Forty-eight patients poisoned with insecticide formulations containing permethrin (a Type I pyret... more Forty-eight patients poisoned with insecticide formulations containing permethrin (a Type I pyrethroid insecticide), xylene, and surfactants are reported here. These patients were diagnosed and treated in the Chang Gung Memorial Hospital in Taiwan from January 1987 to June 1999. Ten patients ingested permethrin in error and 38 patients attempted suicide. Gastrointestinal tract signs and symptoms were most common (35/48; 73%), and included sore throat, mouth ulcerations, dysphagia, epigastric pain, and vomiting. Pulmonary abnormalities were documented in 29% (14/48) of patients. Aspiration pneumonitis occurred in eight patients, including onefatal case. Pulmonary edema was observed in two patients. Sixteen patients (33%) had central nervous system involvement including confusion (6/48; 13%), coma (10/48; 21%), and seizures (4/48; 8%). Cardiovascular symptoms in 3/48 (7%) patients were limited to arrhythmias and shock. Mild renal and hepatic dysfunction was found in 5/48 (10%) and 3/48 (6%) of patients, respectively. Leukocytosis occurred in 16 patients (33%) but was not associated with infection. Only one death occurred during this 12.5-year period. Poisoning caused by ingesting insecticides containing permethrin, xylene, and surfactant manifests primarily gastrointestinal tract symptoms and signs. The involvement of the central nervous system and lungs were less common, but clinically more significant. The relative contributions of the 20% permethrin, 70% xylene, and 10% surfactant to these toxic manifestations, however, is uncharacterized.
Eye/skin chemical splashes are a significant problem. Diphoterine is an hypertonic, polyvalent, a... more Eye/skin chemical splashes are a significant problem. Diphoterine is an hypertonic, polyvalent, amphoteric compound developed in France as an eye/skin chemical splash water-based decontamination solution. In vitro and in vivo, it actively decontaminates approximately 600 chemicals, including acids, alkalis, oxidizing and reducing agents, irritants, lacrimators, solvents, alkylating agents, and radionuclides. Its chemical bond energy for such agents is greater than that of tissue receptors. Its hypertonicity impedes chemical tissue penetration and may remove some amount of skin/cornea-absorbed toxicants not already bound to tissue receptors. Diphoterine chemical reactions are not exothermic. Diphoterine and its acid/alkali decontamination residues are not irritating to the eyes or skin; it is essentially nontoxic. Diphoterine can prevent eye/skin burns following chemical splashes and results in nearly immediate pain relief.
A 24.year-old woman ingested an unknown amount of potassium cyanide in a suicide attempt. Coma an... more A 24.year-old woman ingested an unknown amount of potassium cyanide in a suicide attempt. Coma and metabolic acidosis developed. Administration of the Lilly Cyanide Antidote kit (Eli Lilly and Co, Indianapolis) resulted in prompt resolution of symptoms and full recovery. Whole blood cyanide level was 13 pg/mL approximately one hour after ingestion. The highest measured methemoglobin level after sodium nitrfte administration was 9.2%, demonstrating that attaining a "therapeutic methemoglobin level" of 25% is unnecessary to fnsure a satisfactory clinical outcome. Because severe hypotension or excessive methemogloblnemia can be caused by the sodium nitrite component of the Lilly kit, only enough to produce an acceptable clinical response should be administered. (Am J Emerg Med 1989;7:437-440. 0 1989 by W.B. Saunders Company.)
Because life-threatening pediatric digitalis toxicity is so unusual, the use of antidigoxin antib... more Because life-threatening pediatric digitalis toxicity is so unusual, the use of antidigoxin antibodies (Fab) has been reported only rarely. We report a multicenter clinical trial (MCCT) conducted from 1978 through 1986 that studied the clinical characteristics and outcomes of 29 pediatric patients with life-threatening digoxin (28) or digitoxin (one) poisoning who received Fab. Their median age was 1.5 years; there were approximately equal groups of boys and girls. Fifteen had underlying cardiac disease. Toxicity resulted from chronic therapy in ten and one-time overdose in 19. Median serum digoxin concentration was 9.4 ng/mL. Of 12 symptoms and signs of toxicity, atrioventricular block was most common . Sixteen patients had ventricular tachycardia and/or fibrillation. Patients had a median of four signs/symptoms. Therapy before Fab was known in 24 patients; 75% had required CPR or ventricular pacing. Six of 18 patients for whom it was recorded had complete resolution of cardiac toxicity within 30 minutes after Fab. Fifteen of 18 patients responded by four hours. Twenty-seven of 29 patients (93%) had complete resolution of signs/symptoms of digitalis toxicity after Fab. No patient experienced allergic reactions; one had transient apnea. Twenty-two of 29 (76%) patients survived; seven patients (24%) ultimately died from underlying congenital or extracardiac problems. We conclude that Fab is effective in children and can play an important role in pediatric digitalis intoxications with severe, life-threatening cardiac toxicity, hemodynamic instability, or hyperkalemia.
