Dystonic reaction associated with dextromethorphan ingestion in a toddler

INTRODUCTION: Accidental ingestions of cough and cold preparations containing dextromethorphan (DM) are common in the toddler age group and rarely have serious consequences. Even large intentional overdoses by adults seldom lead to serious morbidity. There have been no previous reports of an extrapyramidal reaction due to a DM ingestion. CASE REPORT: We report a 30-month-old girl who ingested approximately 38 mg/kg dextromethorphan. She presented with opisthotonus, ataxia, and bidirectional nystagmus. There was no change in her status with the administration of naloxone. The child was given diphenhydramine with clearing of her opisthotonus but persistence of her ataxia and nystagmus. DISCUSSION: A moderate ingestion of dextromethorphan in a toddler resulted in extrapyramidal symptoms with opisthotonus that responded to diphenhydramine. Dextromethorphan is known to have complex CNS effects and, in sufficient doses, may have dopamine receptor blocking activity resulting in this dystonic reaction.     

Efficacy and safety of adenosine in diagnosis and treatment of regular tachycardia in the elderly

BACKGROUND: Adenosine is currently used in the treatment and differential diagnosis of regular tachycardia. However, the efficacy of its employment has not been studied in elderly people. METHODS: We evaluated the safety, and the diagnostic and therapeutic utility of adenosine in elderly people aged over 70 years with regular sustained tachycardia, compared with a group of patients aged under 70 years affected by the same arrhythmia. Adenosine was given to 107 patients in increasing bolus doses up to 18 mg during regular broad and narrow complex tachycardia; 49 patients were aged 70 and over, and 58 patients were aged less than 70 years. In the former group, surface ECG showed 38 narrow complex tachycardias and 11 broad complex ones; in the second group there were 48 narrow complex tachycardias and 10 broad complex ones. RESULTS: Adenosine was effective in 94% of the elderly patients and in 93% of the younger patients. In the group aged over 70 years, adenosine restored sinus rhythm in 37% of patients and revealed the mechanism of arrhythmia in 57%. Adenosine restored sinus rhythm in 50% of patients under 70 years and revealed atrial or sinus tachycardia in 43%. The incidence of symptomatic side effects and peri-conversion ventricular arrhythmias was similar in the two groups. There were ventricular pauses over 3 s long in four (8%) of the older patients (maximum pause 7 s) and in two patients (3%) of the group under 70 years (maximum pause 6 s). No adverse haemodynamic effects were observed. CONCLUSION: These data demonstrate the safety and the value of adenosine in the diagnosis and treatment of regular tachycardia in elderly patients.     

Zinc gluconate: acute ingestion

CASE REPORT: Despite the popularity of zinc gluconate for use in attenuation of common cold symptoms, there is little information on the effects of acute overdose. A 17-year-old male ingested approximately 85 tablets or 4 g zinc gluconate (570 mg elemental zinc). He experienced severe nausea and vomiting within 30 minutes of the ingestion but had no further sequelae such as diarrhea, gastric erosions, esophageal burns, shock, neurologic dysfunction, symptoms of anemia, or hepatic inflammation. Serum zinc level was 4.97 mg/dL at approximately 5 hours postingestion.     

Accidental ingestion of a zinc and copper sulfate preparation

CASE REPORT: An 86-year-old woman accidentally ingested a preparation containing zinc and copper sulfate. At ninety minutes after ingestion, the peak plasma concentration was 1979 micrograms/dL for zinc and 209 micrograms/dL for copper, suggesting preferential absorption of zinc. The major complications were gastric and bronchial inflammation due to the corrosive properties of these compounds. Systemic manifestations also developed with cardiovascular failure and renal insufficiency, but the patient made a complete recovery. In addition to symptomatic treatment, chelation therapy with dimercaprol and D-penicillamine was given for 48 h. CONCLUSION: The available clinical and toxicokinetic data do not support the benefits of chelation in addition to supportive therapy.     

