case, a description of some of the health and legal aspects, an overview of the steps taken by TCAS to address the case requirements and a brief summary of the outcome. Names and critical identifying data have been redacted to comply with privacy and legal guidelines.
| This case study illustrates how circumstantial evidence can be misinterpreted and how drug-impaired judgment and behavior can be regarded as evidential in a toxicological causation assessment. A motorcyclist was fatally injured when he collided with a city bus in a business district... ( ) |
| This case study summarizes the events leading up to and following a fatal boating accident on Florida's intracoastal waterway. It illustrates the role of back-extrapolation and weight-of-evidence (WOE) in an alcoholic impairment assessment and demonstrates how behavior and judgment on the part of the defendant can be considered as evidential in a toxicological analysis... ( ) |
| This case study summarizes a matter in which a group of campers were overcome by carbon monoxide poisoning. It illustrates the importance of taking the initiative to acquire necessary objective evidence to refute presumptions through a scientifically credible toxicological assessment.... ( ) |
| This case study summarizes the events leading up to and following a widespread contamination case involving local residents and a company disclaiming responsibility for damages. It illustrates the role of weight-of-evidence (WOE) in a toxicological analysis and demonstrates how meticulous attention to detail can be a deciding factor in a complex assessment... ( ) |
| This case study recounts the circumstances surrounding a woman's claims that exposure to a chemical stripping agent caused burns, infection and damage to her immune system. The outcome illustrates the importance of validating claims against medical history and assessing toxicological factors according to peer-reviewed literature in order to establish reasonable... ( ) |
| This case study summarizes the events following the death of an elderly man involved in a motor vehicle accident and demonstrates how pharmacological factors and behavior on the part of the defendant can be considered as evidential in a toxicological analysis... ( ) |
| This case study recounts the circumstances relating to a teacher faced with pending dismissal for alleged drug use based on erroneous interpretation of cocaine in hair test samples. This case illustrates the importance of applying a correct, peer-reviewed scientific methodology to laboratory analyses and interpreting the results in line with established... ( ) |
| This case study demonstrates how causation can be demonstrated by weight-of-evidence (WOE) and how objective investigation of contributing factors can play a pivitol role in formulating an expert opinion to reasonable toxicological certainty. Toxic encephalopathy can be caused by repeated exposure to high-level refinery hydrocarbon vapors. A process engineer worked for seven... ( ) |
| This case study illustrates the role of toxicological weight-of-evidence (WOE) in a case involving exposure to mold inside a motor home. It also illustrates how analytical measurements and medical history can be considered as evidential in a toxicological analysis. Shortly after purchasing a new motor home, the owner noticed... ( ) |
| This case study summarizes events relating to the death of a man with a history of seizure disorder who was fatally exposed to pesticides in his unventilated basement apartment. It illustrates the role of an impartial toxicological assessment in litigation involving pesticides... ( ) |
| This case study reviews a residential contamination case involving local residents exposed to water contaminated with PAHs and PCBs flooding their properties. It illustrates the importance of applying generally-accepted, peer-reviewed toxicological assessment methods and the steps necessary to present scientifically credible findings in litigation.... ( ) |
| This case study illustrates the role of toxicological weight-of-evidence (WOE) in a motor vehicle accident case involving polypharmacology and antidepressants. It also illustrates how drug interactions can be considered evidential in a toxicological causation assessment. On the evening prior to a serious motor... ( ) |
| In this case study, a passenger severely injured in a motor vehicle fire filed a lawsuit against the vehicle manufacturer. The case partially rested on whether or not the driver could be shown to have been intoxicated. The surprising outcome was based on a little known but well-documented fact concerning endogenous alcohol which can be created following... ( ) |
| This case study summarizes the events surrounding the filing of a lawsuit by residents against a company for allegedly contaminating the local water supply with trichloroethylene, a chemical used in industrial cleaning and degreasing. It further illustrates how exposure evidence, historical factors, a residential questionnaire and a toxicological risk... ( ) |
| This case study summarizes the events leading up to and following the filing of a lawsuit by a woman against her employer for an injury allegedly suffered as a consequence of a toxic exposure to a cleaning chemical. It illustrates the important role a toxicological assessment can play in litigation and demonstrates how inference and assumption can... ( ) |
| This case study summarizes a matter in which a window worker was killed while on the job, resulting in the filing of a lawsuit for negligence. It illustrates how toxicological interpretation of historical factors and application of... ( ) |
| This case study summarizes a recent matter in which a worker was injured while on the job, then later denied Workmen's Compensation benefits when drug use was alleged. It illustrates the key importance of rebutting presumptions... ( ) |
Toxic Exposure Studies
Toxic exposure studies provide descriptive and instructional information pertaining to some of the various toxic agents with which TCAS has been involved on numerous occasions. Studies outline the steps typically required to assemble relevant site data and assess exposure, toxicity and risk. In some instances we have included demonstratives TCAS has used in past hearings and trials for educational and instructional purposes. No names or identifying information have been included due to privacy and legal considerations.
| has been involved in numerous cases involving TCDD exposures. We have had considerable experience in conducting toxicological risk assessments for TCDD, PCBs and other dioxin congeners. As part of our approach to presenting toxicological information in a manner that can be easily understood by a judge and jury, we have produced many demonstratives... ( ) |
| For more than two decades, has been retained in cases involving LNAPLs. We have significant experience in establishing the source(s), age and characteristics of LNAPL. We have performed LNAPL risk assessments on behalf of individuals, private industry and government agencies such as the New York State DEC, New Jersey DEC and others . We have offered unbiased... ( ) |
| "Toxicology case studies provide readers with insights into some of the cases with which we have been involved. TCAS is committed to providing our clients with the full benefit of our experience in the widest possible range of capacities."