The safety, efficacy and pharmacokinetic parameters of 5 g of hydroxocobalamin given intravenousl... more The safety, efficacy and pharmacokinetic parameters of 5 g of hydroxocobalamin given intravenously, alone or in combination with 12.5 g of sodium thiosulfate, were evaluated in healthy adult men who were heavy smokers. Sodium thiosulfate caused nausea, vomiting, and localized burning, muscle cramping, or twitching at the infusion site. Hydroxocobalamin was associated with a transient reddish discoloration of the skin, mucous membranes, and urine, and when administered alone produced mean elevations of 13.6% in systolic and 25.9% in diastolic blood pressure, with a concomitant 16.3% decrease in heart rate. No other clinically significant adverse effects were noted. Hydroxocobalamin alone decreased whole blood cyanide levels by 59% and increased urinary cyanide excretion. Pharmacokinetic parameters of hydroxocobalamin were best defined in the group who received both antidotes: t1/2 (alpha), 0.52 h; t1/2 (beta), 2.83 h; Vd (beta), 0.24 L/kg; and mean peak serum concentration 753 mcg/mL (560 mumol/L) at 0-50 minutes after completion of infusion. Hydroxocobalamin is safe when administered in a 5 gram intravenous dose, and effectively decreases the low whole blood cyanide levels found in heavy smokers.
0 Abstract -Ivermectin is a veterinary antiparasitic medication for domestic animals. Two cases o... more 0 Abstract -Ivermectin is a veterinary antiparasitic medication for domestic animals. Two cases of human exposure to veterinary preparations of ivermectin are reported. Patient number one accidentally self-injected ivermectin and developed nausea, pallor, and transient pain and numbness in the affected extremity. Patient number two, a 4-year-old child, ingested an unknown amount of the paste preparation and remained asymptomatic. As ivermectin is being used with increasing frequency in veterinary medicine, more human exposures may be anticipated. 0
Four patients with elevated serum boric acid levels after single, acute ingestions of 10 to 297 g... more Four patients with elevated serum boric acid levels after single, acute ingestions of 10 to 297 grams were reported to the Rocky Mountain Poison and Drug Center (RMPDC) between January 1983 and August 1985. Systemic effects were absent. In 1983-4, 364 cases of boric acid exposure were reported to the RMPDC with only one fatality from a probable chronic ingestion. Vomiting, nausea, diarrhea, and abdominal cramps were rather common. Systemic effects were notably absent in acute ingestions. Five of three hundred sixty-four patients had measured serum levels and were the only ones hospitalized. These observations suggest that significant poisoning is unlikely to result from a single, acute ingestion of boric acid. Serum boric acid levels appear to correlate poorly with clinical toxicity following acute ingestion.
Journal of Occupational and Environmental Medicine, 1990
Four cases of serious methylene chloride (dichloromethane) poisoning, including fatalities, in sm... more Four cases of serious methylene chloride (dichloromethane) poisoning, including fatalities, in small-scale furniture-stripping shops were reported to the Rocky Mountain Poison and Drug Center between 1984 and 1988. Adequate ventilation systems and use of recommended respirators may seem impractical or overly expensive to the operators of such shops. Twenty-one shops in the metropolitan Denver, Colorado area were surveyed. A half-facepiece respirator with organic vapor cartridges was worn at least part-time in 14 of 21 shops; none was worn in 7. In 10 of 21 shops, workers had experienced dizziness, headache, or nausea when stripping furniture. Current safety practices in small-scale furniture-stripping shops may be inadequate to keep methylene chloride exposure levels in compliance with latest recommendations, and serious or fatal overexposure can occur.