Cardiac anatomy and diastolic filling in professional road cyclists

The electrophysiologic effects of intravenous verapamil (0.15 mg/kg) and oral sustained-release verapamil (verapamil-SR) (240 mg once daily for 7 days) were studied in 17 patients with paroxysmal supraventricular tachycardia (SVT). Ten patients had atrioventricular (AV) nodal reentrant tachycardia and 7 had AV reciprocating tachycardia involving an accessory AV pathway. Both preparations significantly prolonged anterograde effective refractory period of the AV node and depressed the retrograde AV nodal conduction system. The sinus cycle length, and atrial and ventricular effective refractory periods were prolonged after oral verapamil-SR. Furthermore, oral verapamil-SR depressed retrograde accessory pathway conduction which was not interfered with by intravenous verapamil. Intravenous verapamil and oral verapamil-SR prevented induction of sustained SVT in 12 of 17 (71%) and 10 of 17 (59%) patients, respectively. Follow-up study with oral verapamil-SR 240 mg once daily in 15 patients for 19 +/- 6 months revealed that among the 8 patients without induction of sustained SVT, 7 have been free of symptomatic arrhythmia; only 1 patient had occasional SVT attacks. For the 7 patients with induction of sustained SVT, 3 patients failed to respond to oral verapamil-SR, 1 patient became symptom free, and the remaining 3 patients had less frequent SVT attacks. Thus, immediate intravenous verapamil testing predicts the electrophysiologic results of oral verapamil-SR therapy, and oral verapamil-SR once daily may be used for long-term prophylaxis of SVT with better patient compliance.     

Case report: reversible QT prolongation with torsades de pointes in a patient with pimozide intoxication

Pimozide is a diphenylpiperidine neuroleptic with well characterized cardiovascular side effects including QT prolongation. So far, life-threatening cardiac arrhythmias, in particular torsades de pointes, have not been described in patients treated with pimozide. The authors describe a patient in whom torsades de pointes developed after the ingestion of 800 mg pimozide as a suicide attempt. After intravenous treatment with lidocaine and magnesium, the patient recovered completely and the QT interval had normalized 5 days after the intoxication. Potential mechanisms leading to torsades de pointes in patients treated with pimozide are discussed.     

Acute poisoning in Izmir, Turkey--a pilot epidemiologic study

Epidemiologic data on poisonings in Turkey are extremely limited. This is a retrospective chart review to describe the prevalence of poisoning in both adults and children, the presenting clinical features, morbidity and mortality to identify how poisoning in Izmir follows the pattern of other countries and how it is unique. Three hundred sixty-five poisoned patients presented to the Dokuz Eylül University Hospital, Ismir in 1989 to 1990. The distribution frequency of substances ingested reflects that of substances available in the home. Poisoning episodes in small children were most likely to involve hydrocarbons, analgesic, caustics or pesticides (55%). Ethanol, anticonvulsants, tricyclic antidepressants, and pesticides (55%). Ethanol, anticonvulsants, tricyclic antidepressants, and pesticides were the most common toxins seen in adults. A significant number of patients presented late in the course of their poisoning. Of those ingesting pharmaceuticals, mushrooms or plants, emesis, but no other modes of decontamination, was reported for 21%. Toxin "antidotes", gastrointestinal decontamination and enhanced drug removal techniques used in other parts of the world were rarely utilized. Nonetheless, only three patients (0.8%) died. This pilot study supports the need for a Regional Poison Information Center offering poison management advice to the general public as well as to members of the health care professions, the initiation of a public education campaign, and regional treatment by physicians trained in medical toxicology.     

Treatment of malignant gliomas: a new approach

The etiology of seizures associated with cocaine use is unclear. Because cocaine seizures are relatively uncommon, they should be diagnosed by exclusion and a neurological workup to rule out central nervous system (CNS) catastrophe should be made. This report describes the clinical findings, treatment, and blood cocaine and metabolite concentrations in a patient who, on two separate occasions, had seizures associated with crack cocaine ingestion. Approximately 1 hour after the ingestion incidents, the patient had multiple, generalized seizures that abated spontaneously. His workup for CNS bleeding, infection, and trauma was negative. Cocaine concentrations on the first incident peaked at 2.48 mg/L and on the second incident peaked at 3.9 mg/L. Other clinical findings included tachycardia, hypertension, diaphoresis, and disorientation. Blood cocaine and metabolite analysis revealed extremely high concentrations. Other than the incident of seizures and transient cardiovascular aberrations, these high concentrations were tolerated by the patient without further sequelae. A review of cocaine-induced seizures and treatment is included.     

