[Circulatory failure after bupropion overdose]. / Allt fler allvarliga förgiftningar med preparatet bupropion.

A case of massive overdose of sustained release bupropion tablets is described. The patient presented with GCS 3, tachycardic and in vasoplegic shock. ECHO and EKG were initially normal. The hemodynamic situation was stabilised with vasopressors, but 18 h after presentation the patient deteriorated with wide complex arrhythmias rapidly progressing to cardiac arrest. The patient was put on VA-ECMO after 35 minutes of CPR. Circulation could be stabilized and ECMO was discontinued after 36 h. The patient was extubated on day 6 and made a complete recovery on discharge two weeks after presentation. At 34h, with ongoing ECMO, 236 tablets (with visible print identifying them as bupropion) were evacuated from the patient's stomach by gastroscopy. The tablets were analysed by NMR (nuclear magnetic resonance) but no longer contained any active substance. Blood levels of bupropion and hydroxybupropion at 36h were 790 and 1300 µg/l. The case illustrates a worrying surge in serious bupropion poisonings as noted by the Swedish Poisons Information Centre during the last 5 years.

Life-Threatening Thrombosis After Large Amounts of Nitrous Oxide Use.

This case report highlights the development of severe, life-threatening thrombotic complications after chronic recreational use of large quantities of nitrous oxide in a 21-year-old patient. In young patients presenting with thromboembolism and nitrous oxide abuse, swift identification of symptoms and management is critical.

[Severe neurologic and psychiatric symptoms after extensive use of nitrous oxide]. / Lustgasbruk gav pseudodemens.

We present a case of severe neurologic and psychiatric symptoms after extensive recreational use of nitrous oxide. The patient also had a transient pancytopenia that responded well to substitution with vitamins. Six months later the patient still had neurologic and psychiatric sequelae, due to the abuse.

[Improved access to test results for toxic alcohols can save lives]. / Bättre tillgång till provsvar för toxiska alkoholer kan rädda liv.

Acute poisoning involving toxic alcohols other than ethanol is not uncommon. Poisonings from drinking isopropanol are rarely life threatening, whereas methanol and ethylene glycol without prompt treatment cause severe metabolic acidosis, organ damage, and death, mainly due to toxic metabolites. Rapid identification of the type of alcohol responsible for the poisoning requires access to 24/7 toxicological service. The analysis of alcohols is usually done with gas chromatographic (GC) methods, which are not always available at smaller or medium-sized hospitals. As a complement to GC methods, reliable enzymatic oxidation procedures are now available for the analysis of ethanol, methanol, and ethylene glycol. The present study showed good agreement (r2 = 0.996) between the results of methanol analysis with a new enzymatic method (Catachem Inc.) and with GC over the clinically relevant concentration range (1-50 mmol/l). Moreover, high concentrations of ethanol (up to 80 mmol/l), ethylene glycol (to 40 mmol/l), isopropanol (to 100 mmol/l) or acetone (to 20 mmol/l) did not interfere with the analytical results for methanol. Toxicological analysis of the two most dangerous alcohols (methanol and ethylene glycol) can now be done with rapid and specific enzymatic methods, which makes it possible to diagnose and treat poisoned patients at smaller regional hospitals.

[Sedating antihistamines - risk of severe intoxication]. / Sedativa antihistaminer ­ risk för allvarlig intoxikation.

Overdoses with the sedating antihistamines alimemazine, hydroxyzine, promethazine and propiomazine have received attention in recent years in Sweden. The Poisons Information Center has noted an increase in calls regarding intoxications, and the National Board of Forensic Medicine has concluded that these substances have directly contributed to a large number of poisoning deaths. When prescribing alimemazine, hydroxyzine, promethazine and propiomazine, their pharmacological properties, such as antihistaminergic and anticholinergic effects, and their anti-arrhythmic potential must be considered. Furthermore, it is important to also consider the risks of severe intoxication in case of overdose. The lowest possible amount should be prescribed. Special attention is required when prescribing alimemazine oral solution.

[Simplified laboratory analysis of ethylene glycol allows improved management of poisoning cases]. / Förenklad analys av etylenglykol kan ge snabbare diagnos vid förgiftningsfall.

Toxicological analysis constitutes an important part of the acute treatment of poisonings. Timely laboratory results are essential for the patient to be diagnosed and treated appropriately, but also to exclude poisoning and avoid unnecessary overtreatment. Ingestion of ethylene glycol may cause acute kidney injury and, in severe cases, death, unless treated early with an antidote (ethanol infusion or fomepizole) to inhibit the formation of toxic metabolites. Diagnosis of poisoning is based on detection of ethylene glycol in plasma or serum, but a challenge remains that acute toxicology service is only available at major hospital laboratories using gas chromatography. A simple enzymatic method for the quantification of ethylene glycol (Catachem) was evaluated as a complement to currently used methods and demonstrated to provide fast and accurate measurement in a clinically relevant concentration range (1-80 mmol/l) with a minimal risk of analytical interference. The method is suitable for use on several automated clinical chemistry analyzers. Use of the enzymatic method can improve availability of acute toxicology service for ethylene glycol and contribute to better healthcare from both a patient and health resource perspective.