0 Abstract-A 22-month-old, 10 kg child ingested 32 mg of chlorambucil and developed irritability,... more 0 Abstract-A 22-month-old, 10 kg child ingested 32 mg of chlorambucil and developed irritability, myoclonic-like muscle jerks, an exaggerated startle reflex, vomiting, and EEG changes within a few hours. The neurologic symptoms improved overnight, and the patient was discharged at about 28 hours postingestion. During the three weeks of follow-up, mild bone marrow suppression occurred and resolved. A normal EEG was reported at 33 weeks postingestion. 0
Severe, acute cyanide poisoning is uncommon and can be very difficult to diagnose if a history of... more Severe, acute cyanide poisoning is uncommon and can be very difficult to diagnose if a history of exposure is unavailable. Victims of smoke inhalation may have significant cyanide poisoning as well as carbon monoxide toxicity. The Lilly Cyanide Antidote Kit currently available in America unfortunately has its own inherent toxicity. An efficacious antidote lacking toxicity is desirable, especially in cases where the diagnosis of cyanide poisoning cannot be made with certainty. Hydroxycobalamin/sodium thiosulfate has been used in France since 1970. Both components have been shown to be safe and efficacious in animal studies. Case reports of human cyanide poisoning treated with hydroxycobalamin/sodium thiosulfate have been published only in French. Animal and human data on the use of this antidotal combination are reviewed. Hydroxycobalamin/sodium thiosulfate is an efficacious cyanide antidote with little inherent toxicity.
A 19-year-old man with a history of intravenous cocaine and amphetamine abuse injected 1.1 mg of ... more A 19-year-old man with a history of intravenous cocaine and amphetamine abuse injected 1.1 mg of epinephrine intravenously from an over-the-counter bronchodilator inhaler. Within seconds, headache, nausea, numbness of hands and feet, precordial chest discomfort, and palpitations developed. The patient was given a sublingual nitroglycerin tablet by a bystander and promptly had a syncopal episode. Hypotension was observed in the emergency department 10 minutes later. Administration of 2 L of Ringer's lactate maintained blood pressure at 80-90 mm Hg systolic. An electrocardiogram showed ischemic changes in the precordial leads. Cardiac enzymes remained normal. Mild hypokalemia and hyperglycemia were observed. This case illustrates an unusual route of abuse of an over-the-counter epinephrine bronchodilator.
A 34 year old, 73 kg man ingested a 1 gram potassium cyanide pellet in a suicide attempt. Within ... more A 34 year old, 73 kg man ingested a 1 gram potassium cyanide pellet in a suicide attempt. Within one hour, coma, apnea, metabolic acidosis, and seizures developed. Sodium nitrite and sodium thiosulfate were administered. Dramatic improvement in the clinical condition occurred by the completion of antidote infusion. Methemoglobin level was 2% immediately after nitrite administration. Serial whole blood cyanide levels were obtained, documenting a highest measured level of 15.68 mcg/mL. Estimations of toxicokinetic parameters including terminal half-life (t 1/2) (19 hours), clearance (163 mL/minute), and volume of distribution (Vd) (0.41 L/kg) were calculated. The nitrite/thiosulfate combination was clinically efficacious in this case and resulted in complete recovery.
Patients frequently come to the emergency department or contact a poison center following exposur... more Patients frequently come to the emergency department or contact a poison center following exposure to plants. These cases are often challenging owing to difficulty in correct identification of the involved plant. A case of two patients who demonstrated anticholinergic syndromes after ingesting an unknown, wild plant is described. Chemical analysis of two suspect plants collected in the same location allowed a probable diagnosis of poisoning from ingestion of henbane (Hyoscyamus niger).
