Raymond J. Roberge

Intentional massive insulin overdose: Recognition and management

A case of intentional massive insulin overdose requiring prolonged glycemic support is presented. Suicidal insulin overdose may be more common than generally appreciated. Because hypoglycemic reactions are evaluated routinely in the ED, emergency physicians should maintain a high degree of suspicion regarding suicidal intent or foul play in diabetics with hypoglycemia who respond minimally to the administration of concentrated glucose solutions or in hypoglycemic presentations by nondiabetics who have access to diabetic medications. Fingerstick glucose evaluations or serum glucose levels should be obtained routinely at 15 to 30 minutes after glucose administration in any hypoglycemic patient to gauge the intensity of glucose use. Inability to maintain euglycemia following glucose administration suggests excessive insulin and requires further workup. Evaluation of serum insulin and C-peptide levels is useful in confirming intentional overdoses in cases that are not clear-cut. Glucose infusion rates must be tailored individually to each overdose situation as great individual variability exists in insulin absorption and effects. The clinician should anticipate the possible need for prolonged glycemic support in this setting.

Rectus abdominis endometrioma.

A 31-year-old woman presented with complaints of increasingly severe right lower quadrant discomfort that had occurred for several days each month over the course of the previous 6 months. A tender mass of the abdominal wall was palpated on physical examination, and subsequent ultrasonography and magnetic resonance imaging disclosed a discrete mass of the body of the right rectus abdominis muscle which was confirmed as endometrial tissue on biopsy. Rectus abdominis endometrioma is a relatively rare cause of abdominal pain which may mimic an acute abdomen. Clinical clues to the diagnosis include previous uterine or gynecological surgery/invasive procedure (with preservation of ovarian function), cyclical nature of the discomfort, and the presence of a palpable mass with or without associated skin color changes.

Use of sodium polystyrene sulfonate in a lithium overdose

A 23-year-old woman with an acute-on-chronic lithium overdose received multiple oral doses of sodium polystyrene sulfonate totaling 150 g over a 24-hour period. During the 33 hours after the institution of therapy, the serum lithium level decreased from 4.20 to 0.68 mEq/L. The calculated serum lithium elimination half-life of 12 hours is significantly shorter than that previously noted in other similar overdoses, and the patient suffered no adverse effects of therapy. Multiple-dose sodium polystyrene sulfonate may be useful in lowering the serum lithium level of select patients with acute lithium overdoses but is not a substitute for hemodialysis in severely ill patients.

Whole bowel irrigation in an acute oral lead intoxication

An 89-year-old man acutely ingested approximately three ounces of a ceramic glaze preparation with a 30% lead oxide content. A blood lead level of 18 micrograms/mL was reported from a sample drawn within 1 hour of ingestion and just prior to gastric lavage. Following lavage, an abdominal radiograph demonstrated lead throughout the small intestine. Whole bowel irrigation was then undertaken and subsequent x-rays demonstrated clearing of all lead in the small bowel. At 16 and 24 hours post-ingestion, blood lead levels rose to 39 micrograms/dL and 42 micrograms/dL, respectively, and the patient then underwent a 5-day course of chelation therapy. This is the first reported case of the use of whole bowel irrigation in an acute lead ingestion. The use of decontamination techniques in acute lead ingestions is reviewed.

Urosepsis associated with vaginal pessary use.

Conservative management of genital prolapse in older women uses vaginal pessaries. Infectious complications of these devices, attributable in some instances to poor routine maintenance, are uncommonly reported. We present 2 cases of genitourinary sepsis associated with unsuspected pessary use and discuss the spectrum of complications reported with these appliances.

Mixed fluoxetine/loxapine overdose and atrial flutter

A 19-year-old man who attempted suicide by ingesting approximately 600 mg fluoxetine (Prozac) and 140 mg loxapine (Loxitane) had two episodes of atrial flutter shortly thereafter. Admission serum fluoxetine, norfluoxetine, and loxapine levels were 1,053 ng/mL, 702 ng/mL, and 40 ng/mL, respectively. This case of atrial flutter in association with an overdose of either of these drugs demonstrates the potential for cardiotoxicity with these agents in the overdose setting. Theoretical mechanisms of cardiotoxicity are presented.

Supraventricular Tachyarrhythmia Associated with Baclofen Overdose

Baclofen overdose occasionally results in cardiac effects, but serious tachyarrhythmias have not been reported. We present the case of a 21-year-old man with an acute baclofen overdose who developed increased cardiac conduction times and a rapid supraventricular tachyarrhythmia which required medical intervention. Acute baclofen toxicity can result in the development of tachyarrhythmias and cardiac monitoring is warranted in acute overdose states.

“cloniderm” toxicity: Another manifestation of clonidine overdose

We present a case of accidental transdermal clonidine toxicity in a six-year-old child who was applying a clonidine patch intermittently to her dermis in the mistaken assumption that it was an adhesive bandage. Although the child appeared to be drug toxic, she repeatedly denied ingestion of any substances to family, paramedics, and hospital staff but was not initially questioned regarding dermal exposure. In dealing with drug toxic states in which the differential diagnosis includes drugs available as transdermal delivery systems, the evaluation should include questions regarding possible dermal exposure and a thorough skin examination.

Acute Chemical Pancreatitis Associated with a Tricyclic Antidepressant (Clomipramine) Overdose

A case of acute chemical pancreatitis and associated prolonged ileus following an acute overdose of the tricyclic antidepressant clomipramine by an adult is reported. Pancreatitis is a rarely-reported serious complication of antidepressant overdose and may lead to prolonged ileus and extended hospitalization.

Ceramic lead glaze ingestions in nursing home residents with dementia

Three cases of acute lead ceramic glaze ingestions that occurred in elderly patients during art therapy classes in nursing homes are reported. Initial blood lead levels were 109 micrograms/dL (5.23 mumol/L), 259 micrograms/dL (10.43 mumol/L), and 85 micrograms/dL (4.08 mumol/L), respectively, and all patients underwent chelation therapy. Two individuals tolerated therapy well and showed no discernable changes from baseline state. One patient with a lead encephalopathy died and is, to the best of our knowledge, the first report of a death directly related to a ceramic lead glaze ingestion. Ceramic lead glaze ingestions among institutionalized patients may be more common than generally appreciated and occasionally are associated with significant morbidity or, rarely, mortality. Simple preventive measures could eliminate the majority of such occurrences.