Raymond J Roberge

Dextromethorphan- and pseudoephedrine-induced agitated psychosis and ataxia: case report.

Pseudoephedrine and dextromethorphan are therapeutic constituents of numerous commonly used, over-the-counter cough and cold preparations. Although this drug combination is generally considered quite safe if utilized in recommended doses, overmedication or overdose can result in serious neurologic and cardiovascular abnormalities that occasionally can be life-threatening. We present a case of a 2-year-old child who developed hyperirritability, psychosis, and ataxia after being overmedicated with a pseudoephedrine/dextromethorphan combination cough preparation, and discuss probable mechanisms of toxicity and risk factors for adverse events.

Flumazenil reversal of carisoprodol (soma) intoxication

A 52-year-old woman presented with central nervous system depression and a Glasgow Coma Score of 9 secondary to ingestion of carisoprodol, a centrally acting muscle relaxant analgesic. After administration of i.v. flumazenil, the patients neurologic status normalized and she required no further therapy. Carisoprodol and its active sedative-hypnotic metabolite, meprobamate, are gamma aminobutyric acid receptor indirect agonists with central nervous system chloride ion channel conduction effects similar to the benzodiazepines, thus making flumazenil a potentially useful antidote in toxic presentations.

Corneal bee sting with retained stinger.

Bee stings of the cornea are rarely reported, but have the potential for causing serious ophthalmologic injuries. We present a case of corneal bee sting with retained stinger apparatus and associated iritis and discuss the pathologic mechanisms of injury, evaluation, and treatment of these uncommon presentations.

Compartment syndrome after simple venipuncture in an anticoagulated patient

An excessively anticoagulated 52-year-old man on chronic warfarin therapy developed a forearm compartment syndrome after venipuncture in an antecubital vein. At fasciotomy, active venous bleeding into the forearm from the venipuncture site was noted, and a large forearm hematoma was evacuated. Anticoagulated patients or those with coagulopathies are at risk for compartment syndrome after percutaneous needle punctures and should be warned of this possibility. Such individuals should be instructed to seek immediate medical attention if any signs or symptoms of this complication occur.

Vaginal pessary-induced mechanical bowel obstruction

We present a case of a mechanical bowel obstruction secondary to an impacted vaginal pessary. As the elderly segment of the population continues to grow, pessary use is increasing in absolute numbers, and clinicians must consider these medical devices when evaluating abdominal, gynecological, and urological complaints in elderly women.

Transdermal drug delivery system exposure outcomes

Transdermal drug delivery systems are increasingly popular, yet few data exist regarding medical outcomes after exposures. Using data collected through a Regional Poison Information System, this retrospective study identified 61 cases of transdermal drug delivery system exposures reported over a recent 5-year period. Exposure routes included dermal (48 patients), oral (10 patients), combined oral and dermal (one patient), parenteral use of gel residue (one patient), and combined oral and parenteral (one patient). Forty-four exposures (72%) were managed by home telephone consultation only. Eleven of 17 patients (18%) evaluated in health care facilities were admitted, including eight (13%) to intensive care units. Hospital admission correlated statistically with clonidine and fentanyl exposures, oral exposures, and drug abuse. Clonidine exposure also correlated statistically with intensive care admission. One fatality was recorded, and all other patients recovered uneventfully. Transdermal drug delivery system exposures are infrequently reported to our regional poison information center but are associated with a significant hospital use and admission rate.

Perionychial infections associated with sculptured nails.

Two cases of perionychial infections associated with the use of sculptured fingernails are presented. Both patients developed paroncyhia necessitating incision and drainage. One patient, a diabetic, had a concomitant subungual abscess and felon which required repeat drainage and debridement as well as intravenous antibiotics over an extended period for complete resolution. Sculptured fingernails may be risk factors for the development of digit infections through various mechanisms, and users of these cosmetic devices, especially diabetics and immunocompromised people, should be made aware of their potential for infectious complications.

Cervical spine injury in low-impact blunt trauma

Few data are available regarding the incidence of cervical spine injuries following relatively low-impact blunt trauma. This prospective level II trauma center study of low-impact blunt trauma found a 1.30% incidence of cervical spine injury. Impressive differences were found in such parameters as population characteristics, modes of injury, elapsed times to emergency department evaluation, and Revised Trauma Scores between this study group and those reported in prospective level I high-impact blunt trauma series. Cervical spine injury in low-impact blunt trauma is significant and often presents less than dramatically, thus emphasizing a need for maintaining a high index of suspicion at all times.

Two chlorzoxazone (Parafon forte) overdoses and coma in one patient: Reversal with flumazenil

Chlorzoxazone (Parafon forte) overdose is rarely reported despite widespread use of this drug. This report describes a case of two episodes of chlorzoxazone overdose and coma in the same patient. Intubation and mechanical ventilation were required on the first presentation. Following the second overdose, intubation was averted and drug effects were reversed by use of the benzodiazepine antagonist, flumazenil. Although chlorzoxazone is not classified as a benzodiazepine, it may interact with benzodiazepine receptors, thus making flumazenil potentially useful in overdose states.

CLONIDINE AND SLEEP APNEA SYNDROME INTERACTION: ANTAGONISM WITH YOHIMBINE

A patient with sleep apnea syndrome, concurrently taking clonidine as an antihypertensive, presented with severe respiratory acidosis, hypotension, and associated central nervous system depression. Acidosis was improved by mechanical ventilation, and central nervous system (CNS) depression and hypotension were reversed with yohimbine. Clonidine may have an additive CNS depressive effect in sleep apnea syndrome and should be used with caution in such patients. Yohimbines sympathetic-enhancing effects may be useful in clonidine toxic states.