Hepatotoxicity from castor bean ingestion in a child.

BACKGROUND: Castor beans contain ricin, one of the most toxic substances known. A biphasic toxicity is described consisting of acute and potentially fatal gastroenteritis followed by damage to the viscera several days later. However, the most current review of the literature states that the above delayed toxicity has not been reported. CASE REPORT: We report a 20-month-old girl with no gastrointestinal symptoms who developed reversible hepatotoxicity beginning 48-72 hours after the ingestion of castor beans. CONCLUSION: It seems prudent to follow for several days any patients who actually chewed castor beans before ingestion.

Effect of point of care testing on length of stay in an adult emergency department.

Devices are now available that are practical for point of care testing (PCT) in hospital settings. Previous studies in clinical settings, however, have failed to demonstrate a reduction in patients' length of stay (LOS) associated with the use of PCT. This randomized controlled study compared PCT with central laboratory testing in a hospital Emergency Department to assess the difference in patients' LOS. Patients randomized to PCT (n = 93) had a median stay of 3 h, 28 min (interquartile range [IR] 2:28 to 5:30), while those allocated to the central laboratory (n = 87) had a median stay of 4 h, 22 min (IR 3:04 to 5:47). The median stay associated with PCT was significantly shorter. Among patients who were destined to be discharged home, there was also a significantly shorter stay, but not among those who were destined to be admitted. It was concluded that the use of PCT can achieve significant time savings in an Emergency Department.

Aspirin poisoning during pregnancy: increased fetal sensitivity.

Descriptions of salicylate poisoning during pregnancy are rare and unique features of perinatal physiology predict an increased sensitivity of the fetus to aspirin poisoning. A 17-year-old, 37-week pregnant woman presented to the hospital stating that she had ingested 50 aspirin tablets per day for 1 month in an attempt to harm her baby and herself. Ultrasound showed fetal demise. Serum salicylate was 620 mg/L with an anion gap of 22.6 and the following blood gases: pO2 108 mm Hg, pCO2 15mm Hg, pH 7.34, and HCO3 8.8 mmol/L. She was successfully treated with alkaline diuresis followed by hemodialysis. She spontaneously delivered a macerated stillborn 2380-g fetus. Autopsy revealed diffuse petechiae in the lungs, heart, thymus, and kidneys. Salicylic acid was found in the cord blood, but quantification was not possible due to the small volume of the blood sample. Our patient supports the hypothesis that the fetus is at greater risk than the mother in salicylate poisoning during pregnancy. Consideration should be given to emergent delivery of term or near-term, aspirin-poisoned fetuses.

Toxicokinetics of acute strychnine poisoning.

BACKGROUND: Strychnine competes with the inhibitory neurotransmitter glycine producing an excitatory state characterized clinically by hyperreflexia, severe muscle spasms, and convulsions. However, the kinetics after overdose have not been well described. CASE REPORT: A 34 year-old male presented to the emergency department 20 minus after ingesting half of a 250-mL container of 2% strychnine sulfate (2.25 g). The reported lethal dose is 100-120 mg. He was alert and oriented and experiencing muscle spasms. His condition deteriorated prompting sedation, muscle paralysis, and tracheal intubation. He was given activated charcoal 100 g per nasogastric tube. He was admitted to intensive care where he was managed with diazepam, pentobarbital, and pancuronium. Despite mild rhabdomyolysis, he recovered and was extubated on day three. Although receiving prophylactic heparin therapy, a massive fatal pulmonary embolus ensued. Eighteen blood specimens for strychnine analysis were obtained from 20 minutes to 51 hours after ingestion. Serum concentrations were determined with gas chromatography-mass spectroscopy. Disappearance followed a first-order process with a t 1/2 of 16 hours (r, = 0.97). DISCUSSION: Our results confirm the findings of an earlier case report of 19 strychnine levels obtained between 4 and 19 hours which described first-order kinetics with a similar t 1/2 of 10 hours. CONCLUSION: Strychnine disappearance in this overdose was well described by a first-order process with a t 1/2 of 10-16 hours.

Leukocytosis, hyperglycemia, vomiting, and positive X-rays are not indicators of severity of iron overdose in adults.

To determine whether leukocytosis, hyperglycemia, vomiting, and opacities in abdominal radiographs are indicators of a serum iron concentration of > 300 micrograms/dL in adult iron overdose patients, a retrospective medical record review was undertaken at a university medical center of all patients older than 12 years of age for whom clinical data were collected before deferoxamine therapy and within 6 hours of iron ingestion. Forty-three patients met the inclusion criteria; 37 were female. The mean and range serum iron concentrations were 382 micrograms/dL and 58 to 710 micrograms/dL, with 34 patients having values of > 300 micrograms/dL. There were no statistically significant relationships between iron concentration of > 300 microgram/dL and leukocytosis, hyperglycemia, vomiting, and opacities in abdominal radiographs (P > .05). Sensitivities, specificities, and positive and negative predictive values indicate poor performance of these parameters as clinical predictors of serum iron concentration of > 300 micrograms/dL. Leukocytosis, hyperglycemia, vomiting, or the presence of opacities in abdominal X-rays are not indicators of a serum iron concentration of > 300 micrograms/dL in adults. These parameters should not be used to assess the severity of iron overdose or to guide its management.

Methanol half-life during ethanol administration: implications for management of methanol poisoning.

STUDY OBJECTIVE: To determine the half-life of methanol in methanol-poisoned patients who are treated with ethanol but not with hemodialysis. DESIGN: Case series. SETTING: University Hospital, University of Manitoba. PARTICIPANTS: Three methanol-poisoned patients treated with ethanol but not with hemodialysis and three similar patients identified by a literature review. RESULTS: Plots of terminal concentration versus time data were inconsistent with zero-order kinetics and were adequately explained by an apparent first-order process. The median half-life of methanol in these patients was 43.1 hours, with a range of 30.3 to 52.0 hours. CONCLUSION: Because of the significantly increased risk of toxicity and complications during ethanol monotherapy, we suggest that hemodialysis be considered for methanol-poisoned patients who are treated with ethanol infusion.

Benign course after massive ingestion of yohimbine.

Yohimbine is an alpha 2 adrenoreceptor antagonist occasionally used in the treatment of impotence. Overdose of this drug is uncommon. We describe a 62-year-old male who ingested 100, 2.0 mg tablets whose only adverse effects were tachycardia, hypertension, and anxiety of brief duration. The limited experience to date suggests a benign course even after massive overdose. Observation would seem to be the management of choice.

Clinical spectrum of sulfonylurea overdose and experience with diazoxide therapy.

We retrospectively reviewed our 10-year experience with the management of sulfonylurea overdose. There were 40 overdoses in 37 patients aged 1 to 78 years, with two deaths and one patient being left in a chronic vegetative state. Blood sugar levels ranged from normal to severe recalcitrant hypoglycemia. Maximal duration of recurrent hypoglycemia was 82 hours. In 21 of 31 patients with hypoglycemia, response to hypertonic glucose therapy was poor, resulting in recurrent hypoglycemia. Six of these patients were treated with intravenous diazoxide and had prompt correction. Overdose of sulfonylurea drugs may produce severe, protracted hypoglycemia poorly responsive to hypertonic glucose therapy. Treatment with diazoxide is rational and effective and may be lifesaving.