Treatments of Calcium Channel Blocker Overdose

Pharmaceutical agents are the most common causes of poisoning in Korea. Calcium channel blockers (CCBs) are commonly used in Korea for the management of hypertension and other cardiovascular diseases, but are associated with a risk of mortality due to overdose. Due to the frequent fatalities associated with CCB overdose, it is essential that the emergency physician is capable of identifying CCB intoxication, and has the knowledge to manage CCB overdose. This article reviews the existing clinical guidelines, retrospective studies, and systematic reviews on the emergency management of CCB overdose. The following are the varied treatments of CCB overdose currently administered. 1) For asymptomatic patients: observation with enough time and decontamination, if indicated. 2) For symptomatic patients: infusion of calcium salt, high dose insulin therapy, and vasopressor (norepinephrine) or atropine for bradycardia. 3) For patients refractory to the first line therapy or with refractory shock or impending arrest: lipid emulsion therapy and extracorporeal membrane oxygenation. 4) As adjunct therapy: phosphodiesterase inhibitors, glucagon, methylene blue, pacemaker for AV block. Small CCB ingestion is known to be fatal for pediatric patients. Hence, close observation for sufficient time is required.

Antidotes of cyanide intoxication

Cyanide poisoning can occur from industrial disasters, smoke inhalation from fire, food, and multiple other sources. Cyanide inhibits mitochondrial oxidative phosphorylation by blocking mitochondrial cytochrome oxidase, which in turn results in anaerobic metabolism and depletion of adenosine triphosphate in cells. Rapid administration of antidote is crucial for life saving in severe cyanide poisoning. Multiple antidotes are available for cyanide poisoning. The action mechanism of cyanide antidotes include formation of methemoglobin, production of less or no toxic complex, and sulfane sulfur supplementation. At present, the available antidotes are amyl nitrite, sodium nitrite, sodium thiosulfate, hydroxocobalamin, 4-dimethylaminophenol, and dicobalt edetate. Amyl nitrite, sodium nitrite, and 4-dimethylaminophenol induce the formation of methemoglobin. Sodium thiosulfate supplies the sulfane sulfur molecule to rhodanese, allowing formation of thiocyanate and regeneration of native enzymes. Hydroxocobalamin binds cyanide rapidly and irreversibly to form cyanocobalamin. Dicobalt edetate acts as a chelator of cyanide, forming a stable complex. Based on the best evidence available, a treatment regimen of 100% oxygen and hydroxocobalamin, with or without sodium thiosulfate, is recommended for cyanide poisoning. Amyl nitrite and sodium nitrite, which induce methemoglobin, should be avoided in victims of smoke inhalation because of serious adverse effects.

Comparison between Emergency Patient Poisoning Cases and the Tox-Info System Database

PURPOSE: The Tox-Info system is a poisonous substance information database developed by the Korean National Institute of Food and Drug Safety Evaluation. The aim of this study was to estimate the coverage effectiveness of the Tox-Info system by comparing the toxic substances included in the database with the distribution of the toxic substances implicated in the cases of intoxicated patients presenting to emergency departments. The secondary aim of the study was to propose any additional substances that should be added to the database. METHODS: We retrospectively reviewed the medical records of patients suffering with toxic exposure who had visited any of 12 selected emergency departments in Korea from January 2010 to December 2011. The identified toxic substances were classified into groups including prescription drugs, agricultural chemicals, household products, animals or plants, herbal drugs, and others. We calculated the coverage rate of the Tox-Info database relative to the number of intoxication cases and the type of toxic substances involved. RESULTS: A total of 5,840 intoxicated patient records were collected. Their mean age was 46.6+/-20.5 years and 56.2% were female. Of the total intoxication cases, 87.8% of the identified toxic substances were included in the Tox-Info database, while only 41.6% of all of the types of identified toxic substances were included. Broken down by category, 122 prescription drugs, 15 agricultural chemicals, 12 household products, 14 animals or plants and 2 herbal drugs involved in poisoning cases were not included in the Tox-info database. CONCLUSION: This study demonstrated the clinical usefulness of the Tox-Info system. While 87.8% of the substances involved in the cases were included in the Tox-Info database, the database should be continuously updated in order to include even the most uncommon toxic substances.