Acetaminophen toxicity in an urban county hospital

BACKGROUND: The prevalence and characteristics of acetaminophen-associated liver injury in hospitalized patients are not well defined. METHODS: We identified patients hospitalized for excessive acetaminophen ingestion at an urban county hospital over a 40-month period (1992 to 1995) and reviewed their medical records to determine the incidence and clinical features of the ingestions and their outcomes. RESULTS: Of the 71 patients studied, 50 were classified as having taken acetaminophen during suicide attempts and 21 as having accidentally poisoned themselves while attempting to relieve pain. The suicidal patients had ingested almost twice as much acetaminophen as those in the accidental-overdose group (median, 20 vs. 12 g; P=0.009). Among the patients for whom data were available, 63 percent of those in the accidental-overdose group and 25 percent of those in the suicidal group had chronic alcohol abuse (P=0.009). The patients in the accidental-overdose group more often had severe liver necrosis (aminotransferase levels, >3500 IU per liter; 52 percent vs. 14 percent; P=0.002), and were more likely to have hepatic coma (33 percent vs. 6 percent, P=0.006). There were four deaths (19 percent) in the accidental-overdose group and one (2 percent) in the suicidal group (P=0.04). Five patients -- three in the accidental-overdose group and two in the suicidal group -- had ingested 4 g of acetaminophen or less. Acetaminophen ingestion accounted for 12 percent of all patients hospitalized with overdoses (71 of 589) and 40 percent of patients with acute liver failure (10 of 25) during the study period. CONCLUSIONS: In an urban county hospital, patients hospitalized with acetaminophen toxicity related to accidental misuse had higher rates of morbidity and mortality than those who attempted suicide, even though the latter had taken more acetaminophen. A higher frequency of chronic alcohol abuse among the patients with accidental overdoses may be one explanation.     

Accidental cetirizine poisoning in a four-year-old boy

Cetirizine is a commonly used non-sedating antihistamine for the symptomatic relief of allergic reactions. Few reports exist on the result of overdose in children. We would like to report the result of a 12 fold overdose of cetirizine in a four-year-old-boy (weight 20 kg) who accidentally ingested 60 mg. Vomiting was induced 1 1/2 hour after ingestion in the out-patient clinic at the local hospital because of severe drowsiness. Due to continued lethargy he was transferred to the referral paediatric department for further observation. He was fully recovered after five to six hours without any treatment. Electrocardiographic monitoring was normal. Five incidents of cetirizine overdose in children have been reported previously. Drowsiness and sedation were observed, but no other side effects. The risk of cardiac events related to an overdose of cetirizine is extremely small. A certain degree of sedation is to be expected.     

Freon inhalational abuse presenting with ventricular fibrillation

Inhalation of volatile halogenated hydrocarbons may produce life-threatening cardiac and neurological toxicity. A 15-year-old boy developed ventricular fibrillation immediately after intentional inhalation of a fluorinated hydrocarbon from an automobile air conditioner recharge unit. After the use of intravenous bretylium, a hemodynamically stable sinus tachycardia was restored. Aspiration pneumonitis and rhabdomyolysis complicated his hospital course before complete neurological recovery. The mechanism and treatment of cardiac arrhythmias after volatile fluorinated hydrocarbon inhalation are reviewed.     

