Jeffrey R. Suchard

Acute Cyanide Toxicity Caused by Apricot Kernel Ingestion

A 41-year-old woman ingested apricot kernels purchased at a health food store and became weak and dyspneic within 20 minutes. The patient was comatose and hypothermic on presentation but responded promptly to antidotal therapy for cyanide poisoning. She was later treated with a continuous thiosulfate infusion for persistent metabolic acidosis. This is the first reported case of cyanide toxicity from apricot kernel ingestion in the United States since 1979.

Assessing physostigmine’s contraindication in cyclic antidepressant ingestions☆

Ingestion of cyclic antidepressant medications or prolongation of the electrocardiographic QRS interval are commonly considered as contraindications to the use of physostigmine as an antidote for antimuscarinic toxicity. This dictum seems to stem from a few well-publicized cases in which administration of physostigmine was temporally associated with the development of asystole. Before the report of these cases, physostigmine was more frequently used and had been considered a first-line antidote for both the neurologic and cardiac toxic effects of cyclic antidepressant overdose. This apparent inconsistency, and a resurgence of interest in physostigmine as an antidote, begs the question of the appropriateness of this drugs contraindication in all cyclic antidepressant ingestions. Review of the published clinical and experimental evidence provides little support for the clinical utility of using electrocardiographic criteria or the ingestion of cyclic antidepressants as contraindications to the use of physostigmine.

Envenomations by rattlesnakes thought to be dead.

To the Editor: Even after suffering potentially fatal injuries, venomous snakes are capable of injuring humans. Klauber performed experiments showing that rattlesnake heads are dangerous for 20 to ...

Atropine Use in Centruroides Scorpion Envenomation

Background: Systemic scorpion envenomation may be associated with hypersalivation and respiratory distress. Atropine can dry secretions, but is not recommended for stings from many foreign scorpions, since it exacerbates adrenergic toxicity to the cardiopulmonary system. Serious adrenergic effects, however, are rare with Centruroides sculpturatus envenomation. Case Series: Five cases of Grade IV C. sculpturatus envenomation whose treatment included atropine were found on retrospective review at one poison control center located in a scorpion-endemic area. No clinically significant adverse effects of atropine were noted. In 3 cases, atropines reversal of hypersalivation and respiratory distress obviated the need for further interventions.

Combined ingestion and subcutaneous injection of elemental mercury.

A 40-year-old man with a history of schizophrenia and inflammatory soft tissue lesions after self-injection of elemental mercury presented to the Emergency Department. Multiple skin abscesses associated with fever required operative debridement. An incidental finding of oral mercury ingestion was followed clinically and did not result in complications. Exposure to elemental mercury through injection or ingestion is an uncommon event, but one the Emergency Physician may encounter. Subcutaneous mercury injection should be managed with local wound debridement, whereas ingestions are rarely of clinical significance.

Recurrent Coagulopathy With Delayed Significant Bleeding After Crotaline Envenomation

Objectives: Report of delayed significant coagulopathy, thrombocytopenia, and bleeding after Crotaline envenomation. Methods: Recurrent coagulopathy and thrombocytopenia have been described after treatment of Crotaline envenomation with Crotalidae polyvalent immune Fab (CroFab). Until now, there have been no reports of significant spontaneous bleeding despite these abnormalities. Results: Crotalidae polyvalent immune Fab has a relatively short half-life compared with previous antivenoms used to treat snake bite. This shorter half-life allows for recurrence of venom effects. Therefore, patients with Crotaline envenomation should undergo close monitoring for recurrence of coagulopathy or thrombocytopenia after treatment with CroFab. Conclusions: If coagulopathy or thrombocytopenia recurs, retreatment with CroFab should be considered to prevent significant bleeding.

Pediatric clonidine poisoning as a result of pharmacy compounding error.

Clonidine is an 2-adrenergic and imidazoline receptor agonist used primarily as an antihypertensive agent. Other indications for clonidine include prophylaxis of migraine headaches, perimenopausal flushing, withdrawal from nicotine or opiates, Tourette’s syndrome, and attention-deficit/hyperactivity disorder (1–3). Notably, the use of clonidine for its psychiatric indications among pediatric patients is increasing (4). Because adult antihypertensive preparations often contain more clonidine than indicated for pediatric use, some pharmacies compound clonidine specially for individual patients on site, a practice that produces additional opportunity for dosing error. We report two cases of pediatric clonidine toxicity caused by such pharmacy compounding errors.