Nonsalicylate, nonsteroidal anti-inflammatory drugs (NSAIDs) can be divided into 4 chemical class... more Nonsalicylate, nonsteroidal anti-inflammatory drugs (NSAIDs) can be divided into 4 chemical classes: acetic acids, fenamic acids, oxicams and propionic acids. Most NSAID overdoses result in a benign outcome. Of 50,614 exposures reported to poison centres in the United States in a 2-year period, 131 (0.26%) had a major outcome, with 10 deaths. Despite the generally mild effects reported in large patient series, isolated case reports have documented serious toxicity, such as seizures, hypotension, apnoea, coma and renal failure. The majority of these consequences occur after ingestion of substantial quantities by adults attempting suicide. Rarely, with ibuprofen and piroxicam, children who ingest small amounts in accidental exposure develop serious toxicity. Typical signs and symptoms of NSAID overdose include nausea, vomiting, headache, drowsiness, blurred vision and dizziness. Seizures are rarely documented across all NSAID classes, with the exception of mefenamic acid (where seizures occur in over one-third of cases), or following massive ingestion of other agents. Drugs in the propionic acid group have produced metabolic acidosis, respiratory depression and coma in severe cases. Ibuprofen is the agent with the most published data on overdose, probably because it is available without a prescription in many countries. Symptoms are unlikely after ingestion of 100 mg/kg or less, and are usually not life-threatening unless more than 400 mg/kg is ingested. There is some relationship between plasma concentrations and the potential for development of symptoms, but plasma concentrations have no impact on treatment decisions. Treatment of NSAID overdose is entirely supportive. Recent trends in emergency department procedures regarding gastric decontamination are evolving towards the recommended administration of activated charcoal without gastric emptying in patients presenting more than 1 hour after ingestion, although gastric lavage, followed by administration of activated charcoal, may be advisable in patients who present earlier. Home administration of syrup of ipecac is still recommended if treatment is given shortly after ingestion, with a few exceptions: for example, ipecac is contraindicated after ingestion of mefenamic acid or ibuprofen in amounts greater than 400 mg/kg. Urine alkalinisation and diuresis have been recommended to enhance the elimination of NSAIDs, based on a pKa in the range of 3 to 5. However, because the drugs are universally highly protein bound, with little unchanged renal excretion, this technique is not likely to be beneficial. Haemodialysis is also unlikely to enhance elimination, but may be required if oliguric renal failure develops. Multiple dose activated charcoal may be useful in enhancing elimination of NSAIDs with long half-lives, such as piroxicam and sulindac.
Forty-eight patients poisoned with insecticide formulations containing permethrin (a Type I pyret... more Forty-eight patients poisoned with insecticide formulations containing permethrin (a Type I pyrethroid insecticide), xylene, and surfactants are reported here. These patients were diagnosed and treated in the Chang Gung Memorial Hospital in Taiwan from January 1987 to June 1999. Ten patients ingested permethrin in error and 38 patients attempted suicide. Gastrointestinal tract signs and symptoms were most common (35/48; 73%), and included sore throat, mouth ulcerations, dysphagia, epigastric pain, and vomiting. Pulmonary abnormalities were documented in 29% (14/48) of patients. Aspiration pneumonitis occurred in eight patients, including onefatal case. Pulmonary edema was observed in two patients. Sixteen patients (33%) had central nervous system involvement including confusion (6/48; 13%), coma (10/48; 21%), and seizures (4/48; 8%). Cardiovascular symptoms in 3/48 (7%) patients were limited to arrhythmias and shock. Mild renal and hepatic dysfunction was found in 5/48 (10%) and 3/48 (6%) of patients, respectively. Leukocytosis occurred in 16 patients (33%) but was not associated with infection. Only one death occurred during this 12.5-year period. Poisoning caused by ingesting insecticides containing permethrin, xylene, and surfactant manifests primarily gastrointestinal tract symptoms and signs. The involvement of the central nervous system and lungs were less common, but clinically more significant. The relative contributions of the 20% permethrin, 70% xylene, and 10% surfactant to these toxic manifestations, however, is uncharacterized.
Eye/skin chemical splashes are a significant problem. Diphoterine is an hypertonic, polyvalent, a... more Eye/skin chemical splashes are a significant problem. Diphoterine is an hypertonic, polyvalent, amphoteric compound developed in France as an eye/skin chemical splash water-based decontamination solution. In vitro and in vivo, it actively decontaminates approximately 600 chemicals, including acids, alkalis, oxidizing and reducing agents, irritants, lacrimators, solvents, alkylating agents, and radionuclides. Its chemical bond energy for such agents is greater than that of tissue receptors. Its hypertonicity impedes chemical tissue penetration and may remove some amount of skin/cornea-absorbed toxicants not already bound to tissue receptors. Diphoterine chemical reactions are not exothermic. Diphoterine and its acid/alkali decontamination residues are not irritating to the eyes or skin; it is essentially nontoxic. Diphoterine can prevent eye/skin burns following chemical splashes and results in nearly immediate pain relief.
