Robert N.E. French

Toxicology in the ICU: Part 2: Specific Toxins

This is the second of a three-part series that reviews the generalized care of poisoned patients in the ICU. This article focuses on specific agents grouped into categories, including analgesics, anticoagulants, cardiovascular drugs, dissociative agents, carbon monoxide, cyanide, methemoglobinemia, cholinergic agents, psychoactive medications, sedative-hypnotics, amphetamine-like drugs, toxic alcohols, and withdrawal states. The first article discussed the general approach to the toxicology patient, including laboratory testing; the third article will cover natural toxins.

Gila monster bite

Abstract A 29-year-old man was bitten on the forearm by a wild Gila monster. Radiographs demonstrated subcutaneous air. During a period of observation, erythema and edema progressed from the forearm to the axilla and he developed a significant leukocytosis. No purulence was found upon surgical evaluation. We hypothesize that air was introduced into the wound by the “pulsing,” chewing-like action that the Gila monster made while it was attached to the mans forearm.

Epidemiology of the reported severity of cottonmouth (Agkistrodon piscivorus) snakebite.

Objective The goal of this study was to analyze trends in the annual rates of reported medical outcomes of cottonmouth (Agkistrodon piscivorus) snakebites in the United States, published in the annual reports of the American Association of Poison Control Centers in the course of 29 years. Methods This was a retrospective analysis of medical outcomes for cottonmouth snakebite victims who developed fatal, major, moderate, minor, or no effects. The annual rates for these medical outcomes were calculated by dividing the annual number of patients in each outcome category by the total annual number of people reported as being bitten by cottonmouths. Negative binomial regression was used to examine trends in annual rates. Results From 1985 through 2011, after controlling for the availability of CroFab, the annual incidence rate of cottonmouth snakebites causing no effect decreased significantly by 7.3%/year (incidence rate ratio [IRR] 0.927, 95% confidence interval [CI] 0.885–0.970), the incidence rate of minor outcomes did not change significantly (IRR 0.989, CI 0.974–1.006), the incidence rate of moderate outcomes increased significantly by 2.3%/year (IRR 1.023, CI 1.004–1.042), and the incidence rate of major outcomes did not change significantly (IRR 0.987, CI 0.935–1.041). One fatality was reported in 2011. Conclusions Annual rates of cottonmouth snakebites producing no effects decreased significantly, those producing minor outcomes did not change significantly, those producing moderate outcomes increased significantly, and those producing major outcomes did not change significantly, from 1985 through 2011.

Toxic industrial chemicals and chemical weapons: exposure, identification, and management by syndrome.

Toxidromes aid emergency care providers in the context of the patient presenting with suspected poisoning, unexplained altered mental status, unknown hazardous materials or chemical weapons exposure, or the unknown overdose. The ability to capture an adequate chemical exposure history and to recognize toxidromes may reduce dependence on laboratory tests, speed time to delivery of specific antidote therapy, and improve selection of supportive care practices tailored to the etiologic agent. This article highlights elements of the exposure history and presents selected toxidromes that may be caused by toxic industrial chemicals and chemical weapons. Specific antidotes for toxidromes and points regarding their use, and special supportive measures, are presented.

Erucism Due to Lepidoptera Caterpillar Envenomation

A 42-year-old woman contacted the Arizona poison center after envenomation by a tricolor buckmoth caterpillar. She had been underneath a mesquite tree when the caterpillar fell onto her left shoulder. Within minutes, a pruritic urticarial eruption had developed.

Gila monster (Heloderma suspectum) envenomation: Descriptive analysis of calls to United States Poison Centers with focus on Arizona cases