1,4-Butanediol content of aqua dots children's craft toy beads.

IntroductionThe U.S. Consumer Product Safety Commission announced a recall of Aqua Dots (Spin Master Ltd.; Toronto, Canada) on November 7, 2007 due to children becoming ill after swallowing beads from these toy craft kits. Reports suggested that the beads contained 1,4-butanediol (1,4-BD), a precursor to gamma-hydroxybutyrate (GHB), rather than the intended, but more expensive 1,5-pentanediol (1,5-PD). We measured the 1,4-BD and 1,5-PD content of Aqua Dots beads to determine if 1,5-PD had been completely substituted with 1,4-BD by the manufacturer, and if the reported clinical effects from swallowing Aqua Dots beads were consistent with the estimated ingested 1,4-BD dose.MethodsIn vitro bench research using gas chromatography-mass spectroscopy (GC-MS) was performed. Dilute samples of pure 1,4-BD and 1,5-PD in water were used for the calibration of the GC-MS instrument. We then soaked Aqua Dots beads in water for varying durations, and the resultant solutions were analyzed for 1,4-BD and 1,5-PD content.ResultsAqua Dots beads weighed 79.3 mg each (± 0.6 mg, SD), and contained 13.7% (± 2.4%, SD) 1,4-BD by weight; this corresponds to a 1,4-BD content of 10.8 mg (± 1.9 mg, SD) per bead. No 1,5-PD was detected in any beads.ConclusionsAqua Dots beads contained a surprisingly high amount (nearly 14%) of extractable 1,4-BD. No 1,5-PD was detected, corroborating reports that this chemical had been completely replaced with a substitute that is metabolized into GHB after ingestion. Reports of ataxia, vomiting, seizure activity, and self-limited coma in children are consistent with the ingestion of several dozen Aqua Dots beads.

Contribution of serum ethanol concentration to the osmol gap: a prospective volunteer study

Background. The contribution of ethanol ([EtOH]) to the osmol gap (OG) is commonly described by the formula [EtOH (mg/dL)]/k, where k is assumed to be 4.6 (one-tenth of its molecular weight) if ethanol behaves ideally in solution. However, several studies on convenience samples of patients suggest that ethanol does not behave ideally and that k may be significantly different from this ideal constant. Objectives. To determine prospectively the relationship between serum ethanol concentration and total serum osmolality in a group of healthy volunteers. Methods. Experimental subjects ingested 20 mL of 100% ethanol diluted in sugar-free soda at a rate of one drink every 10 min, up to a maximum of seven drinks. Control subjects ingested 20 mL of water diluted in sugar-free soda at the same rate. Blood samples were obtained at baseline and then at every 20 min for 180 min to measure serum [EtOH] concentration, electrolytes, glucose, and osmolality (via freezing-point depression). The OG was calculated by subtracting predicted osmolality from measured osmolality. The OG was then divided by [EtOH] to determine the coefficient of ethanols contribution to total serum osmolality. Results. A total of 10 volunteers (five men and five women; mean age, 38.8 years, and range, 28–49 years) participated in and completed the study. Eight (four male and four female) were in the experimental group, and two (one male and one female) were in the control group. Mean peak [EtOH] was 229 mg/dL (median, 223.5 mg/dL; IQR, 171–273 mg/dL) and a linear relationship between [EtOH] and OG (Pearson coefficient of 0.98) was found. Using covariate correction for each subjects baseline OG, k was calculated to be 4.25 (95% CI, 4.13–4.38) averaged over all participants. Conclusions. In this volunteer study, the coefficient describing the contribution of ethanol to serum osmolality (k) was found to be 4.25. This indicates that ethanol contributes more to total serum osmolality than would be predicted for an ideal solute.

Fatalities Due to Dichloromethane in Paint Strippers: A Continuing Problem

BACKGROUND Exposure to dichloromethane (DCM or methylene chloride - CH₂ Cl₂ ) in paint strippers continues to be an avoidable source of morbidity and mortality. DCM has been under regulatory scrutiny by occupational and consumer product agencies since the identification of its carcinogenicity in the mid-1980s. METHODS We investigated two independent workplace incidents that resulted in three cases of DCM intoxication from paint stripper use. RESULTS Each incident investigated resulted in a fatality. A third worker suffered obtundation requiring hospitalization and intubation. CONCLUSIONS The continued occurrence of fatalities and other serious injuries due to DCM-containing paint strippers in the United States calls for a re-evaluation of existing regulatory strategies.