A 24.year-old woman ingested an unknown amount of potassium cyanide in a suicide attempt. Coma an... more A 24.year-old woman ingested an unknown amount of potassium cyanide in a suicide attempt. Coma and metabolic acidosis developed. Administration of the Lilly Cyanide Antidote kit (Eli Lilly and Co, Indianapolis) resulted in prompt resolution of symptoms and full recovery. Whole blood cyanide level was 13 pg/mL approximately one hour after ingestion. The highest measured methemoglobin level after sodium nitrfte administration was 9.2%, demonstrating that attaining a "therapeutic methemoglobin level" of 25% is unnecessary to fnsure a satisfactory clinical outcome. Because severe hypotension or excessive methemogloblnemia can be caused by the sodium nitrite component of the Lilly kit, only enough to produce an acceptable clinical response should be administered. (Am J Emerg Med 1989;7:437-440. 0 1989 by W.B. Saunders Company.)
Because life-threatening pediatric digitalis toxicity is so unusual, the use of antidigoxin antib... more Because life-threatening pediatric digitalis toxicity is so unusual, the use of antidigoxin antibodies (Fab) has been reported only rarely. We report a multicenter clinical trial (MCCT) conducted from 1978 through 1986 that studied the clinical characteristics and outcomes of 29 pediatric patients with life-threatening digoxin (28) or digitoxin (one) poisoning who received Fab. Their median age was 1.5 years; there were approximately equal groups of boys and girls. Fifteen had underlying cardiac disease. Toxicity resulted from chronic therapy in ten and one-time overdose in 19. Median serum digoxin concentration was 9.4 ng/mL. Of 12 symptoms and signs of toxicity, atrioventricular block was most common . Sixteen patients had ventricular tachycardia and/or fibrillation. Patients had a median of four signs/symptoms. Therapy before Fab was known in 24 patients; 75% had required CPR or ventricular pacing. Six of 18 patients for whom it was recorded had complete resolution of cardiac toxicity within 30 minutes after Fab. Fifteen of 18 patients responded by four hours. Twenty-seven of 29 patients (93%) had complete resolution of signs/symptoms of digitalis toxicity after Fab. No patient experienced allergic reactions; one had transient apnea. Twenty-two of 29 (76%) patients survived; seven patients (24%) ultimately died from underlying congenital or extracardiac problems. We conclude that Fab is effective in children and can play an important role in pediatric digitalis intoxications with severe, life-threatening cardiac toxicity, hemodynamic instability, or hyperkalemia.
The safety, efficacy and pharmacokinetic parameters of 5 g of hydroxocobalamin given intravenousl... more The safety, efficacy and pharmacokinetic parameters of 5 g of hydroxocobalamin given intravenously, alone or in combination with 12.5 g of sodium thiosulfate, were evaluated in healthy adult men who were heavy smokers. Sodium thiosulfate caused nausea, vomiting, and localized burning, muscle cramping, or twitching at the infusion site. Hydroxocobalamin was associated with a transient reddish discoloration of the skin, mucous membranes, and urine, and when administered alone produced mean elevations of 13.6% in systolic and 25.9% in diastolic blood pressure, with a concomitant 16.3% decrease in heart rate. No other clinically significant adverse effects were noted. Hydroxocobalamin alone decreased whole blood cyanide levels by 59% and increased urinary cyanide excretion. Pharmacokinetic parameters of hydroxocobalamin were best defined in the group who received both antidotes: t1/2 (alpha), 0.52 h; t1/2 (beta), 2.83 h; Vd (beta), 0.24 L/kg; and mean peak serum concentration 753 mcg/mL (560 mumol/L) at 0-50 minutes after completion of infusion. Hydroxocobalamin is safe when administered in a 5 gram intravenous dose, and effectively decreases the low whole blood cyanide levels found in heavy smokers.