This is an informational and instructional website devoted to toxicology. It presents both original and edited public-domain content compiled as a useful educational resource. References and footnotes have been included wherever possible and image sources have been cited where appropriate. Although most pages can be printed or downloaded as PDF files (and we encourage you to make constructive use of our information), this website is copyrighted and material may only be reproduced and/or distributed with prior permission from TCAS, LLC.  Join Section Contact Us Simulation Case LibraryBelow are our peer reviewed cases. We hope you learn something new and helpful to further your toxicology education. Please download these to build your medical knowledge and education. The cases will emphasize key teaching points important in emergency toxicology. All downloads are in .PDF format. To submit a new case, please complete and submit the New Simulation Case form. Submit New Case  Acute Amitriptyline OverdosePatient is a 36-year-old female with a history of anxiety and depression brought to the emergency department by EMS for altered mental status and possible overdose.  Acute Aspirin OverdosePatient is a 40-year-old female with a history of anxiety, ADHD, and polysubstance abuse brought to the emergency department by EMS for altered mental status, agitation, and rapid respirations.  Acute Calcium Channel Blocker OverdosePatient is a 22-year-old female with a history of migraine, depression/anxiety, and ADHD brought to the emergency department by EMS for altered mental status, seizure, and rapid respirations.  Acute Ethanol WithdrawalProtect the patient’s airway. At a minimum, this must include assigning continuous evaluation and surveillance of the airway to another team member.  Acute Iron Overdose (Pediatric: Adolescent)Patient is a 15-year-old male with no significant past medical history who is brought to the emergency department by his mother after reportedly ingesting approximately 90 tablets of iron about 3 hour...  Calcium Channel Blocker OverdosePatient is a 56-year-old man with a history of hypertension and depression who is delivered to the emergency department by EMS following an intentional ingestion of verapamil (both immediate and exten...  Cannabis Ingestion with Severe Intoxication in a ChildThis is a 3-year-old male with no significant past medical history who presents after the mother found him lethargic at home with the older sister who is also acting altered. The child presents with s...  Carbon Monoxide-Cyanide Toxicity (House Fire)Patient is a 26-year-old male with no known PMH who is brought in by EMS from scene of a house fire, unconscious at the scene, status-post witnessed generalized tonic-clonic movements while en route t...  Carbon Monoxide PoisoningThis is a case of a 23-year-old man presenting with altered mental status after complaining of headache and syncope while he was at work.  Caustic IngestionThe patient is a 17-year-old male with a history of depression and prior alcohol abuse who presents to the emergency department with his ex-girlfriend after ingesting “Poolife Rapid Shock.”  Centruroides Scorpion EnvenomationPatient is a 3-year-old male without medical history brought to the emergency department by parents for agitation and foaming at the mouth  Chronic Aspirin OverdoseA 58-year-old male with a history of gout and coronary artery disease presents to the ED with nausea, vomiting, diarrhea and low-grade fevers.  Chronic Digoxin ToxicityThe patient is a 63-year-old male with a history of atrial fibrillation, HTN, and CHF brought to the emergency department by EMS for nausea and vomiting for the past four days and confusion that began...  Cocaine Overdose45 year-old male found unresponsive in his office. Patient works at a bank downtown. According to his co-worker, he appeared healthy when arriving to work.  Cyanide Toxicity (House Fire)This is a case of a 50-year-old male found unresponsive in burning house. EMS found the patient unresponsive, hypotensive, and tachycardic with soot around the mouth/nares.  Digoxin ToxicityThis is a case of a 69-year-old woman who is brought in by EMS after her husband called 911 for increasing confusion, vomiting, and reduced level of consciousness.  Diphenhydramine OverdoseThis is a case of an otherwise healthy 15-year-old girl who ingests a large number of diphenhydramine tablets in a self-harm attempt.  Diphenhydramine-Acetaminophen OverdoseThis is a case of an otherwise healthy 25-year-old woman brought to the ED by EMS after her roommate found her acting oddly.  Ethylene Glycol IngestionPatient is a 52-year-old female with a history of alcoholism and depression brought to the emergency department by EMS for altered mental status and alcohol intoxication.  Hydrocarbon ExposureThe patient is a 2-year-old male with a history of bronchiolitis who presents to the ED with his mother after ingesting “TIKI® torch fuel.”  Hydrofluoric Acid ToxicityYou are a resident in the ED in an urban area. EMS on the radio reports they are transporting to you a 35-year-old male who was working in a glass etching factory and spilled a chemical solution on hi...  INH ToxicityPatient is a 5-year-old girl with no known medical history brought in from the babysitter’s house after a seizure.  Opioid Overdose40-year-old man found unconscious at a bar after work. According to his work colleagues, he was in his usual state of health today.  Organophosphate ExposureThis is a case of a 27-year-old man who presents with vomiting, weakness, diaphoresis, and altered mental status.  Pediatric Clonidine OverdoseThis is a case of a 5-year-old otherwise healthy boy who is found somnolent by his parents. Unknown to them at the time, he ingested approximately 10 clonidine tablets. The pills belong to his older b...  Pediatric Ethylene Glycol IngestionThis is the case of a 2.5-year-old male toddler who presents to the ED with an accidental ingestion of ethylene glycol.  Pregnant Patient With Intentional Iron OverdoseThis is a case of a 33-yr-old female with no significant PMH who presents with nausea, bloody emesis, abdominal pain.  Rattlesnake EnvenomationPatient is a 66-year-old female brought to the emergency department by EMS after being bitten by a rattlesnake while gardening in her yard.  Rattlesnake BiteThis is a case of a 32-year-old man who is brought to the emergency department reporting a snakebite by a prairie rattlesnake while working in the local zoo that afternoon.  Repeated Supratherapeutic Acetaminophen ToxicityThis is a case of a 38-year-old man with a past medical history of alcoholism/alcohol abuse and biliary colic who now presents with nonspecific symptoms of malaise, nausea, vomiting, and upper abdomin...  Serotonin SyndromePatient is a 24-year-old female with a history of depression and anxiety. The patient is brought to the emergency department by EMS for vomiting, agitation, and “seizures.”  Tricyclic Antidepressant OverdoseThis is a case of a16-year-old girl who is brought to the ED from home by her mother for altered mental status.  Case Studies in Medical ToxicologyFrom the American College of Medical Toxicology
Point of Care Content, Elsevier Clinical Solutions, Cincinnati, USAYou can also search for this editor in PubMed Google Scholar Department of Emergency Medicine, Divisions of Medical Toxicology and Pediatric Emergency Medicine, Carolinas Medical Center, Charlotte, USADivision of medical toxicology, department of emergency medicine, rutgers new jersey medical school, newark, usa, department of emergency medicine, division of medical toxicology, university of southern california, los angeles, usa, department of critical care medicine, university of pittsburgh medical center, pittsburgh, usa.
