Thomas R. Caraccio

Lidocaine Toxicity from Topical Mucosal Application: With a Review of the Clinical Pharmacology of Lidocaine

A case is reported of an infant who experienced seizures while being treated with a topical lidocaine 2% solution (Xylocaine® 2% Viscous) for teething. The pharmacology of lidocaine is reviewed to alert physicians to the potential dangers of topical mucosal application of these preparations.

Self-poisoning among adults using multiple transdermal nicotine patches

OBJECTIVEnTo investigate the characteristics and outcomes of poisoning cases involving the dermal application of multiple transdermal nicotine patches.nnnDESIGNnCase series; prospective postmarketing surveillance over a 24 month period.nnnSETTINGnTelephone reports from 34 participating US poison centers.nnnPATIENTSnHuman poisonings involving more than one transdermal nicotine patch applied simultaneously.nnnRESULTSnNine cases of dermal exposure to 2-20 transdermal nicotine patches were reported. Cases resulted from either intentional misuse or suicide attempts and included concomitant exposure to other drugs in 7 of 9 cases. Mean age was 45 years; seven of nine patients were female. All suffered medical complications including seizures (3 subjects), other central nervous system changes (8 subjects), cardiovascular effects (6 subjects), and respiratory failure (4 subjects). Eight patients were hospitalized; all recovered. Plasma nicotine/cotinine concentrations did not correlate with the severity of illness.nnnCONCLUSIONSnThis case series demonstrated that simultaneous application of several transdermal nicotine patches can be implicated in adult suicide attempts. While signs of toxicity included gastrointestinal complaints, changes in level of consciousness, seizures and parasympathetic effects typical of nicotine poisoning, the frequent presence of co-intoxicants complicated the clinical course. As the accessibility of transdermal nicotine patches increases, increasing misuse of these products by suicidal adults is likely.

Acute Renal Dysfunction in Acetaminophen Poisoning

Although acetaminophen (APAP)-associated liver injury is well recognized, there are few reports describing APAP nephrotoxicity, and most of them are single cases. It has also been suggested that N-acetylcysteine (NAC), used to treat the hepatotoxicity, may be harmful to the kidneys. To examine this contention and to determine whether renal involvement in APAP poisoning is at all common, we analyzed the incidence and outcome of acute renal dysfunction in patients hospitalized for APAP overdose reported to our regional poison center over a year. Eleven APAP-poisoned patients had elevated liver function tests; nine of them had azotemia. Those with higher AST levels tended to be younger and to have lower APAP levels on admission. Two patients with acute renal injury died after admission. The other seven patients with renal dysfunction recovered in 2 to 7 days. Six of these received NAC; their mean serum creatinine fell from 3.2 ± 2.0 versus 1.7 ± 0.9 mg/dL (p < 0.05). We conclude that acute renal failure is not uncommon in APAP poisoning and appears to be unrelated to the degree of liver injury. NAC therapy did not seem to worsen nephrotoxicity.

Gastrointestinal Dialysis with Activated Charcoal and Cathartic in the Treatment of Adolescent Intoxications

This article reports five patients who had taken a substantial medication overdose and presented in coma. Two had taken a salicylate overdose and three a phenobarbital overdose (one of these ingested a combination of phenobarbital and phenytoin). The cases were treated by our standard protocol of supportive therapy and alkaline diuresis plus repetitive oral doses of activated charcoal (gastrointestinal dialysis). All patients were alert and oriented within 24 hours. Toxicokinetic analysis of the blood levels is discussed. Gastrointestinal dialysis represents a relatively noninvasive method that may benefit certain intoxicated patients even after systemic absorption has occurred. The technique and recommendations for its use are discussed and described in detail.

Intravenous mercury injection and ingestion: clinical manifestations and management.

Background: Mercury is a complex toxin with clinical manifestations determined by the chemical form, route, dose, and acuity of the exposure. Parenteral injection of elemental mercury remains uncommon. Case Report: A 40-year-old male injected 3 mL of elemental mercury intravenously and ingested 3 mL as a suicide attempt. Within 24 hours, he became dyspneic, febrile, tachycardic, and voiced mild gastrointestinal complaints. Chest X-ray revealed scattered pulmonary infiltrates and embolized mercury bilaterally. A ventilation/perfusion scan demonstrated ventilation/perfusion deficits. Additionally, his renal function declined, as manifest by minor elevations in blood urea nitrogen and creatinine and decreased urine output. Pulmonary therapy, intravenous hydration, and chelation using 2,3-dimercaptoscuccinic acid (DMSA/Succimer) were started. Over the next 36 hours, the patients pulmonary and renal functions improved. Temperature and heart rate subsequently normalized, and symptoms at discharge were mild exertional dyspnea. Discussion: Liquid mercury injected intravenously embolizes to the pulmonary vasculature and perhaps vessels in other organs such as heart and kidney. In-situ oxidation to inorganic mercury, which is directly toxic to a variety of tissues, may help explain the multisystem involvement. Conclusion: Significant pulmonary dysfunction accompanied by radiographically demonstrated mercury emboli and temporary abnormalities in several organs improved shortly after initiation of chelation. The impact of chelation on long-term outcome of parenteral mercury exposure remains uncharacterized.

Ingestion of small flat disc batteries

Management of ingestions of small flat disc batteries has been controversial. The Nassau County Medical Centers Long Island Regional Poison Control Center has had 30 calls concerning battery ingestions in the past 16 months. In 1976, the National Clearinghouse for Poison Control Centers reported 42 battery ingestions for the entire nation. Only one of our cases required surgery because the battery remained in the cecum for five days. The battery was removed intact. Management guidelines for ingestions of batteries containing alkali or toxic metals are suggested.

Combined antipyretictherapy: Another potential source of chronicacetaminophen toxicity

The Journal has recently published 2 articles and an editorial that discussed mortality from chronic acetaminophen toxicity in children.[1] [3] The Poison Center has recently encountered an innovative way in which a pediatricianis instructions can produce confusion and potentially lead to acetaminophen or ibuprofen intoxication. Six calls to our center from May 1, 1997, through February 20, 1998, alerted us that parents had been instructed by their pediatricians to administer acetaminophen for fever, and if the temperature had not responded in 2 hours, to administer ibuprofen. The parents called because they were confused about the instructions and times of administration of these 2 medications. Although none of these cases resulted in toxicity, we are concerned about the concept and the potential for drug intoxication and interactions. Similar instructions have been written on medication order sheets of children in the hospital.

Methylene chloride inhalation: an unusual form of drug abuse

Methylene chloride is a chlorinated hydrocarbon used widely in home and industry. Its intentional abuse has not been reported previously. We describe the case of a 14-year-old boy who presented with lethargy, nausea, and chills six hours after the intentional inhalation of a household product containing methylene chloride. The patients elevated carboxyhemoglobin level responded well to 100% oxygen therapy. The pathophysiology and treatment of methylene chloride are discussed.

Mercuric chloride poisoning due to ingestion of a stool fixative

We present a case of ingestion of a commonly used stool fixative containing 675 mg of mercuric chloride per 15 mL vial. Early chelator therapy with dimercaprol and aggressive hydration were initiated and the patient remained asymptomatic. Safety packaging of this product is recommended.

Paraquat Intoxication: Report of a Fatal Case. Discussion of Pathophysiology and Rational Treatment

AbstractThe toxicologic details of a fatal case of paraquat intoxication, including serial chest X rays, effect of charcoal hemoperfusion on the paraquat blood levels, and findings on autopsy are presented. A review of the mechanism of toxicity is discussed with a guideline protocol of management of this type of severe intoxication.