0 Abstract -Ivermectin is a veterinary antiparasitic medication for domestic animals. Two cases o... more 0 Abstract -Ivermectin is a veterinary antiparasitic medication for domestic animals. Two cases of human exposure to veterinary preparations of ivermectin are reported. Patient number one accidentally self-injected ivermectin and developed nausea, pallor, and transient pain and numbness in the affected extremity. Patient number two, a 4-year-old child, ingested an unknown amount of the paste preparation and remained asymptomatic. As ivermectin is being used with increasing frequency in veterinary medicine, more human exposures may be anticipated. 0
Four patients with elevated serum boric acid levels after single, acute ingestions of 10 to 297 g... more Four patients with elevated serum boric acid levels after single, acute ingestions of 10 to 297 grams were reported to the Rocky Mountain Poison and Drug Center (RMPDC) between January 1983 and August 1985. Systemic effects were absent. In 1983-4, 364 cases of boric acid exposure were reported to the RMPDC with only one fatality from a probable chronic ingestion. Vomiting, nausea, diarrhea, and abdominal cramps were rather common. Systemic effects were notably absent in acute ingestions. Five of three hundred sixty-four patients had measured serum levels and were the only ones hospitalized. These observations suggest that significant poisoning is unlikely to result from a single, acute ingestion of boric acid. Serum boric acid levels appear to correlate poorly with clinical toxicity following acute ingestion.
Journal of Occupational and Environmental Medicine, 1990
Four cases of serious methylene chloride (dichloromethane) poisoning, including fatalities, in sm... more Four cases of serious methylene chloride (dichloromethane) poisoning, including fatalities, in small-scale furniture-stripping shops were reported to the Rocky Mountain Poison and Drug Center between 1984 and 1988. Adequate ventilation systems and use of recommended respirators may seem impractical or overly expensive to the operators of such shops. Twenty-one shops in the metropolitan Denver, Colorado area were surveyed. A half-facepiece respirator with organic vapor cartridges was worn at least part-time in 14 of 21 shops; none was worn in 7. In 10 of 21 shops, workers had experienced dizziness, headache, or nausea when stripping furniture. Current safety practices in small-scale furniture-stripping shops may be inadequate to keep methylene chloride exposure levels in compliance with latest recommendations, and serious or fatal overexposure can occur.
0 Abstract-A 22-month-old, 10 kg child ingested 32 mg of chlorambucil and developed irritability,... more 0 Abstract-A 22-month-old, 10 kg child ingested 32 mg of chlorambucil and developed irritability, myoclonic-like muscle jerks, an exaggerated startle reflex, vomiting, and EEG changes within a few hours. The neurologic symptoms improved overnight, and the patient was discharged at about 28 hours postingestion. During the three weeks of follow-up, mild bone marrow suppression occurred and resolved. A normal EEG was reported at 33 weeks postingestion. 0
Severe, acute cyanide poisoning is uncommon and can be very difficult to diagnose if a history of... more Severe, acute cyanide poisoning is uncommon and can be very difficult to diagnose if a history of exposure is unavailable. Victims of smoke inhalation may have significant cyanide poisoning as well as carbon monoxide toxicity. The Lilly Cyanide Antidote Kit currently available in America unfortunately has its own inherent toxicity. An efficacious antidote lacking toxicity is desirable, especially in cases where the diagnosis of cyanide poisoning cannot be made with certainty. Hydroxycobalamin/sodium thiosulfate has been used in France since 1970. Both components have been shown to be safe and efficacious in animal studies. Case reports of human cyanide poisoning treated with hydroxycobalamin/sodium thiosulfate have been published only in French. Animal and human data on the use of this antidotal combination are reviewed. Hydroxycobalamin/sodium thiosulfate is an efficacious cyanide antidote with little inherent toxicity.
A 19-year-old man with a history of intravenous cocaine and amphetamine abuse injected 1.1 mg of ... more A 19-year-old man with a history of intravenous cocaine and amphetamine abuse injected 1.1 mg of epinephrine intravenously from an over-the-counter bronchodilator inhaler. Within seconds, headache, nausea, numbness of hands and feet, precordial chest discomfort, and palpitations developed. The patient was given a sublingual nitroglycerin tablet by a bystander and promptly had a syncopal episode. Hypotension was observed in the emergency department 10 minutes later. Administration of 2 L of Ringer's lactate maintained blood pressure at 80-90 mm Hg systolic. An electrocardiogram showed ischemic changes in the precordial leads. Cardiac enzymes remained normal. Mild hypokalemia and hyperglycemia were observed. This case illustrates an unusual route of abuse of an over-the-counter epinephrine bronchodilator.