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Tax calculation will be finalised at checkout Other ways to accessLicence this eBook for your library Institutional subscriptions About this bookThe ACMT National Case Conference (NCC) is a monthly discussion of novel or interesting cases in medical toxicology. Participation is through online webinar, and the conferences are recorded to allow for review at any time. The cases in this book are taken from recordings of NCC with edits and revisions by contributors and editors to demonstrate educational points. The majority of the case information is from the original recording and represents actual patient presentations. However, some of the details have been changed and fictional information added to enhance the educational value. This volume covers a broad range of toxicological topics, and specialty guidance is offered at the end of every case to aid non-toxicologists. The dilemmas are applicable to both academic and clinical medicine. A list of relevant questions is also provided for each case. Subjects include common toxicological problems, rare presentations of common problems, common problems with controversial treatments or difficult diagnoses, and rare problems. Case Studies in Medical Toxicology from the American College of Medical Toxicology is a detailed reference text on specific toxicological issues and also serves as a practical review for those taking board exams. As a result, this volume is an important and necessary resource for medical students, residents, and fellows, as well as primary-care physicians, intensivists, and toxicologistsCase Studies in Medical Toxicology from the American College of Medical Toxicology is a detailed reference text on specific toxicological issues and also serves as a practical review for those taking board exams. As a result, this volume is an important and necessary resource for medical students, residents, and fellows, as well as primary-care physicians, intensivists, and toxicologists. All proceeds from this book will be donated to the Medical Toxicology Foundation. Similar content being viewed by others The Diagnostic Process in Medical Toxicology
Table of contents (28 chapters)Front matter, case 1 laundry pod ingestion in an adult.
Case 2 Coma and Metabolic AcidosisMichael D. Levine Case 3 Diet Pill Ingestion in a Child
Case 4 Salicylate Ingestion
Case 5 Exotic Snake Envenomation
Case 6 Medication Error in the Delivery Room
Case 7 Delirium and Bradycardia Following Opioid Dependency Treatment
Case 8 Necrotic Skin Lesion
Case 9 Isoniazid IngestionCase 10 status epilepticus following recreational drug insufflation.
Case 11 An Acute Medical Condition in a Patient with Opiate Dependence
Case 12 Acute Hepatitis
Case 13 Thyroid Supplement Ingestion
Case 14 Blue or Rigid: Pick your ToxinCase 15 overdose in a patient with parkinson disease.
Case 16 Snake Bite to the Hand
Case 17 Ultra-Rapid Opioid Detoxification
Case 18 Concentrated Hydrogen Peroxide Ingestion
Case 19 Nicotine Toxicity
Editors and AffiliationsLeslie R. Dye Christine Murphy Diane P. Calello Aaron Skolnik About the editorsDr. Christine Murphy received a master’s degree in chemistry from The College of William and Mary and her medical degree from the Medical College of Virginia. She completed her residency training in Emergency Medicine at Virginia Commonwealth University and a fellowship in Medical Toxicology at Carolinas Medical Center. She is currently an Assistant Professor at Carolinas Medical Center and Director of the Medical Toxicology Fellowship Program. Her current interests include alternative uses for existing antidotes, alternative pain management strategies, and current trends in recreational drugs of abuse. She is board certified in Pediatrics, Pediatric Emergency Medicine, Medical Toxicology and Addiction Medicine. Dr. Calello is a national expert on pediatric lead poisoning, use of critical care methods in poisoning patients, and the impact of the opioid and emerging drug epidemic on the young child. After matriculating from the Chicago Medical School, Dr. Michael Levine completed an emergency medicine residency at the Brigham and Women's/Massachusetts General Hospital. He subsequently attended the Banner Good Samaritan Medical Center in Phoenix, Arizona, where he completed his medical toxicology fellowship. Michael Levine is currently faculty at the University of Southern California, where he serves as Chief of the Division of Medical Toxicology. His current research interests are mostly focused on toxicity from antiplatelets and anticoagulants. He is on the editorial board of the Journal of Medical Toxicology. Dr. Aaron Skolnik received his Medical Doctorate from the University of Pittsburgh School of Medicine and completed residency in emergency medicine at Brigham and Women’s/Massachusetts General Hospital in Boston, MA. Thereafter, Aaron graduated from the medical toxicology fellowship at Banner Good Samaritan Medical Center in Phoenix, AZ and joined the faculty of the University of Arizona College of Medicine, Phoenix. He is board-certified in Emergency Medicine, Medical Toxicology, and Addiction Medicine. Currently, he is completing additional fellowship training at the University of Pittsburgh in Critical Care Medicine, Neurocritical Care, and extracorporeal life support. ABAT Examination Study GuideTips for Success