Ratio of pulmonary venous to mitral A velocity is a useful marker for predicting mean pulmonary capillary wedge pressure in patients with left ventricular systolic dysfunction

OBJECTIVE: To determine the effect of oral magnesium hydroxide [Mg(OH)2] on iron absorption after simulated iron overdose in human subjects. METHODS: A randomized, controlled crossover study was conducted in healthy adult male human volunteers taking no medications. Subjects received an average of 5.0 mg/kg elemental iron orally followed 1 hour later by either oral administration of 4.5 g of Mg(OH)2 per g ingested elemental iron or no treatment. Serial serum specimens were obtained over the 12 hours following iron ingestion and stored at -60 degrees C until standard serum iron assay was performed. After a 2-week washout period, the subjects were enrolled in the alternative trial arm. Individual baseline diurnal variation in serum iron levels was determined over a 12-hour period on the day prior to each trial. Area under time-concentration curves (AUCs) were calculated, and the AUC due to experimental iron ingestion (deltaAUC) was determined by subtracting the baseline diurnal AUC from the experimental AUC for each subject. RESULTS: Thirteen healthy adult male subjects were enrolled. Mean +/- SEM for deltaAUC due to experimental iron ingestion followed by treatment with Mg(OH)2, 78 +/- 23 micromol(hr)/L, was significantly less than that followed by no treatment, 144 +/- 33 micromol(hr)/L (p = 0.03 by signed rank test). CONCLUSIONS: Magnesium hydroxide, administered 1 hour post-iron ingestion at an oral dose of 4.5 g per g elemental iron ingested, significantly reduced iron absorption during a 12-hour period following simulated mild iron overdose in healthy adult human volunteers.     

Pediatric coin ingestion: a home-based survey

To improve understanding of the natural history of pediatric coin ingestions, an anonymous, home-based mail survey of parents followed by a five-physician private pediatric practice in suburban Maryland was conducted. Of 2,263 families surveyed, 798 (35.3%) responded, representing 1,510 children. Sixty-one (4.0%, 95% confidence interval: 3.1% to 5.1%) children had swallowed a coin, at a mean age of 2.8 years. Fifty-two (85%) coin ingestions were managed at home, usually without calling a physician or poison control center. Only 9 (15%) children were examined by a physician. No child (95% confidence interval: 0% to 4.9%) underwent a removal procedure or had an adverse outcome. Most coin ingestions were found to have been managed at home, often without calling a physician or poison control center. Hospital- or poison control center-based studies underestimate coin ingestion incidence and overestimate the frequency of complications.     

The uterine and cardiovascular effects of oral fenoterol hydrobromide

Fenoterol hydrobromide was administered as a 5 mg tablet to 10 patients in oxytocin-induced labour and the effects on uterine activity and on the cardiovascular system of mother and baby were evaluated. The drug took effect within 30 minutes in 8 of the 10 patients and it reduced uterine activity to less than 30 per cent of the original. Fenoterol caused a moderate maternal tachycardia, raised systolic and decreased the diastolic blood pressure.     

Effects of magnesium sulfate and lidocaine in the treatment of ventricular arrhythmias in experimental amitriptyline poisoning in the rat

OBJECTIVES: Amitriptyline poisoning is associated with ventricular arrhythmias. Standard treatment is sodium bicarbonate but further intervention may be necessary. The present study compared the actions of lidocaine and magnesium sulfate on ventricular tachycardia induced by amitriptyline. DESIGN: Nonrandomized, controlled, intervention trial. SETTING: University laboratory. SUBJECTS: Thirty male Wistar rats anesthetized with pentobarbital and mechanically ventilated. INTERVENTIONS: After pretreatment with norepinephrine, the animals were subjected to a continuous infusion of amitriptyline. After the appearance of ventricular tachycardia, they were treated with magnesium sulfate (45 mg/kg + 15 mg/kg/min) or lidocaine (1 mg/kg + 0.5 mg/kg/min) or glucose infusion as a control. MEASUREMENTS AND MAIN RESULTS: In the group treated with magnesium sulfate, electrocardiogram tracings demonstrated that nine of ten animals converted from ventricular tachycardia to sinus rhythm compared with one of ten in both the lidocaine- and glucose-treated groups (p < .001). The animals treated with magnesium sulfate also had a significantly longer total time in sinus rhythm (10.0 +/- 1.6 mins) than those rats treated with lidocaine (1.7 +/- 1.5 mins) or glucose (1.5 +/- 1.5 mins). Magnesium sulfate significantly decreased blood pressure and heart rate, but no severe hemodynamic side effects were observed. CONCLUSIONS: Magnesium sulfate is effective in converting ventricular tachycardia in hyperadrenergic amitriptyline poisoning. In contrast, lidocaine had no effect on arrhythmias.     

