Magdalena Łukasik-Głębocka

Flubromazolam – A new life-threatening designer benzodiazepine

Abstract Context: In addition to designer benzodiazepines such as etizolam, deschloroetizolam, pyrazolam, diclazepam, nifoxipam, or clonazolam, a new psychoactive substance like flubromazolam, triazole of flubromazepam has become available. Flubromazolam is currently not marketed as a medication but rather as a research chemical and recreational drug. It mostly causes sedative effects but also has moderate anti-anxiety and muscle relaxant effects. A case of a severe intoxication of flubromazolam has been reported. Case details: A 27-year-old man, presented with deep coma, bilateral pinpoint unreactive pupils, acute respiratory failure and hypotension, complicated by hypoxic ischemic changes in the central nervous system. A positive result of a urine screening test confirmed the presence of benzodiazepines, which resulted in administration of flumazenil and improved patient consciousness. Quantitative method of liquid chromatography indicated flubromazolam in the patient’s serum at 59 ng/mL and urine at 105 ng/mL about 19 h after ingestion of 3 mg dose. On admission, serum creatine kinase was 15 960 U/L. The patient was treated with mechanical ventilation, intravenous fluids, flumazenil and continuous infusion of norepinephrine at a dose of 0.12 µg/kg/min. The patient survived and on the ninth day of hospitalization he was transferred to the Department of Neurology. Discussion: Flubromazolam is a new designer drug. Recreational use may be a cause of prolonged, severe intoxication associated with coma, hypotension, and rhabdomyolysis.

Acute topiramate overdose - clinical manifestations

Introduction. The clinical manifestations of acute topiramate toxicity are described. Methods. Seven cases of acute and acute-on-chronic topiramate toxicity observed in two clinical units of Polish Poison Control Centers in 2004–2005 were analyzed. Results. The patients were 4 women and 2 men aged between 16 and 38 (mean 21.0 ± 8.4) years. The doses of topiramate ranged from 10.7 to 218 mg/kg. The most frequent symptom was somnolence (66.7%) and, vertigo, agitation, and mydriasis were less common (33.4%). One patient who was not previously treated with topiramate experienced three secondarily generalized tonic-clonic seizures. Metabolic acidosis, lasting for 3–7 days, was observed in four cases, and did not influence the outcome. Conclusions. The clinical manifestations of acute poisonings with topiramate ranged from asymptomatic to severe, but no distant sequelae or fatalities were observed. The course of acute poisoning seems to be more severe in patients who were not previously treated with topiramate.

Barium Determination in Gastric Contents, Blood and Urine by Inductively Coupled Plasma Mass Spectrometry in the Case of Oral Barium Chloride Poisoning

A serious case of barium intoxication from suicidal ingestion is reported. Oral barium chloride poisoning with hypokalemia, neuromuscular and cardiac toxicity, treated with intravenous potassium supplementation and hemodialysis, was confirmed by the determination of barium concentrations in gastric contents, blood, serum and urine using the inductively coupled plasma mass spectrometry method. Barium concentrations in the analyzed specimens were 20.45 µg/L in serum, 150 µg/L in blood, 10,500 µg/L in urine and 63,500 µg/L in gastric contents. Results were compared with barium levels obtained from a non-intoxicated person.

Intravenous and oral suicidal e-liquid poisonings with confirmed nicotine and cotinine concentrations

The increasing availability of e-cigarettes is a potential toxicological concern. E-cigarettes appeared on the Polish market in 2006, and since 2009 they have been widely available with a new source of nicotine, the so-called e-liquid. In this paper two cases of suicidal oral and intravenous poisonings with the e-liquid are described. The clinical courses of these poisonings are presented. Nicotine and cotinine concentrations in the patients blood were determined using high performance liquid chromatography with diode array detection. In the course of intoxication patient No. 1, classic symptoms of acute nicotine poisoning without convulsions were observed. Nicotine and cotinine concentrations measured in serum were 0.096 and 4.4mg/L, respectively. The case of patient No. 2, admission with no typical symptoms of nicotine poisoning was identified, except unconsciousness and slow respiration. Nicotine and cotinine concentrations in the serum at the time of No. 2 admissions were determined to be 0.8 and 1.3mg/L, respectively. With the increasing number of e-liquid poisonings cases, it should be aware that these products can be a readily available source of poison.