The unknown known: non-cardiogenic pulmonary edema in amlodipine poisoning, a cohort study.

Context: Amlodipine is the most common calcium channel blocker (CCB) on the Swedish market, and poison center (PC) consultations for amlodipine overdoses are increasing. The clinical picture is dominated by vasodilation with relative preservation of cardiac function. CCBs selectively dilate vessels on the afferent side of the capillary network which, in states of preserved or increased blood flow may lead to edema formation, including non-cardiogenic pulmonary edema (NCPE). This complication has been considered rare in CCB poisoning. In this cohort study of nineteen amlodipine poisonings with high amlodipine blood levels, the incidence and clinical significance of NCPE in severe amlodipine poisoning are explored.Methods: During 2017-2018 the Swedish PC prospectively encouraged the gathering of blood samples in amlodipine poisonings with symptoms requiring treatment with inotropes or vasopressors. Samples were sent by mail to the Forensic Toxicology Division at the Swedish National Board of Forensic Medicine for screening and quantification of relevant toxicants. Patients with blood amlodipine levels >0.25 µg/mL were included in a cohort whose case details were gathered from medical records and PC-case notes with a special focus on signs of NCPE.Results: Nineteen patients met the blood amlodipine inclusion criteria. Four (21%) died and one patient was treated with VA-ECMO. Nine patients developed NCPE defined as a need for positive pressure ventilation (PPV) while having an echocardiographically normal left ventricular function.Conclusion: In this prospective cohort study of consecutive and analytically confirmed significant amlodipine poisonings NCPE was a common finding occurring in 47% of the whole cohort and in 64% of patients who did not go on to develop complete hemodynamic collapse.

[Simplified N-acetylcystein treatment after paracetamol overdose - new recommendations from Swedish Poisons Information Centre]. / Ny förenklad motgiftsbehandling vid förgiftning med paracetamol - Giftinformationscentralen ändrar sin doseringsanvisning för N-acetylcystein.

Since the late 1970s N-acetylcystein has been used as an antidote after paracetamol intoxication. The treatment is traditionally given as three consecutive infusions for 20 hours and 15 minutes. The total dose given is 300 mg/kg. Half of this amount is given as a bolus during the first 15 minutes of treatment.  This regime has proven very efficient in avoiding liver injury. However, side effects, caused by histamine release, are common (10-15%). Symptoms as flush, urticaria and, in rare cases, bronchospasm, angioedema and circulatory shock typically appear during the bolus dose and may lead to interrupted and inadequate treatment. In addition, the regime is complicated leading to a risk of administration errors. During the last years several publications have described the use of a model with two infusions instead of three. The first and the second infusions are merged and given over four hours. The third infusion and the total dose are left unchanged. This modified regime has been shown to reduce side effects and seems not to increase the risk of liver injury. As of November 1, 2019, the Swedish Poisons Information Centre will change its recommendations to the new two-infusion protocol.

[Improved and harmonised laboratory analysis of paracetamol provides safer assessment of poisoning cases]. / Bättre labbanalys av paracetamol ger säkrare bedömning av förgiftningsfall - Bestämning av koncentrationen är grunden för rätt behandling.

Toxicological analysis is an important part of the acute treatment of various intoxications. Rapid laboratory responses are important for the patient to be assessed and treated correctly, and also to exclude poisoning and thus avoid unjustified and costly overtreatment. In Sweden, paracetamol (acetaminophen) is one of the most common pharmaceuticals in drug poisoning. Paracetamol overdose can cause severe liver damage unless treated early with the antidote acetylcysteine. A nation-wide initiative for improved laboratory measurement of paracetamol in plasma/serum samples has resulted in a marked reduction in the inter-laboratory coefficient of variation to generally below 10%. The introduction of a harmonized national reporting range for plasma/serum paracetamol covering at least 50-5 000 µmol/l was also recommended. This initiative will hopefully contribute to better healthcare from both a patient and health resource perspective in cases of paracetamol poisoning.

[High dose insulin euglycemia therapy ­ an important addition to the treatment arsenal in severe toxic myocardial depression]. / Högdos insulin­­euglykemiterapi vid svår ­toxisk myokard­depression - Ett viktigt tillskott i behandlingsarsenalen.

High dose insulin euglycemia therapy - an important addition to the treatment arsenal in severe toxic myocardial depression Fifty-nine patients who developed hemodynamic symptoms necessitating treatment with vasopressors or inotropes after poisoning with calcium channel blockers (CCB) and beta blockers (BB) between January 2010 and August 2016 were identified by a search of the Poisons Information Centre database. In-hospital circulatory arrest occurred in 16/59 (27 %) and the mortality rate was 7/59 (12 %). Two cases of analytically confirmed combined BB and CCB poisoning were treated with high dose insulin therapy (HIE) and are presented in detail. The outcome in both cases was good. They were the only cases in the study population treated with HIE, although signs of cardiac dysfunction was present in 55/59 (93%) and in all cases of circulatory arrest. Animal studies and international clinical cases indicate that HIE is a safe and effective method to improve cardiac function in CCB and BB poisoning, and its implementation in Sweden may improve the outcome for this at risk population.