Edward J. Otten

Use of amrinone and glucagon in a case of calcium channel blocker overdose

Hypotension resulting from calcium channel blocker ingestion often is refractory to standard therapeutic modalities. Amrinone and glucagon have been used separately and in combination with other agents in the treatment of calcium channel blocker overdose. We report the successful use of both amrinone and glucagon in the treatment of a 30-year-old woman who ingested 3.6 g of verapamil and presented with refractory hypotension. The use of the two agents together may provide improved inotropic support with minimal increases in myocardial oxygen consumption. In this case, the combination of amrinone and glucagon was safe and effective in the management of the hemodynamic instability associated with calcium channel blocker overdose.

Report on envenomation by a Gila monster (Heloderma suspectum) with a discussion of venom apparatus, clinical findings, and treatment

Human envenomations by Heloderma species are a rare but clinically important medical problem. We report a case of an adult male bitten on the left hand by a 50-cm male, captive specimen of Heloderma suspectum (Gila monster). Immediate signs and symptoms included pain at the bite site radiating into the arm and axilla and swelling of the hand and forearm. Systemic complaints of nausea, diaphoresis, and dizziness (without a decrease in blood pressure) lasted approximately 1 hour, and laboratory studies were normal. The patients course was uneventful except for persistent hyperesthesia, which eventually abated. Two types of helodermatid bites produce distinct clinical pictures. The chewing bite potentially causes more envenomation than the slashing bite. The venom contains a number of protein and nonprotein components including serotonin, a bradykinin-releasing substance, protease, hyaluronidase, helodermin, and gilatoxin. The clinical presentation of a helodermatid bite can include pain, edema, hypotension, nausea, vomiting, weakness, and diaphoresis. No antivenin is commercially available. Treatment is supportive, and although first aid measures such as suction or compression may impede venom movement, they are unproved. Cryotherapy, tourniquet, and excision are dangerous and should not be used.

Severe rhabdomyolysis following a viral illness: A case report and review of the literature

Rhabdomyolysis is a syndrome often associated with alcohol and drug abuse. It may also be seen following viral infections, but is a complication not often considered. We report a case of severe rhabdomyolysis following an influenza-like illness. Despite the extreme elevation of creatinine phosphokinase, 230,600 IU/L, this patient did not develop acute renal failure in contrast to most of the previously documented case reports of rhabdomyolysis associated with influenza virus. This case report illustrates the difficulty in predicting which patients are at risk for developing acute renal failure and emphasizes the need for aggressive treatment of any patient suspected of having rhabdomyolysis.

Catfish spine envenomation: a case report and literature review

Catfish spine envenomations are common injuries, reported in both freshwater and saltwater. Such injuries are complex puncture wounds, often complicated by severe infection. Signs and symptoms range from simple local pain and bleeding to systemic manifestations with hemodynamic compromise. Care and treatment involve aggressive pain management, judicious wound cleansing, prophylactic antibiotics, and close follow-up. A case of catfish spine envenomation from a freshwater catfish is presented here.

Cinchonism : two case reports and review of acute quinine toxicity and treatment

Two cases of acute quinine toxicity are presented, one from self-poisoning and the other from an unidentified source. Both patients presented with acute bilateral blindness. They also experienced the classic symptoms of cinchonism, including nausea, vomiting, and tinnitus. Prolongation of the Q-T interval developed in both patients. Serum quinine levels of 5.3 mg/L and 13 mg/L were measured. Although their visual acuity improved, both patients had some residual deficit at follow-up. A review of the literature, including clinical presentation and emergency medicine diagnosis and management, is also presented.

Blood levels of diazepam after endotracheal administration in dogs

A pilot study was performed to evaluate the endotracheal administration of diazepam. Five mongrel dogs were anesthetized and orotracheally intubated. Diazepam in a dose of 0.5 mg/kg was delivered through a red rubber catheter placed through the endotracheal tube. Diazepam levels were then measured at 0, 30, and 60 seconds, and at 2, 5, 15, 30, and 60 minutes. Arterial blood gas determinations were performed at 0, 10, 30, 60, and 90 minutes. In all dogs peak serum levels averaged 1,500 ng/ml +/- 541 ng/ml, which is well above therapeutic anticonvulsant levels (150 ng/ml to 600 ng/ml). Arterial pH an PCO2 did not change dramatically from control values during the period of study. Arterial PO2 showed a transient drop of approximately 10 to 30 mm Hg within the first 60 minutes, but returned nearer the control values by the end of 90 minutes. the endotracheal administration of diazepam has been shown to be effective in achieving rapid therapeutic serum levels of the drug. Further study is needed to determine any deleterious effects on the lungs before this method of administration can be recommended for use in humans.