The use of Cordanum in combination with Corinfar-Retard for the treatment of ectopic arrhythmias in the sick sinus syndrome in patients with ischemic heart disease

38 patients with ischemic heart disease (IHD) and sick sinus syndrome (SSS) received combined therapy with nifedipine (Corinfar-Retard) and talinolol (Cordanum). The former drug had a positive chronotropic effect on the heart, the latter's chronotropic effect was slightly negative. All the patients had sinus bradycardia and ectopic arrhythmia which needed therapeutic correction: supraventricular and ventricular extrasystoles, fibrillation paroxysms or/and atrial flutter, paroxysmal supraventricular tachycardia, ventricular tachycardia. Cordanum was given in a dose 50 mg twice a day, Corinfar-Retard 20 mg twice a day for 16 days. 30 patients responded to the treatment. In addition to good subjective response, episodes of extrasystoles, paroxysms, flutter and fibrillation occurred much less frequently. Side effects resulted in the treatment discontinuation in 3 patients.     

The clinical spectrum of Jin Bu Huan toxicity

Herbal medications and other nontraditional medical therapies are becoming increasingly popular in the United States. We describe three children and three adults in whom severe toxic effects developed after ingestion of a Chinese herbal medication, jin bu huan, which is sold as Jin Bu Huan Anodyne Tablets. Jin bu huan produced distinct clinical syndromes after acute ingestion in children and long-term use in adults. A single, acute ingestion in children rapidly produced life-threatening neurologic and cardiovascular manifestations, while long-term jin bu huan use in adults was associated with hepatitis. Jin bu huan contains levo-tetrahydropalmatine, a potent neuroactive substance. The constituents of jin bu huan are misidentified on the package, resulting in significant delay in identifying the plant alkaloid responsible for its toxicity. Although perceived as innocuous, jin bu huan may produce major health effects. The highly concentrated formulation, the lack of childproof packaging, and the product insert listing indications for the treatment of serious medical conditions may all contribute to the development of toxic reactions.     

Soil ingestion estimates for children residing on a superfund site

Soil ingestion estimates were obtained from a stratified, simple random sample of 64 children aged 1-4 years residing on a superfund site in Montana. The study was conducted during the month of September for 7 consecutive days. The study utilized a mass-balance methodology in which eight naturally occurring soil tracers (Al, Si, Ti, Ce, Nd, La, Y, and Zr) believed to be poorly absorbed by the gastrointestinal tract were employed to provide soil ingestion estimates. Food and fecal samples were analyzed on a daily basis. Soil/dust samples representative of where the children played during the study period were obtained. Very high compliance among the participants was maintained throughout the study. The identical methodology employed in the childrens' study was used in an adult study of tracer recovery in 10 subjects over 28 days of observation to provide validation that soil ingestion over the range of 20 to 500 mg/day could be detected. Soil ingestion was estimated by each soil tracer via traditional methods as well as by an improved approach using five trace elements (Al, Si, Ti, Y, and Zr), called the Best Tracer Method (BTM), which substantially corrects for error due to misalignment of tracer input and output as well as error occurring from ingestion of tracers from nonfood, nonsoil sources, while being insensitive to the particle size of the soil/dust ingested. According to the BTM, the median soil ingestion was less than 1 mg/day while the upper 95% was 160 mg/day. No significant age (1 year vs 2, vs 3) or sex-related differences in soil ingestion were observed. These estimates are lower than estimates observed in another study in Massachusetts during September and October. Significant methodological improvements in this study as compared to previously conducted soil ingestion studies include the selection of a representative sample of children, longer study duration, inclusion of dietary recommendations to reduce food tracer input and variability, use of the BTM, and a stronger adult validation study with respect to number of subjects, and duration and range of possible soil ingestion rates. Despite these methodological improvements, evidence exists that this study displays a net residual negative error, suggesting that the above estimates are below the true soil ingestion. The magnitude of this residual negative error cannot be quantified with the BTM but is likely to not affect the median by more than 40 mg/day, while the impact of such an error on the upper end of the distribution is more uncertain.