The attached list of topics provides some direction as to what types of topics are usually tested. While this list may seem exhaustive, it truly reflects the wide knowledge base required of ABAT Diplomates. Analgesics and Anti-inflammatory Medications Acetaminophen N-acetylcysteine Aspirin and salicylates Sodium bicarbonate Colchicine NSAIDs/COX-2 inhibitors Opioid analgesics Opioid antagonists Anticoagulants Direct thrombin inhibitors Factor Xa inhibitors Heparin Protamine Low molecular weight heparins Warfarin Vitamin K Anticonvulsants Barbiturates Carbamazepine Gabapentin Levetiracetam Oxcarbazepine Phenytoin and fosphenytoin Tiagabine Topiramate Valproic acid Levocarnitine Antidiabetics and hypoglycemic Alpha-glucosidase inhibitors Biguanides Gliptins GLP-1 analogues Insulins Dextrose Meglitinides Sulfonylureas Octreotide Thiazolidinediones Antihistamines and anticholinergics Physostigmine Antimicrobial agents Antibacterials Antifungals Antimalarials Antituberculous medications Isoniazid Pyridoxine Antivirals Antimigraine medications Ergot alkaloids Triptans Antineoplastics Methotrexate Gluparidase Leucovorin Cardiopulmonary medications Antidysrhythmic agents (Class IA; Class IB; Class IC; Class III; Class IV) Beta-adrenergic antagonists Glucagon Calcium channel blockers Insulin-euglycemia therapy Cardioactive steroids/Digoxin Digoxin-specific antibody fragments Digitalis-like compounds Methylxanthines and selective beta2-adrenergic agonists Caffeine Theophylline Other antihypertensives Clonidine Cathartics Decongestants Dietary and Nutritional Agents Athletic performance enhancers Diet aids Herbal products Iron Deferoxamine Vitamins and minerals Drugs of abuse Amphetamines Body stuffers and body packers Cocaine Designer drugs Disulfiram and disulfiram-like reactions Ethanol Gamma hydroxybutyrate Hallucinogens Heroin Inhalants Marijuana and analogs Nicotine Phencyclidine Synthetic stimulants Extravasation injuries Inhalational anesthetics Local anesthetics Lipid therapy Neuromuscular blockers Nonprescription drugs Psychopharmacologic agents Antipsychotics Butyrophenones Neuroleptic malignant syndrome Phenothiazines Atypical antipsychotics Cyclic antidepressants Lithium Monoamine oxidase inhibitors Sedative-Hypnotics Barbiturates Benzodiazepines Flumazenil Bromides Serotonin reuptake inhibitors and atypical antidepressants Serotonin syndrome Skeletal muscle relaxants Thyroid medications Borates Chemical warfare agents Chlorates Dioxin (TCDD) Formaldehyde Household toxins Antiseptics and disinfectants Camphor Caustics, corrosives (acid and alkali) Disc batteries Chlorine and chloramine gas Essential oils Fluoride Hydrocarbons Pesticides Hydrofluoric acid Toxic alcohols Ethylene glycol and glycol ethers Methanol Ethanol Fomepizole Barium Carbamates Chlorinated hydrocarbons Herbicides Insect repellents Methyl bromide and other fumigants Organophosphates Atropine Pralidoxime Phosphorous Pyrethrins/pyrethroids Rodenticides Sodium monofluoroacetate Strychnine Riot control agents Solvents ENVIRONMENTAL/OCCUPATIONAL Air pollution (indoor and outdoor) Botanicals/plants Carbon monoxide Hyperbaric oxygen therapy Chemical warfare agents Cyanide Hydroxocobalamin Sodium and amyl nitrites Sodium thiosulfate Hazardous materials, hazardous spills/waste Heavy metals Aluminum Antimony Arsenic Dimercaprol Bismuth Cadmium Chromium Cobalt Copper Lead Calcium disodium EDTA Succimer Manganese Mercury Nickel Selenium Silver Thallium Prussian blue Zinc High pressure injection injuries Hydrogen sulfide Industrial exposures Inhalation toxicity – gases, fumes, vapors Metal fume fever Nitrogen dioxide Pulmonary irritants Simple asphyxiants Smoke inhalation Isocyanates Methemeglobin inducers Methylene blue Occupational cancer risk Occupational exposure theory Potassium iodide Sick building syndrome TLV’s and other occupational exposure limits Toxic oil syndrome Water pollution BIOLOGICALS Biological warfare agents Anthrax Botulism Botulinum antitoxin Ciguatera fish poisoning Food poisoning Mushrooms Scombroid fish poisoning Shellfish poisoning Tetrodotoxin poisoning Toxic envenomations Arthropods Antivenoms Marine envenomations Scorpions & Antivenoms Snake and reptile envenomations & Antivenoms Analytical methodology Anion gap metabolic acidosis Blood levels of toxic substances Cancer promoters and carcinogens Cardiac toxicity of poisons Dermatologic reactions Drug induced illness Drug interactions Drug metabolism Enhancing elimination Epidemiologic study design and interpretation Epidemiology of poisonings Evidence based medicine approaches Extracorporeal drug removal Extrapolation of animal data to humans Fetal toxicity of xenobiotics Hepatotoxicity, toxin induced Laboratory analysis of toxins Mutagenesis Neonatal drug withdrawal Neonatal transplacental toxicity Nephrotoxicity of toxins Neuropathies Toxin induced Pharmacokinetics Pulmonary toxicity Teratogens and teratogenicity Therapeutic drug monitoring Toxicokinetics Toxidromes Withdrawal syndromes GENERAL/OTHER Agricultural related poisonings Antidotes First aid for poisonings Foreign body ingestions and exposures Gastric decontamination procedures History of toxicology Multiple chemical sensitivity syndrome Poison prevention Risk communication Risk evaluation If you would like to download a PDF of this, please click here Last updated March 24, 2014 The following references have been identified as useful resources used by candidates who have successfully passed the ABAT exam. This reference list does not specifically promote any particular resource but is designed to direct candidates to reputable sources that may be used to tailor their own needs during the exam preparation process. An effort should be made to use current editions.
Last Updated May 2024 The ABAT examination contains two sections: Multiple choice questions and Problem Solving. Both the Multiple Choice and Problem Solving sections are delivered in a computerized form. All answers will be submitted electronically via computer. Specifications for Multiple Choice Questions The questions will measure the candidate’s ability to recall certain general facts about specific agents within the above categories. More importantly, the candidate will apply this basic factual knowledge to make clinical decisions presented within the framework of the questions. The multiple choice questions will be of a type with 4 possible choices with one correct answer. This multiple-choice examination lasts four (4) hours.