A 34 year old, 73 kg man ingested a 1 gram potassium cyanide pellet in a suicide attempt. Within ... more A 34 year old, 73 kg man ingested a 1 gram potassium cyanide pellet in a suicide attempt. Within one hour, coma, apnea, metabolic acidosis, and seizures developed. Sodium nitrite and sodium thiosulfate were administered. Dramatic improvement in the clinical condition occurred by the completion of antidote infusion. Methemoglobin level was 2% immediately after nitrite administration. Serial whole blood cyanide levels were obtained, documenting a highest measured level of 15.68 mcg/mL. Estimations of toxicokinetic parameters including terminal half-life (t 1/2) (19 hours), clearance (163 mL/minute), and volume of distribution (Vd) (0.41 L/kg) were calculated. The nitrite/thiosulfate combination was clinically efficacious in this case and resulted in complete recovery.
Patients frequently come to the emergency department or contact a poison center following exposur... more Patients frequently come to the emergency department or contact a poison center following exposure to plants. These cases are often challenging owing to difficulty in correct identification of the involved plant. A case of two patients who demonstrated anticholinergic syndromes after ingesting an unknown, wild plant is described. Chemical analysis of two suspect plants collected in the same location allowed a probable diagnosis of poisoning from ingestion of henbane (Hyoscyamus niger).
Nonsalicylate, nonsteroidal anti-inflammatory drugs (NSAIDs) can be divided into 4 chemical class... more Nonsalicylate, nonsteroidal anti-inflammatory drugs (NSAIDs) can be divided into 4 chemical classes: acetic acids, fenamic acids, oxicams and propionic acids. Most NSAID overdoses result in a benign outcome. Of 50,614 exposures reported to poison centres in the United States in a 2-year period, 131 (0.26%) had a major outcome, with 10 deaths. Despite the generally mild effects reported in large patient series, isolated case reports have documented serious toxicity, such as seizures, hypotension, apnoea, coma and renal failure. The majority of these consequences occur after ingestion of substantial quantities by adults attempting suicide. Rarely, with ibuprofen and piroxicam, children who ingest small amounts in accidental exposure develop serious toxicity. Typical signs and symptoms of NSAID overdose include nausea, vomiting, headache, drowsiness, blurred vision and dizziness. Seizures are rarely documented across all NSAID classes, with the exception of mefenamic acid (where seizures occur in over one-third of cases), or following massive ingestion of other agents. Drugs in the propionic acid group have produced metabolic acidosis, respiratory depression and coma in severe cases. Ibuprofen is the agent with the most published data on overdose, probably because it is available without a prescription in many countries. Symptoms are unlikely after ingestion of 100 mg/kg or less, and are usually not life-threatening unless more than 400 mg/kg is ingested. There is some relationship between plasma concentrations and the potential for development of symptoms, but plasma concentrations have no impact on treatment decisions. Treatment of NSAID overdose is entirely supportive. Recent trends in emergency department procedures regarding gastric decontamination are evolving towards the recommended administration of activated charcoal without gastric emptying in patients presenting more than 1 hour after ingestion, although gastric lavage, followed by administration of activated charcoal, may be advisable in patients who present earlier. Home administration of syrup of ipecac is still recommended if treatment is given shortly after ingestion, with a few exceptions: for example, ipecac is contraindicated after ingestion of mefenamic acid or ibuprofen in amounts greater than 400 mg/kg. Urine alkalinisation and diuresis have been recommended to enhance the elimination of NSAIDs, based on a pKa in the range of 3 to 5. However, because the drugs are universally highly protein bound, with little unchanged renal excretion, this technique is not likely to be beneficial. Haemodialysis is also unlikely to enhance elimination, but may be required if oliguric renal failure develops. Multiple dose activated charcoal may be useful in enhancing elimination of NSAIDs with long half-lives, such as piroxicam and sulindac.
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Papers by Alan H. Hall