ACMT Toxicology Visual Pearls: Discolored Skin and Urine

A patient is brought to the Emergency Department by EMS (Emergency Medical Services) from a house fire. The patient’s skin and urine are discolored as shown. What is the most likely cause of the discoloration?
- Acute liver failure
- An antidote administered by prehospital provider
- Carbon monoxide poisoning
- Massive hemolysis
The above question is common from patients with a history of an allergic reaction seen for a repeat emergency department visit. The manufacturers of EpiPen caution not to use the pen beyond the expiration date, and if the drug solution becomes discolored (oxidation). But EpiPens are expensive! Is there harm in using the pen beyond the expiration date? What should we tell our patients?
Several years ago I created a resource for my ED rotation that I share with pharmacy students, pharmacy residents, and EM physician residents. It contains most of the guidelines and position statements on EM drug therapy that I utilize most often and is updated as new iterations are published. We’d like to share this tool with you to be used/modified to meet your rotation needs.
The seeds of the Suicide Plant, when ingested, may result in significant toxicity, including the ECG findings shown. Which kind of toxicity does it cause?