Specifications for the Problem Solving Section The clinically-oriented, problem solving cases (3) are geared to assess the ability of the candidate to assess a patient scenario provided in a layered pattern (with no regression to the earlier section) typically providing a diagnostic (eg. differential diagnosis based on history and clinical findings, assessment strategies to include laboratory, radiologic, and use of pharmacologic antagonists), stabilization (eg. initial supportive care, empiric therapies), and therapeutic plan (eg specific interventions to include antidotes, methods of enhanced elimination) to work the problem through to resolution in an evidenced-based approach. In addition, the candidate should be able explain the underlying rationale and mechanisms of action for all assessment and management interventions, as well as organ-specific pathophysiology and sequelae for potential toxins. A second type of problem (1) will assess a more non-clinical role in addressing a statistical review of a toxicology literature article (critiquing a published study with regards to its study design strengths and weaknesses, and interpretation with extrapolation of results to practice). The candidate is given a brief introductory vignette of each of the four topics and is allowed to decide the order in which they choose to answer each of the four topics. Each topic is comprised of two to four separate sections which are further broken down to specific questions that focus on information provided in that section, as well as, past sections. Once a candidate completes a section of the case study, the candidate will submit the answers electronically before receiving the next section of the case study. Once each part of the exam is completed and submitted electronically via the exam online platform, there is no regression to the earlier section. Once all sections of a case study are completed, the individual is free to start any of the remaining case studies during the six (6) hour examination period.
The ABAT exam is a comprehensive examination that evaluates a candidate’s breadth of toxicology knowledge, problem solving skills pertinent in the management of poisoning case studies, proficiency in diagnosing the unknown poisoned patient; and the ability to critically evaluate scientific literature including the proper application of statistics. This study guide is designed to help candidates have an overall understanding of the rigorous nature and format of the exam. In addition, it includes many useful tips during the preparation process. However, it is important to note that use of this guide is not a guarantee of exam success. In order to become a Diplomate of the American Board of Applied Toxicology (DABAT), a candidate must successfully complete the credential review process and pass the ABAT examination. The ABAT examination is offered annually at the North American Congress of Clinical Toxicology (NACCT) meeting typically held in September or early October. The ABAT exam is a two-part examination administered over a two-day period. The exam is provided only in English. The first day of the exam is comprised of four multi-part, essay-formatted topics. The candidate is given a brief introductory vignette of each of the four topics and is allowed to decide the order in which they answer each of the four topics. Once each part of the exam is completed and submitted electronically via the online exam platform, there is no regression to the earlier section of the exam question. Three of the topics are toxicology-related, problem-solving case studies. These case studies encompass a wide variety of topics including acute and chronic exposures to drugs, biological agents, environmental toxins, and chemicals. The fourth topic is designed to evaluate the candidate’s ability to critically evaluate a published scientific journal article. Candidates are expected to complete all four questions in six (6) hours. The second day of the exam is comprised of 125 multiple-choice questions covering a variety of toxicology topics in a four (4) hour time frame. These questions are designed to measure diversity of knowledge. Please contact the President of ABAT if you have any additional questions. The following describes some pertinent logistics of the examination. These guidelines are subject to change. The candidates will be instructed regarding the current test taking rules on the day of the examination. * You must be a member in good standing with AACT * The Board will be grading your Multiple Choice and Problem Solving sections of the exam. For the Problem Solving, please remember to type out your responses clearly. Full sentences may not be required for some answers, lists are appropriate if asked. All answers should be provided in English. * You may take as many breaks of 10 minutes or less out of the exam room as you desire, but observe these rules:
* Drinks and/or snacks are permissible if desired. Water is typically supplied for test takers. * A lab reference sheet, a calculator and a pen with scratch paper will be provided by the exam Proctor and collected at the end of each day. Please turn off the audible tones of cell phones and pagers. * You must submit all test materials to the Proctor before you leave the exam area. Last updated: May 2024 Recent candidate exam takers of the American Board of Applied Toxicology were invited to complete an online survey regarding their experience and resources utilized to prepare for the ABAT exam. Eighteen (18) responses were recorded when the survey closed. Eighty-eight (88%) of respondents had passed the exam in the last 3 years. The following summarizes pertinent information from the survey that current exam candidates may find useful.
44% started more than 12 months prior to the exam 11% started 6 to 12 months prior to the exam 39% started 2 to 6 months prior to the exam
(also see the ABAT Reference List for suggestions)
Get InvolvedVolunteer for a committee, as a section chair, student chapter mentor, author Question of the Day and more! Support AACTBecome a ‘Friend of the Academy’ through a tax-deductible financial contribution. Donating is just a text away!  The sample exam questions provided are representative of the new exam format that was implemented in 2017 and updated in 2022.Domain i: conduct of toxicology studies. 