Unilateral angioedema.

Angiotensin converting enzyme inhibitor-induced angioedema is typically easily recognizable in the emergency department. Angioedema lateralizing to one side, however, is infrequently reported, rare, and has the same potential of progression to airway compromise. We present of a case of an 80-year-old man with angioedema of the lower lip that had regressed prior to significant progression of right sided angioedema of the tongue and oropharynx.

An outbreak of severe coagulopathy from synthetic cannabinoids tainted with Long-Acting anticoagulant rodenticides.

Objective: To describe a large regional poison center's experience managing an outbreak of long-acting anticoagulant rodenticide (LAAR) poisoning associated with synthetic cannabinoid (SC) use.Methods: This is a retrospective review of exposures reported to the Illinois Poison Center between March 10 and August 1, 2018. All cases coded as exposure to Δ9-tetrahydrocannabinol homologs were identified. Patients with suspected SC use, positive LAAR testing, and coagulopathy (signs or symptoms of bleeding or international normalized ratio [INR] > 2) were included. If confirmatory LAAR testing was performed and resulted as negative, the patient was excluded from this analysis. In the absence of LAAR testing, patients with suspected SC use, an INR >2, and no alternative explanation of coagulopathy were included. Suspected SC use was defined as use suspected by a member of the treating team or reported by the patient. Presenting signs and symptoms, laboratory findings, management, healthcare utilization, outcomes, and disposition of patients affected by this outbreak were reported.Results: One hundred seventy-eight cases met inclusion criteria. Most patients were male (73%) and young to middle-aged (median age 32, IQR 25-40). Most presented to hospitals in Peoria (35%) and Cook (31%) counties. Median hospitalization was three days (IQR 2-4). Eighty-eight percent of patients presented with an INR >10. Eighteen cases had qualitative anticoagulant testing, all of which were positive for brodifacoum. Other identified LAARs included difenacoum (10/18) and bromadiolone (1/18). Sixty-three percent of patients had back, flank or abdominal pain; 70% of patients presented with hematuria. One hundred six cases received IV vitamin K1; no adverse or anaphylactoid reactions were reported. Forty-one (22%) patients left AMA. Thirty-eight patients (21%) were re-hospitalized during the study period. Patients leaving AMA were 1.6 times more likely to be re-hospitalized than patients with other dispositions. Intracranial hemorrhage, present in 3% of total cases, was present in 4 of 5 fatalities.Conclusions: We describe an outbreak of multiple LAARs contaminating SCs. Patients presented with bleeding from varied sites, often required blood products, factor replacement, and high dose vitamin K1 for stabilization.

Management of severe bupropion poisoning with intravenous lipid emulsion.

BACKGROUND: Bupropion toxicity is characterized by central nervous system and cardiovascular toxicity. Intravenous lipid emulsion (ILE) has been suggested as a treatment by some for the treatment of refractory bupropion toxicity. This recommendation is based largely on published case reports and cases presented at scientific meetings. The objective of this study is to characterize the outcomes of patients with suspected bupropion toxicity in which ILE was administered and the indications for its use. METHODS: Electronic records from one regional poison center were searched for intentional bupropion ingestions from 1 January 2009 through 31 December 2015. Cases in which ILE was administered or death was listed as the outcome were further analyzed. RESULTS: There were 1274 cases of suspected bupropion ingestion reported during the study period with 14 reported deaths. Nine cases of ILE administration were identified. Of these, four patients expired and five survived. One of the survivors had neurologic sequelae necessitating placement in a long-term care facility. Patient complications after ILE administration were common and included continued hypotension in 7 cases, recurrent seizures in 3 patients, ARDS in two patients, and renal failure in one patient. CONCLUSIONS: The high mortality and complication rate after ILE in this study sample does not reflect the positive outcome benefit seen in previous published case reports. Further characterization of the efficacy and complications of ILE in bupropion toxicity is needed.

Those Salicylate Cases-How Sweet Are They?

Owing to the complex metabolism of salicylates, both hyperglycemia and hypoglycemia have been reported with salicylate poisoning. The aim of this study was to characterize this relationship. Data from the Illinois Poison Center were retrospectively queried over a 5-year period (2008-2012), and patients with a salicylate concentration ≥30 mg/dL were included. Hypoglycemia and hyperglycemia were defined as glucose concentrations <55 and >140 mg/dL, respectively. Of the 160 patients included, most were normoglycemic (81%) and 19% were hyperglycemic. No patient experienced hypoglycemia. Our study indicates that hypoglycemia may be a very rare occurrence in the setting of salicylate poisoning. Clinicians must remain vigilant, regardless of the glucose concentration, when entertaining salicylism as an etiology in appropriate patients.

Digoxin-Specific Antibody Fragment Dosing: A Case Series.

Digoxin-specific antibody fragments (DSFab) are used for the treatment of poisoning by cardiac glycosides, such as pharmaceutical digoxin. Dosing of this therapy for chronic and acute poisonings is based on the steady-state serum concentrations of digoxin, historical data in acute ingestions, or empiric regimens purportedly based on the average requirements. Empiric dosing for adult patients involves utilization of 3-6 vials for chronic poisoning and 10-20 vials for acute poisoning. The aim of this study was to describe the average dosing requirements based on the steady-state serum concentration of digoxin or historical data and compare this with the empiric dosing regimens. We performed a retrospective analysis of cases over an 11-year period presented to the Illinois Poison Center where administration of DSFab was recommended. We identified 140 cases of chronic digoxin poisoning and 26 cases or acute digoxin poisoning for analysis. The average dose of DSFab recommended in the cases of chronic digoxin poisoning was 3.05 vials (SD ± 1.31). The average dose of DSFab recommended in the cases of acute digoxin poisoning was 6.33 vials (SD ± 5.26). These values suggest that empiric dosing regimens may overestimate the need for DSFab in cases of both chronic and acute poisonings of pharmaceutical digoxin.

Forgoing the Folate?-Contemporary Recommendations for Methanol Poisoning and Evidence Review.

Methanol poisonings can produce significant toxicity in humans, including acidosis, blindness, and death. The current mainstay of therapy is alcohol dehydrogenase (ADH) inhibition to prevent formation of formic acid and hemodialysis to correct acidosis and remove both parent compound and toxic metabolite. Folate has been recommended as an adjunctive therapy to increase formic acid oxidation into carbon dioxide and water. We retrospectively reviewed recommendation of folate therapy for methanol poisoning by our regional poison center from 2002 to 2012. One hundred two patients met inclusion criteria. Our findings demonstrate a sharp decline in folate recommendation over the course of the study period (48% vs. 12% during the years 2002-2006 and 2007-2012, respectively), despite similar rates of ADH inhibition, hemodialysis, and serious outcomes. This may be related to the approval of the use of fomepizole in methanol poisoning in 2002, which provides a quicker, more reliable means of ADH inhibition than ethanol infusions. We also provide a review of the available evidence of folate use in methanol poisoning.