Using simulation to create a unique regional ECMO program for the Greater Poland region

Background: “ECMO for Greater Poland” is a program being developed to serve the 3.5 million inhabitants of the Greater Poland region (Wielkopolska) based on an approach already implemented in the USA1 or Qatar.2,3Method: The program is complex and takes full advantage of the ECMO perfusion therapy opportunities to save the life of patients in the Greater Poland region. The main implementation areas are: – treatment of patients with hypothermia;4 – treatment of reversible severe respiratory failure;5 – treatment of acute intoxication resulting in cardiorespiratory failure6 or other critical conditions resulting in heart failure; – in the absence of response to treatment and eventual death, and with donor authorization, there is possible organ transplantation from a non-heart beating donor (NHBD) to another patient.7 This led to the development of a program for donation after circulatory death (DCD). Study: The program will help to put in place a Medical Rescue System including ECMO (Figure 1). It requires training in specialized resuscitation, perfusion, and transplantation teams in the implementation of this “ECMO rescue chain”. The main strength of the program is the widespread use of extracorporeal perfusion. All program arms in the use of ECMO should be implemented in parallel to maximize its positive impact.Figure 1. Organizational model of “ECMO for Greater Poland” – “ECMO rescue chain” scheme divided into three stages: prehospital, hospital/perfusion, and transplantation. As this organizational model is complex and expensive, we used high-fidelity medical simulation to prepare for the real-life implementation of our ECMO program. During 4 months, we performed scenarios including: – “ECMO for DCD” which includes: prehospital identification, CPR ALS (cardiopulmonary resuscitation advanced life support), perfusion therapy (CPR-ECMO or DCD-ECMO), inclusion and exclusion criteria matching, mechanical chest compression, transport, DCD confirmation, and donor authorization, the veno-arterial (VA) cannulation of a mannequins artificial vessels, and starting on-scene organ perfusion.7 – “ECMO for INTOXICATION” which includes: hospital identification (Department of Toxicology), poisoning treatment, CPR ALS, mechanical chest compression, VA cannulation, for the implementation of ECMO therapy and transport to another hospital (Department of Cardiac Surgery).6 – “ECMO for RRF” (reversible respiratory failure) which includes: hospital identification (Regional Department of Intensive Care) – inclusion and exclusion criteria matching, ECMO team transport (80 km), therapy confirmation, veno-venous cannulation for the implementation of perfusion therapy, and return transport (80 km) with ECMO to another hospital in a provincial city (Clinical Department of Intensive Care), where the veno-venous (VV) ECMO therapy was continued for the next 48 hours.5 The training programs, in a short time, resulted in a team being appropriately trained to successfully undertake the complex procedures. Soon after these simulations, Maastricht category II DCD procedures were performed involving real patients and resulting in two double successful kidney transplantations, for the first time in Poland. One month later, we treated two hypothermia patients and, for the first time in the region, also treated on ECMO an adult patient with reversible respiratory failure. Conclusions: The “ECMO for Greater Poland” program will allow the use of perfusion therapy for the inhabitants of Wielkopolska in a comprehensive manner, covering all critical disease states, by what appears to be a unique regional program in Poland. The full-scale, high-fidelity simulation enabled standardized training and testing of new, commonly, and rarely used procedures, and facilitated clinicians’ skills development.

Post-Injection Delirium/Sedation Syndrome after Olanzapine Long-Acting Intramuscular Injection – Who is at Risk?

The post‐injection olanzapine delirium/sedation syndrome (PDSS) was observed in a 60‐year‐old Caucasian, schizophrenic, non‐smoker and underweight [body mass index (BMI), 18.2 kg/m2] women after the fourth intramuscular injection of 405 mg olanzapine pamoate. Clinical symptoms of PDSS were similar to those of acute oral olanzapine intoxication. The patient received supportive treatment and recovered fully. High olanzapine concentrations in serum, with maximum level of 698 ng/mL, were confirmed by liquid chromatography with tandem mass spectrometry (LC‐MS/MS). The authors wonder whether a low BMI and advanced age may predispose patients to PDSS occurrence.