1. In a reproductive toxicity study, what is the “fertility index”? A) the percentage of live fetuses per litter B) the percentage of attempted matings that result in pregnancies C) the ratio of fetuses at 14 days gestation/total implantations) D) the ratio of early fetal deaths/total implantations 2. What changes in serum enzyme levels are indicative of acute hepatocellular injury? A) increased alanine aminotransferase and aspartate aminotransferase) B) increased lactate dehydrogenase and decreased bilirubin C) increased sorbitol dehydrogenase and lipase D) increased 5′ nucleotidase and decreased urea nitrogen 3. What are the four core tester strains of Salmonella typhimurium used in the Ames (bacterial reverse mutation) assay? A) TA 1535, TA 100, TA 1538, TA 98 B) TA 1540, TA 200, TA 1520, TA 80 C) TA 1548, TA 202, TA 1505, TA 92 D) TA 1536, TA 110, TA 1518, TA 85 4. The in vivo micronucleus test is often used in a standard battery of genetic toxicity assays. In this test, what do the observed micronuclei represent? A) pyknotic nuclei from cells with decreased cytoplasmic to nuclear ratios B) clumps of ribosomes and associated RNA fragments C) membrane-bounded structures that contain chromosomal fragments or whole chromosomes D) binucleated remnants of germ cells 5 . What is the target organ of streptomycin-induced toxicity? A) eye B) heart C) ear D) liver Answers to Domain I1. B 2. A 3. A 4. C 5. C Domain II: Mechanistic Toxicology1.What property of beryllium-containing compounds is the reason they are not readily absorbed from the gastrointestinal tract? A) they form insoluble phosphate precipitates at the pH of the intestinal tract B) they are chelated by bile salts in the small intestine C) their size prevents passage through cell membranes D) they are converted to an oxide form 2. What is the mechanistic basis for cyclosporin A-induced cholestasis? A) interaction with the cytoplasmic receptor, cyclophilin B) inhibition of transcription of message (mRNA) for critical cytokines C) induction of programmed cell death in centrilobular hepatocytes D) inhibition of ATP-dependent transporter(s) in the bile canalicular membrane 3. What is the mechanism of neurotoxicity for strychnine? A) glycine receptor antagonist B) GABA uptake inhibitor C) glutamate receptor agonist D) blockade of muscarinic cholinoceptors 4. What condition will increase transport of a substance across the blood-brain barrier? A) high ionization B) strong binding to lipoproteins C) strong binding to plasma proteins D) cysteine binding Answers to Domain II1. A 2. D 3. A 4. D Domain III: Risk Assessment1. The antifungal drug ketoconazole specifically inhibits a cytochrome P450 isozyme responsible for the biotransformation of many drugs, among them midazolam. In a patient taking ketoconazole (200 mg/day PO), what would be the difference, if any, in this patient’s exposure (AUC0-24h) to midazolam if midazolam was administered intravenously (IV) vs. orally and why? A) no difference in IV vs. oral exposure because oral bioavailability of midazolam is 100% and is not metabolized by enterocytes B) increased exposure by the oral route because ketoconazole inhibits both the intestinal and hepatic P450 isozymes C) decreased exposure by the oral route because ketoconazole increases midazolam export from enterocytes via P-glycoprotein D) decreased exposure by the IV route because ketoconazole preferentially inhibits P450 metabolism in enterocytes 2. What is the expected response of an individual exposed to a single absorbed dose of 10 rads (0.1 Gy) of whole body X-irradiation? A) severe bone marrow depression B) permanent sterilization C) no adverse response D) vomiting 3. Ethanol, retinoids, valproic acid, and the angiotensin converting enzyme (ACE) inhibitors share what primary characteristic? A) induce liver toxicity B) lower blood pressure C) cause developmental toxicity D) induce central nervous system effects 4. Drug X is available as a 2.5% solution (w/v) in a 100-ml bottle. The desired intravenous dosage of this drug is 5 mg/kg body weight. What volume of drug should be injected if the patient weighs 50 kg? A) 0.2 ml B) 1.2 ml C) 2.0 ml D) 10 ml 5. What is a limitation of the benchmark dose approach in risk assessment? A) does not use the full range of doses and responses studied B) cannot be used when a clear “no observed adverse effect level” (NOAEL) has already been attained C) is based on a predefined benchmark response that is arbitrary D) cannot be used to extrapolate beyond the range of administered doses Answers to Domain III1. B 2. C 3. C 4. D 5. C Domain IV: Applied Toxicology1. What was the regulatory response to the Delaney clause? A) permitted most food additives to be declared generally recognized as safe (GRAS) B) prohibited EPA from setting safe exposure levels for environmental carcinogens C) prohibited FDA from approving food additives found to cause cancer in animals D) was applied only to food additives demonstrating human evidence of carcinogenicity 2. A patient is admitted to the emergency room with decreased heart rate, blood pressure, body temperature, and pupil size. At intake, the patient appeared very sleepy, and a family member stated that he was recovering from recent surgery. Exposure to what class of agent explains the patient’s symptoms? A) a narcotic analgesic B) a non-narcotic analgesic C) an antacid D) a benzodiazepine tranquilizer 3. What point source is the most significant contributor to air pollution by mass in suburban areas? A) cattle farms B) transportation C) electric power generation D) waste disposal 4. What food-borne exposure poses the greatest human-health risk worldwide? A) chemical contaminants/adulterants B) bacterial contamination C) mycotoxins and molds D) food additives Answers to Domain IV1. C 2. A 3. B 4. B
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Murder by Poison: Two High-Profile Forensic Toxicology Cases Photo courtesy of ozy.com. Forensic toxicology is one of the many fields of science that populates the intriguing world of investigative forensics. The main purpose of forensic toxicology is to aid law enforcement in understanding the extent to which ingested substances contributed to a person’s impairment or death. Combining biology with pharmacology, forensic toxicologists play vital roles in murder investigations in which the suspected cause of death is poison. To that end, here are two high-profile murder cases that were solved using the expertise of skilled forensic toxicologists. Angel of Death We hand over a lot of trust to those who work in the medical field. Vulnerable and sick, hospital patients assume that while under the care of nurses, they are in good hands. But, unfortunately for the people of a small Indiana community in the mid-1990s, their trust was misplaced. Between 1993 and 1995, a nurse named Orville Lynn Majors was linked to 130 of the 147 deaths at the Intensive Care Unit of Vermillion County Hospital in rural Indiana. Of course, while acting as a nurse in an I.C.U. will certainly expose one to death, this nurse was no ordinary health care provider. Dubbed the “Angel of Death,” Nurse Majors was convicted in 1999 for injecting six patients with heart-stopping, lethal doses of epinephrine and potassium chloride. Although he is not officially blamed for 130 deaths, there is a great deal of suspicion surrounding these deaths due to Majors’ exposure to these patients. His serial killing spree lasted for a couple of years in the mid-1990s, and the only reason his actions were brought to light was due to a routine study conducted by the hospital. The results of the study revealed that by 1994, the intensive care unit had a death rate of 120, despite the number being only 31 during years’ prior. Law enforcement was notified by the hospital of this spike in deaths. An investigation was opened, and 15 bodies were immediately exhumed for autopsies. Forensic toxicologists conducted tests, which revealed the lethal doses of the substances injected by Majors. Prosecutors were able to definitively tie Majors to six deaths, even though the killer had been alone with many more of the patients who passed away. Experts believe Majors was responsible for the death of more people, but his skill in mixing poison cocktails allowed him to use the defense of ‘death by natural causes.’ Majors was sentenced to a staggering 360-year prison sentence but passed away in 2017 due to – ironically – heart issues.  Photo courtesy of fanphobia.net. (Janie Lou Gibbs) In one of the most disturbing poison cases of the last century, Janie Lou Gibbs was responsible for the deaths of her husband, three sons and grandson. That’s right, she killed her own children and grandchild. And how did she do it? Rat poison and arsenic. Born on Christmas in 1932, Gibbs was an active member of her local church, and a dedicated home daycare operator. Then, one day, something changed. After 18 years of marriage to her husband, Marvin, she decided one evening to kill him by putting rat poison in his dinner. Gibbs’ plan did not immediately work. Marvin didn’t die, but instead was admitted to the local hospital after falling ill from what the doctors believed to be – naturally occurring liver issues. As the sweet wife she was, Gibbs decided to bring homemade soup to the hospital so that Marvin could enjoy a home cooked meal. The problem was, the soup was laced with arsenic. He soon died of “liver disease.” In a surprising twist, Gibbs donated a significant amount of Marvin’s life insurance proceeds to her church. Less than a year later, this wife and mother from hell poisoned her youngest son, Marvin, Jr. Authorities chalked up his death to his unfortunate inheritance of his father’s liver disease. Gibbs escaped without any suspicion. And, she donated some of her son’s life insurance proceeds to her church – again. Like a macabre broken record, Gibbs once again killed a year later. This time, she poisoned another one of her sons. His death, like the others before, was attributed to a natural cause. With only one living child remaining, the sadistic killer struck yet again. But, this time, Gibbs skipped a generation and killed her newborn grandson, Raymond. Less than a month later, Gibbs poisoned her son, Robert, who was the father of the murdered baby. Finally, Gibbs’ “luck” had run out. A family physician grew suspicious after the back-to-back deaths of a healthy newborn and his equally healthy father. An autopsy was immediately conducted on Robert, who was found to have ingested a lethal amount of arsenic. Forensic toxicologists worked with investigators in exhuming and testing the bodies of Gibbs’ other deceased family members. All five victims had their causes of death changed from natural to homicide by poison. Gibbs was initially found mentally unfit to stand trial and was confined to a mental institution. Years later, she was successfully prosecuted, convicted and sentenced to five life terms. In her elder years, Gibbs was diagnosed with Parkinson’s disease and released to the custody of her sister. In 1999, the killer died of natural causes. There’s something so disturbing about poison cases. Maybe it’s the deliberate premeditation. Or the slow painful death. Most likely it’s a combo of both. Are you aware of any poison cases as troubling as those above?  Read the latest in the Forensic Mystery Award-winning Series. 2018 Bronze Medal for Mystery from Readers’ Favorite 2018 Finalist from BookViral Millennium Book Award SCENE OF THE CRIME, A Chip Palmer Forensic Mystery Please join me: Newsletter Sign-Up Author Blog: https://authorjenniferchase.com/Book & crime talk: http://blogtalkradio.com/jennifer-chase, books: compulsion dead game dark mind dead burn dark pursuit. Dead Cold Scene of the Crime Silent Partner Body of the Crime ScreenwritingShare this:.  About jchasenovelist1 response to murder by poison: two high-profile forensic toxicology cases. Pingback: Forensic Genealogy Finds the Killer: 3 Cold Cases Recently Solved #crime #coldcase | Author Jennifer Chase Leave a comment Cancel replySocial media.
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CASE STUDY 3–1Common side effects would be included in all major compendia (e.g., Micromedex® 2.0, Clinical Pharmacology, or Facts & Comparisons) which would be a good initial search. In addition, some of the adverse effect specific resources (e.g., Meyler's Side Effects of Drugs) would be appropriate to consult for less common side effects. CASE STUDY 3–2There are a variety of resources that could be consulted for this information including the text Drugs in Pregnancy and Lactation or some of the major compendia (possibly, Micromedex® 2.0 or Clinical Pharmacology). The resources classify levofloxacin as an agent with unknown safety, but likely to be safe. In order to best answer this question, the requestor should determine if the disease state has other treatment options which have more data available and if the infant is receiving any formula supplementation. CASE STUDY 3–3The student might start a search for general information in a toxicology text such as Goldfrank's Toxicologic Emergencies. That could be followed with a search in Micromedex® 2.0 to find some general toxicology information; specifically the POISINDEX component of that resource would provide comprehensive information on this topic. The student would do best to search using the generic name of the medication, in this case using chlorpheniramine. CASE STUDY 3–4In a case you are not familiar with a term, a general Internet search might be a good start to help streamline your search. An Internet search shows that AMDUCA stands for Animal Medicinal Drug Use Clarification Act of 1994. Knowing that the term refers to a specific piece of legislation, you would be prompted to consider searching the American Veterinarian Medical Association web page or Food and Drug Administration web page. CASE STUDY 3–5Since this would be an off-label use, there may be less data in the tertiary resources. In this case it is likely more efficient to do a search in the secondary resources. Medline is a good place to start. Initially conducting a search with no restrictions/limits ensures that valuable information is not missed. If the initial search yields a significant number of results, then a restriction to human clinical trials would be beneficial. When conducting this search, it is important to realize that the term female sexual arousal disorder has changed over time, so maybe a more general search for female sexual dysfunctions will give more responses. In addition, searching for the specific drug sildenafil will yield useful data, but expanding the search using the class of drugs will provide more data. CASE STUDY 3–6Get free access through your institution, pop-up div successfully displayed. This div only appears when the trigger link is hovered over. Otherwise it is hidden from view. Please Wait |
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Toxicology, this patient does not meet criteria for gastric lavage as she meets neither of two criteria for this intervention: ingestion of a potentially life- threatening amount of a poison and presentation within 60 minutes of ingestion.