Availability of Toxicologic Screening Tests in the Emergency Department

PURPOSE: The role of a point of care test (POCT) is currently becoming important when treating patients and making decisions in the emergency department. It also plays a role for managing patients presenting with drug intoxication. But the availability of the test has not yet been studied in Korea. Therefore, we investigated the utility and the availability of POCT for drug screening used in the emergency department. METHODS: This was a retrospective study for those patients with drug intoxication between January 2007 and December 2010 in an urban emergency department. RESULTS: Between the study period, 543 patients were examined with a Triage(R)-TOX Drug Screen. Among those, 248 (45.7%) patients showed negative results and 295 (54.3%) patients showed positive results. The sensitivity of the test for benzodiazepine, acetaminophen and tricyclic antidepressants were 85.9%, 100%, 79.2%, respectively. CONCLUSION: POCT of drug screening in emergency department showed good accuracy especially in patient with benzodiazepine, acetaminophen and tricyclic antidepressant intoxication. Therefore, it can be useful diagnostic tool for the management of intoxicated patients.

A Case of Papuloerythroderma of Ofuji which Responded to Treatment with Cyclosporine / 대한피부과학회지

Papuloerythroderma of Ofuji is an uncommon dermatological disorder of unknown etiology and is characterized by a pruritic eruption of widespread confluent papules in vast sheets over the skin, but spares the skin folds (the so-called 'deck-chair' effect). We present a case of a patient with papuloerythroderma of Ofuji of unknown cause. Treatment with oral and topical corticosteroids, antihistamines, and narrow-band UVB phototherapy proved to be ineffective in helping the condition but considerable clinical improvement was obtained with cyclosporine.

A Randomized Prospective Trial Comparing Oral Sodium Phosphate with Magnesium citrate in Preparing of Patients for Double Contrast Barium Enema

PURPOSE: The purpose of this study was to compare two bowel preparation agents, sodium phosphate solution with magnesium citrate solution. MATERIALS AND METHODS: A total of 94 subjects that underwent a double-contrast barium enema were included in this study. Bowel preparation before performing the barium study was done by using a sodium phosphate solution in 47 subjects and by using a magnesium citrate solution in the other 47subjects. We evaluated the presence or absence of side effects when using these bowel preparation agents. Two radiologist who were blinded to the type of bowel preparation evaluated the quality of bowel preparation at the colonic segments (ascending, descending, and sigmoid colon) on the radiographs obtained by double-contrast barium enema, with regard to stool cleansing, water retention, barium coating and bubble formation. RESULTS: The side effects, such as abdominal clamping pain, nausea, hunger pain and chill occurred more frequently in the sodium phosphate group than in the magnesium citrate group (p<0.001). Stool retention was more frequently found in the magnesium citrate group (p<0.001). However, no statistical difference was noted on the status of water retention and barium coating between two groups. Gas bubble formation was more commonly seen in the sodium phosphate group (p<0.001). The sodium phosphate solution appeared to be more effective in cleansing the right colon (p=0.001). CONCLUSION: Sodium phosphate solution appears to be more effective for colonic cleansing, with a lower incidence of side effects, than when using magnesium citrate solution.

A Case of Contact Dermatitis due to Ranunculus sceleratus Linne / 대한피부과학회지

The Ranunculus sceleratus Linne is a plant which belongs to Ranunculus Linne, Ranu-nculaceae. We report a case of contact dermatitis due to Rannunculus sceleratus Linne. The patient developed painful, inflamed erythematous patches with a tense bullae on application sites of the crushed plant for the therapy of arthralgia on both knees. We did patch tests on a health volunteer and topical application of a rabbit's skin with its crushed leaf, stalk and root. Their results were compared with each other.

A Case of Churg-Strauss Syndrome Showing Hemorragic Bullae / 대한피부과학회지

A 61-year old woman was presented with various sized, tense and hemorrhagic bullae on the extremities with edema for 10 days. She had a history of bronchial asthma and had a tingling sensation on both legs. Laboratory findings showed leukocytosis, hypereosinopilia and p-ANCA(+). Chest radiograph showed patchy infiltrations in the left upper lobe. Water's view showed bilateral maxillary antral mucosal thickening. Electromyography showed polyneuropathy on both lower legs. Histopathologically, there were conspicuous infiltration of eosinophils within bulla and around vessels in the dermis and radially distributed histiocytes in the degenerated collagen. Treatment with prednisolone 30 mg per day showed a dramatic improvement in symptoms.