Wybrane aspekty epidemiologii napadu drgawek gorączkowych u dzieci

STRESZCZENIE Drgawki gorączkowe u dzieci są najczęstszym stanem napadowym pochodzenia mózgowego, ich częstość wynosi 4–5 na 100 000 na rok w populacji dzieci w wieku przedszkolnym. Celem pracy była ocena epidemiologiczna napadów drgawek gorączkowych u dzieci. Materiał i metody. Do badania włączono grupę 176 dzieci w wieku od 6. miesiąca życia do 5. roku życia, które były hospitalizowane w Specjalistycznym Zespole Opieki Zdrowotnej nad Matką i Dzieckiem w Poznaniu w okresie od 1 stycznia 2008 do 31 grudnia 2009 roku z powodu epizodu napadu drgawek gorączkowych. W analizie retrospektywnej uwzględniono takie czynniki jak: wiek i płeć oraz porę doby i roku, podczas których pojawiły się drgawki gorączkowe. Wyniki. W analizowanej grupie 176 dzieci 61,93% (n = 109) pacjentów stanowili chłopcy, a 38,07% (n = 67) dziewczynki. W badanej populacji zaobserwowano istotne statystycznie różnice pomiędzy płcią dzieci a wystąpieniem drgawek gorączkowych. Najczęściej drgawki gorączkowe występowały u dzieci w wieku poniemowlęcym (1.–3. rok życia) i dotyczyły 67,05% pacjentów, a średnia wieku wyniosła 23 miesiące +/– SD 13 miesięcy. Najwięcej napadów drgawek gorączkowych zanotowano w okresie jesienno-zimowym, ze szczytem występowania w styczniu (17,61%), lutym (12,50%) i grudniu (10,23%). Stwierdzono istotnie statystycznie różnice występowania drgawek gorączkowych w badanych grupach w zależności od miesiąca i pór roku. Najczęściej napad drgawek gorączkowych występował w godzinach popołudniowych i wieczornych pomiędzy godziną 15.00 a 18.00 u 42 dzieci (23,86%). Zaobserwowano istotnie statystycznie różnice wystąpienia drgawek gorączkowych w badanych grupach w zależności od pory dnia. Wnioski. Na wystąpienie drgawek gorączkowych w badanej populacji narażeni są bardziej chłopcy niż dziewczęta oraz dzieci w wieku poniemowlęcym. Najczęściej epizod napadu drgawek gorączkowych obserwowano w okresie jesienno-zimowym ze szczytem występowania w styczniu, lutym i grudniu, a także w godzinach popołudniowych i wieczornych. Wykazano, że pojawienie się napadu drgawek gorączkowych jest zależne od pór roku i miesięcy oraz pory dnia. Słowa kluczowe: epidemiologia, dzieci, drgawki gorączkowe SUMMARY Febrile convulsions in children is the most common paroxysmal state of cerebral origin, the frequency is 4–5/100 000 per year in the population of preschool children. The aim of the study was to evaluate the epidemiological febrile seizures in children. Material and methods. The study included a group of 176 children aged 6 months to 5 years who were hospitalized in the Specialized Complex of Health Care for Mother and Child in Poznan from 1 January 2008 to 31 December 2009 with an episode of febrile convulsions. In a retrospective analysis were taken into account factors such as age and sex, time of day and year, during which there were febrile seizures. Results. In the analyzed group of 176 children 61.93% (n = 109) were boys and 38.07% (n = 67) girls. In the study population was observed a statistically significant difference between the gender and the occurrence of febrile seizures. The most common febrile seizures occurred in toddlers (1–3 years old) and affected 67.05% of patients, the average age 23 months +/– SD 13 months. Most febrile seizures were recorded in the autumn winter period, with a peak incidence in January (17.61%), February (12.50%) and December (10.23%). It was found a statistically significant difference of febrile seizures in the studied groups depending on the month and seasons. The most commonly febrile seizures occurred in the afternoon and evening, between 3 pm and 6 pm in 42 children (23.86%). There was a statistically significant difference in febrile seizures in the studied groups depending on the time of day. Conclusions. The study has shown that boys are exposed to more febrile seizures than girls and toddlers. Frequently the episodes of febrile convulsions were observed in the autumn-winter period of peak incidence in January, February and December, as well as in the afternoon and evening. It has been shown that the occurrence of febrile convulsions is dependent on the seasons and months as well as the time of day.