Abstract Background. The Gila monster (Heloderma suspectum) is a venomous lizard native to the deserts of southwestern United States (US) and northern Mexico. The purpose of this study was to describe human exposures to Gila monsters reported to US poison control centers (PCCs) with a focus on Arizona cases. Methods. The American Association of Poison Control Centers’ National Poison Data System (NPDS) was used to access and retrospectively review all calls to US PCCs, concerning Gila monsters between January 1, 2000 and October 31, 2011. In addition, detailed records from the two Arizona PCCs were reviewed for the same time period. Results. A total of 319 calls regarding Gila monsters were identified in the NPDS. Of these, 105 (33%) were human exposures; most (79%) occurred in males. A total of 71 (68%) of these 105 cases were referred to a health care facility (HCF); 30 (29%) were managed on-site. Of the 71 HCF referrals, 36 (51%) were discharged home and 17 (24%) were admitted. Most (65%) admissions were to an intensive care unit (ICU). Arizonas PCCs received 70 unique reports of Gila monster bite. Most (77%) of the bites in Arizona involved an upper extremity. Eight (11%) involved patients under the age of 18 years. Eleven (16%) Arizona cases were work-related. Twenty-eight (40%) of the 70 bites in Arizona were evaluated in a HCF, but not admitted. Eleven (16%) were admitted, of which five were to an ICU. Six patients had edema of airway structures; three required emergent airway management, one by cricothyrotomy. There were no deaths. Conclusion. Gila monster bites are uncommon. Many cases did not require hospitalization. Edema of airway structures is an infrequent, but life-threatening complication.

Intentional use of carbapenem antibiotics for valproic acid toxicity: A case report

The interaction between valproic acid (VPA) and carbapenem antibiotics is well described with previous reports suggesting a reduction in VPA half‐life between 47% and 90%. As described in this case, this interaction might be beneficial in the setting of toxic VPA ingestion.

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Keywords Bodypacker .Deferasirox .Hyperemesis .N-acetylcysteine .CannabisAaron B. Skolnik and Anne-Michelle Ruhade Bakker JK, Nanayakkara PW, Geeraedts LM Jr, deLange ES, Mackintosh MO, Bonjer HJ. Body Packers: aPlea for Conservative Treatment. Langenbecks ArchSurg. 2012 Jan; 397(1):125-30. Epub 2011 Oct 8.Background: Smuggling of drugs via internal concealment,known as “body packing,” is on the rise. Early methods ofinternal concealment relied on swallowed drug packets con-structed from available materials such as balloons and con-doms. Packet rupture was associated with high mortality.Modern drug packets are machine produced and carry alower risk of rupture. Body packers may present with non-life-threatening symptoms such as nausea or bowel obstruc-tion. The optimal approach to management of these patientsis not known.Research Question: This study aims to evaluate the effica-cyof aprotocol for diagnosis andtreatmentof body packers,including determining the need for surgical intervention.Methods: A retrospective chart review was performed overa 6-year period. Patients were identified by a recordeddiagnosis of “body packer.” All patients included in thestudy were treated according to a protocol including vitalsign monitoring, laboratory testing, and radiographs. If plainabdominal X-rays were inconclusive, a CT scan of theabdomen was performed. The study centers protocol man-dated surgical removal of drug packets for signs of drugintoxication, ileus, or persistence of drug packets in thestomach for >48 h. Surgically treated patients were com-pared to conservatively managed patients.Results: Cocaine was the most commonly found drug inboth surgically (n064) and conservatively managed (n079) patients. There was no significant difference in thenumber of packets ingested between groups. Surgicallymanaged patients had higher prevalence of abdominalpain (53 vs. 31 %) and vomiting (20 vs. 13 %) atpresentation. Sixteen percent of surgical patients devel-oped a wound infection, 16 % had a fascial dehiscence,and 8 % had both. Wound infection was associated witha longer length of hospitalization. Mean hospital lengthof stay was significantly prolonged in surgically man-aged patients (7 vs. 2 days). Comparing asymptomaticpatients who underwent surgery for packets remaining inthe stomach >48 h to those with drug packets in the stomachfor 48 vs. 48 h. Surgical treatment should be reserved for thosepatients with ileus or signs of drug intoxication.Critique: This study is limited by its retrospective nature.As a single-center study, the results may not be general-izable to different patient populations. The cutoff time of48 h to determine surgery was chosen arbitrarily. Optimaltiming of surgical intervention in asymptomatic patients isstill not certain. The ideal surgical approach to packetretrieval is unknown and the surgical method in this studywas not standardized. The authors note that wound compli-cations occurred at higher frequency than expected for lap-arotomy when compared to several references. Alternative