The Bispectral Index and Modified Observer's Assessment of Alertness/Sedation Scale Comparable to Effect Site Concentration of Propofol in Koreans / 대한마취과학회지

BACKGROUND: Propofol has been frequently used for sedation or hypnosis in anesthesia and is relatively accurate in the dose-response relationship for hypnosis. The aim of this study was to define the bispectral index and modified observer's assessment of alertness/sedation (OAA/S) scale at various effect site concentrations (Ce) of propofol in Koreans. METHODS: Fifty premedicated (atropine 0.5 mg, I.M.) adult patients (ASA class I or II, 20 55 yrs) scheduled for elective orthopedic surgery were studied. Propofol was infused until 2 min after the target concentration equilibrated with the effect site concentration (Ce) of propofol using Master TCI. The target concentration of propofol was stepwise increased at intervals of 0.5 microgram/ml until BIS reached 40, BIS and OAA/S at each Ce of propofol were checked. If SpO2 decreased below 90%, oxygen (4 l/min) was given via nasal cannula. RESULTS: BIS was 97.9 +/- 0.2 and OAA/S 5 +/- 0.0 at a Ce of propofol of 0 microgram/ml; the Ce of propofol was 3.5 microgram/ml and OAA/S 0.1 +/- 0.3 at a BIS of 41.1 +/- 2.5. Also, systolic BP at a Ce of propofol above 1.0 microgram/ml and diasolic BP at a Ce of propofol above 1.5 microgram/ml significantly decreased compared to the control (P < 0.05). However, heart rate did not show any difference compared to the control value. Above a 1.0 microgram/ml Ce, fifty-eight percent of patients showed SpO2 < 90%, but there was no incidence of apnea. There were significant correlations between Ce of propofol, BIS and OAA/S. CONCLUSIONS: BIS showed a significant correlation with Ce of propofol (Spearman's r = 1.0) (P < 0.0001). The Ce of propofol was above 3.0 microgram/ml for BIS50.

The Effect of Concentration of Nitrous Oxide on Bispectral Index and Sedation Score / 대한마취과학회지

BACKGROUND: Bispectral index (BIS) has been designed to measure objectively the degree of sedation and hypnosis for several anesthetics. It is predicted that sedation and hypnosis during nitrous oxide inhalation affect BIS in an unusual manner due to a different mechanism compared to usual hypnotics. The aim of this study was to evaluate the effect of different concentration of nitrous oxide inhalation on BIS and sedation score. METHODS: Forty unpremedicated ASA physical status I or II patients scheduled for lower extremity surgery were studied. After performing epidural anesthesia, patients inhaled gradually increasing concentrations of nitrous oxide from 0 to 67% (15 minutes for each concentration) via a tightly sealed face mask. At the end of each inhalation, BIS and OAA/S scale (Observers's Assessment of Alertness/ Sedation scale) were assessed. RESULTS: The increasing concentrations of inhaled nitrous oxide resulted in significant reduction of the OAA/S scale but in no change of BIS. Concentrations of nitrous oxide exceeding 50% affected behavior or emotion of the patients. CONCLUSIONS: Following increasing concentrations of inhaled nitrous oxide, sedation score was reduced significantly but BIS was not affected.

The Effect of Tetraethylammonium Chloride on the Impulse Conduction Block by bupivacaine / 대한마취과학회지

Potassium channel blockers slow depolarization, broaden the action potential, and thus pro- mote the open and inactivated Na+ channel states. The ability of local anesthetics to reduce the amplitude of compound action potential(CAP) of rat sciatic nerve was examined in the presence and absence of teteraethylammonium chloride(TEA) that selectively block K+ channels, In the presence of 1.3X10-5 M bupivacaine that inhibit the CAP by 22.5% at tonic stimulation, the addition of TEA(10-1M) increased this inhibition by another 27.5% and increased another 50% by phasic stimulation(20Hz). Also, dose response curve of bupivacaine in the presence of TEA(10-1M) showed marked shift to left of curve. The re- covery kinetics of bupivacaine in the presence of various coneentration of TEA(10-2-10-1M) showed marked delay of recovery(2X10-2 M), reocurrence of inhibition(90min,5X10-2 M), even no recovery(10-1M). TEA alone slightly depolarized the resting membrane which was represented as increment of CAP height from 0.9%(3min) to 12.3%(80min), and broadened mid-peak amplitude width by 2 times in 5X10-1M, 5.3 times in 1M. These experiments directly demonstrated that TEA potentiated the inhibition of CAP by bupivacaine and showed the poesibility of mixture of TEA and local anesthetics to potenti- ate impulse conduction blockade.