Mitigation of Pennyroyal Oil Hepatotoxicity in the Mouse

OBJECTIVES Pennyroyal oil ingestion has been associated with severe hepatotoxicity and death. The primary constituent, R-(+)-pulegone, is metabolized via hepatic cytochrome P450 to toxic intermediates. The purpose of this study was to assess the ability of the specific cytochrome P450 inhibitors disulfiram and cimetidine to mitigate hepatotoxicity in mice exposed to toxic levels of R-(+)-pulegone. METHODS 20-g female BALB/c mice were pretreated with either 150 mg/kg of cimetidine intraperitoneal (IP), 100 mg/kg of disulfiram IP, or both. After one hour, mice were administered 300 mg/kg of pulegone IP and were killed 24 hours later. Data were analyzed using ANOVA. Post-hoc t-tests used Bonferroni correction. RESULTS There was a tendency for lower serum glutamate pyruvate transaminase in the disulfiram and cimetidine groups compared with the R-(+)-pulegone group. The differences were significant for both the cimetidine and the combined disulfram and cimetidine groups compared with the R-(+)-pulegone group. Pretreatment with the combination of disulfiram and cimetidine most effectively mitigated R-(+)-pulegone-induced hepatotoxicity. CONCLUSIONS Within the limitations of a pretreatment animal model, the combination of cimetidine and disulfiram significantly mitigates the effects of pennyroyal toxicity and does so more effectively than either agent alone. These data suggest that R-(+)-pulegone metabolism through CYP1A2 appears to be more important in the development of a hepatotoxic metabolite than does metabolism via CYP2E1.

Acute pulmonary toxicity to nitrofurantoin

Nitrofurantoin is a widely prescribed antibiotic used for the treatment of urinary tract infections. In some patients it can produce an acute pulmonary reaction ranging from mild dyspnea to noncardiogenic pulmonary edema. Symptoms include fever, dyspnea, chills, cough, and chest pain. Physical examination generally reveals an acutely ill, extremely apprehensive patient in varying degrees of respiratory distress. Fever is usually present and there is an increase in heart rate and respiratory rate. Cyanosis, rales, and a maculopapular rash are common findings. Laboratory studies typically demonstrate a leukocytosis with eosinophilia, varying degrees of hypoxia and hypocapnia, and a mild to moderate elevation of the erythrocyte sedimentation rate. The chest x-ray study may be normal but more often demonstrates bilateral lower lobe interstitial infiltrates frequently accompanied by pleural effusions. Treatment in the majority of cases requires only stopping the drug, but steroids, bronchodilators, or antihistamines may be used in selected cases. Once the diagnosis is made and the drug withdrawn, prognosis for full recovery is excellent.

Case files of the University of Cincinnati fellowship in medical toxicology: two patients with acute lethal occupational exposure to hydrogen sulfide.

We are presenting cases of 2 employees of a chemical plasticsmanufacturing plant who experienced acute, brief, inhalationalexposure to lethal concentrations of hydrogen sulfide in a con-fined space. Eight other coworkers not present in the immediateexposure area also presented to local health care facilities withmild complaints of headache, nausea, and dizziness, but they suf-fered no significant sequelae.Patient #1 was a 55-year-old man who, while working in a con-fined space, uncoupled a nozzle from a steam pipe, collapsedwithin one minute, and suffered cardiopulmonary arrest. He had aprior history of asthma, hyperlipidemia, coronary artery disease,and was taking lisinopril, aspirin, and lipitor. Following chest com-pressions and rescue breathing, both by on-scene responders andEMS, the patient’s blood pressure was 210/110 mmHg, the pulsewas 100 bpm, and ventilation was assisted at 14/minute. On exam-ination, the patient was minimally combative, with a Glasgowcoma score of 6 (E1, V1, M4), with pupils 3mm bilaterally and reac-tive to light. The patient had a small partial-thickness burn to theright chest, presumed to be a thermal burn from steam or the hotpipe. No cyanosis or pulmonary crackles were noted. Because of res-piratory distress, the patient was intubated on-scene using fentanyl,diazepam, and vecuronium by the combined nurse-physician Air EMS flight team. Post-intubation vital signs were as follows:blood pressure 130/69 mmHg, pulse 95 bpm, respirations 14/min(assisted), and oxygen saturation 98% on 100% FiO

Venomous snakebite in a patient allergic to horse serum

The management of snake envenomation is a clinical challenge. The definitive therapy, antivenin, is potentially harmful and should not be used indiscriminately. However, the morbidity and mortality from the envenomation usually outweigh any adverse reactions to the antivenin therapy. Most reactions can be divided into two general categories: type I (immediate hypersensitivity) reaction, which may be life-threatening, and the more common type III (immune complex) reaction characterized by serum sickness. It is vital to evaluate the patients potential for developing adverse reactions from antivenin and to be prepared to provide appropriate therapy. The administration of epinephrine and antihistamines can be lifesaving in type I reactions, while steroids and antihistamines can ameliorate type III reactions.