Kevin L. Wallace

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.

Blunt aortic trauma: signs of high risk.

In the last 10 years, our center has managed 60 cases of aortic rupture from blunt chest trauma. Nineteen patients died (32%), 11 of whom were moribund on admission. Two patients out of ten who had undergone aortography at other institutions arrived at our hospital with massive bleeding in the left chest and died despite immediate operation. Six patients exsanguinated 1 to 2 1/2 hours after admission while aortography was being arranged or performed, and review of these cases to identify clinical signs of high risk revealed that left hemothorax, pseudocoarctation, and/or supraclavicular hematoma were present in five of the six. It appeared that the survival rate of patients suspected of blunt aortic trauma who had any of these clinical signs might be improved if they were taken directly to the operating room. To investigate this possibility we reviewed all cases from the past 10 years (excluding patients moribund on arrival or who had aortography elsewhere) in whom suspicion of aortic trauma led to aortography or surgery. Thirteen of the 17 patients (76%) with one or more signs of high risk had torn the aortic isthmus, compared to 26 of 154 patients (17%) without these signs. Five of the high-risk group (29%) exsanguinated, compared to one (less than 1%) of the others. No patient in this series died from unsuspected aortic trauma, which we attribute to the liberal use of aortography. Except for the patients with exsanguinating hemorrhage preoperatively, there were no operative or postoperative deaths.(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric poisoning from over-the-counter imidazoline-containing products

We present two instructive cases of imidazoline poisoning in young children. Imidazoline decongestants, readily available in numerous non-prescription preparations, can rapidly produce toxicity from oral ingestion and topical application. Signs and symptoms depend on whether peripheral or central alpha 2-adrenergic receptor stimulation predominates. Timely diagnosis depends on a high index of suspicion and careful questioning about the availability of these over-the-counter products. Standard toxicologic management will prevent significant morbidity. No specific antidote exists.

Acute propylene glycol ingestion.

Background: We describe a case of acute propylene glycol toxicity following ingestion of ethanol and propylene glycol-containing antifreeze in which blood lactate, serum propylene glycol, ethanol, and CO2 concentrations were serially measured. Case Report: A 61-year-old man was hospitalized after acute ingestion of ethanol and automotive antifreeze. His clinical presentation and course were essentially unremarkable. Initial lab tests revealed serum ethanol concentration, 167 mg/dL, normal serum electrolytes and osmol gap, 120 mOsm/kg. Intravenous 10% ethanol infusion was begun for suspected ethylene glycol toxicity and discontinued at approximately 17 hours post-ingestion. Toxicological analysis of urine was positive for ethanol and propylene glycol, and negative for ethylene glycol, methanol, and isopropanol. Blood lactate was mildly elevated and serum CO2 concentration was normal. Gas chromatographic analysis of serial serum specimens for propylene glycol concentration revealed a maximum value of 470 mg/dL at 7 hours and a nonlinear decline to below detection limit (3 mg/dL) at 57 hours after antifreeze ingestion. The patient was discharged on hospital day 2. Conclusion: The propylene glycol elimination pattern, absence of significant acid–base disturbance, and minimal lactate elevation in this case are consistent with ethanol-related inhibition of propylene glycol metabolism. The effect of ethanol on clinical outcome after acute propylene glycol intoxication remains uncertain.

Postcollection rise in methemoglobin level in frozen blood specimens.

A patient with nonspecific complaints had four previous venous blood samples showing elevated methemoglobin fractions of 15.6–20.1%. Cooximetry on a fresh specimen revealed a methemoglobin fraction of 0.8%, while that reported by the original laboratory on the simultaneously collected specimen was 14.9%. The laboratory assayed the specimen after holding it in frozen storage. Venous blood from a healthy volunteer was assayed by cooximetry after storage under conditions of room temperature (22–24°C), refrigeration (1–4°C), and freezing (−14 to −12°C). Methemoglobin level in frozen-thawed specimens rose over time from 1.8% (0.29 g/dL) at 6 hour to 10.9% (1.71 g/dL) after 6 days. With the exception of a single specimen stored in an EDTA-containing tube at room temperature for 6 days, methemoglobin in nonfrozen specimens never exceeded 0.8% (0.12 g/dL).

Expediting the early hospital care of the adult patient with nontraumatic chest pain: Impact of a modified ED triage protocol

A prospective study that compared a traditional emergency department (ED) triage protocol with an expedited protocol was conducted to determine if minimizing the subjectivity of nursing triage would result in more efficient management of adult patients presenting with nontraumatic chest pain. The traditional protocol triaged 382 patients into 1 of 5 categories of acuity. The expedited study group (418 patients) were triaged as usual but subsequently were treated as if they were triage category 1 or 2 (medical evaluation within 15 minutes of arrival). Traditional triage led to 40% of acute myocardial infarction (AMI) patients being triaged into inappropriately low-acuity categories. The expedited protocol resulted in significant improvement in the following intervals: ED arrival to triage, triage to cubicle, ED arrival to cubicle, ED arrival to electrocardiogram (ECG) ordered, ED arrival to ECG available, ED arrival to physician evaluation, and ED arrival to decision to thrombolyse. Study patients with non-AMI cardiac chest pain and AMI cardiac chest pain were evaluated by a physician an average of 12 minutes and 8 minutes after ED arrival, respectively. Delays in interdepartmental processes, such as ECG-technician responsiveness, thrombolysis protocol fulfillment and thrombolytic agent delivery, negated benefits derived from improvements in internal processes. Effective coordination of the numerous processes involved in the initial ED management of adult patients with nontraumatic chest pain is required to make thrombolytic therapy for AMI within 30 minutes of patient arrival a routinely achievable goal.