Five bottles were responsible for seven deaths and three more bottles were found. No suspect was ever located but this led to anti-tampering packages. - verdict: In 1986 Stella , a Seattle woman laced Excedrin with cyanide. She killed her husband then placed three more bottles on the shelves to make it look like a random killing.
Case Studies in Toxicology: Polypharmacology Induces "Sleep Driving". This case study illustrates the role of toxicological weight-of-evidence (WOE) in a motor vehicle accident case involving polypharmacology and antidepressants. It also illustrates how drug interactions can be considered evidential in a toxicological causation assessment.
Toxicology Case Studies. 11 terms. R1ley123. Preview. Vital Vocabulary. 73 terms. quizlette51206429. Preview. Prions. 34 terms. smiley_280. Preview. Terms in this set (28) Mary Blandy. Poisoned her father to change his temperament towards her new fiancé with arsenic poisoning. Charles Hall.
Study with Quizlet and memorize flashcards containing terms like 22 yo male was found unresponsive in a parked car. Pupils are constricted (miosis) Vitals: BP 124/68, HR: 64, R: 6, T: 36.8C Skin warm and Dry, 2 y/o found lethargic, gasping respiration, HR 75, BP 90/50, miosis. Had a discarded clonidine patch on her, 12 m/o found unarousable in crib. HR 72, BP 80/40, RR 22, miosis. Found a ...
The cases will emphasize key teaching points important in emergency toxicology. Here are our peer reviewed cases. The cases will emphasize key teaching points important in emergency toxicology. ... This is a case of a 38-year-old man with a past medical history of alcoholism/alcohol abuse and biliary colic who now presents with nonspecific ...
About this book. The ACMT National Case Conference (NCC) is a monthly discussion of novel or interesting cases in medical toxicology. Participation is through online webinar, and the conferences are recorded to allow for review at any time. The cases in this book are taken from recordings of NCC with edits and revisions by contributors and ...
The student might start a search for general information in a toxicology text such as Goldfrank's Toxicologic Emergencies. That could be followed with a search in Micromedex ® 2.0 to find some general toxicology information; specifically the POISONDEX component of that resource would provide comprehensive information on this topic.. The student would do best to search using the generic name ...
Epidemiology Questions 1. List the specific strengths and weaknesses of this study. 2. List the general strengths and weaknesses of epidemiology for providing an answer to Mary Beth's question. Toxicology Toxicologists study poisons or toxins by detection, isolation, identification, and determination of their effects on the human body.
A list of relevant questions is also provided for each case. Subjects include common toxicological problems, rare presentations of common problems, common problems with controversial treatments or difficult diagnoses, and rare problems.Case Studies in Medical Toxicology from the American College of Medical Toxicology is a detailed reference ...
ABAT Examination Study Guide. Start studying at least 8-12 months prior to the examination, devoting a minimum of 1-2 times per week to exam preparation. Plan a systematic review of the vast amount of topics that require study. Consider creating a table comprised of an extensive list of topics (the List of Potential Exam Topics is below).
Introduction. SK was a 63-year-old male who was found unresponsive in the front yard of his home on May 6, 2019. He was taken to hospital, but all attempts at resuscitation were unsuccessful. SK's past medical history included chronic pain (following a fall from his bike with left rib fracture in May 2018), hypertension, and depression.
Description. Toxicology Cases for the Clinical and Forensic Laboratory brings together carefully selected case studies to teach important principles relating to drug and toxin exposures. Each case study includes contemporary clinical and forensic toxicologist studies that include a comprehensive analytical and clinical approach to patient ...
Case Studies in Toxicology: Death and Taxus - MDedge
The sample exam questions provided are representative of the new exam format that was implemented in 2017 and updated in 2022. Domain I: Conduct of Toxicology Studies. 1. In a reproductive toxicity study, what is the "fertility index"? A) the percentage of live fetuses per litter B) the percentage of attempted matings that result in pregnancies
A selection of toxicology cases, investigated by the author, is discussed to illustrate the broad range of cases that can be encountered by a forensic toxicologist. Emphasis is placed on the application of basic principles to address out of the ordinary problems and the utilization of non-standard toxicology methods drawn from other areas of ...
Case Studies in Toxicology: When Doing More for the Sake of Better Health Goes Wrong | MDedge.
Combining biology with pharmacology, forensic toxicologists play vital roles in murder investigations in which the suspected cause of death is poison. To that end, here are two high-profile murder cases that were solved using the expertise of skilled forensic toxicologists. Angel of Death. We hand over a lot of trust to those who work in the ...
Anthrax Cases of 2001. -Anthrax found in letter shortly after 911 that took the lives of 5 americans. Michael Jackson. -Propofol was the cause of death. Marylin Monroe. -Overdosed on barbiturates while consuming a long list of drugs. Study with Quizlet and memorize flashcards containing terms like Jim Jones, Mary Blandy, Eva Rablen and more.
The CFSRE has developed NPS reports and interactive tools to provide forensic practitioners, researchers, public health officials and other notable stakeholders with real-time actionable data pertaining to the identification and proliferation of emerging drugs. In this presentation, 3 case series will be discussed to understand the workflow for ...
Conclusion. Clinical case studies in toxicology, combined with experimental investigations, are indispensable tools for understanding the adverse efects of toxic exposures. These studies provide insights into clinical manifestations, mechanisms of. *Correspondence to: James Cullen, Department of Toxicology, Nagoya University, Nagoya, Japan.
Debapratim Ganguly, Soutrik Ghosh, Sukanta Dutta, Atanu Chandra. BMJ Case Reports CP Oct 2022, 15 (10) e252217; DOI: 10.1136/bcr-2022-252217. Atypical organophosphate poisoning and a successful case of prolonged intubation in a low-resource newly developed intensive care unit in rural Zambia. Lara Bowell, Mark Timothy Williams.
Please consult the latest official manual style if you have any questions regarding the format accuracy. AMA Citation Answers for Case Studies. In: Malone PM, Malone MJ, ... The student might start a search for general information in a toxicology text such as Goldfrank's Toxicologic Emergencies. That could be followed with a search in ...