Emergent complications of the newer anticonvulsants.

BACKGROUND: Multiple new anticonvulsants have been introduced recently and they are supplanting the older medications. Whereas the older drugs have well-recognized side effects, both in typical therapeutic doses and in overdosage, the properties of the newer ones are unique and largely unknown to all but sub-specialists. OBJECTIVES: This article gives a concise overview of the potential complications of these new medications in both therapeutic use and overdose. DISCUSSION: Clinically significant side effects of the new anticonvulsants, such as metabolic acidosis from topiramate, autoimmune reactions from lamotrigine, hyponatremia from oxcarbazepine, or psychosis from levitiracetam can cause serious morbidity and mortality if unrecognized. The effects of these medications in overdose are also largely unknown to most emergency physicians. CONCLUSIONS: This article reviews the major potential side effects of the new seizure medications and the treatment of their overdoses for the practicing emergency physician.

Crack cocaine causing fatal vasoconstriction of the aorta.

Cocaine is the most powerful central nervous stimulant found in nature. All forms of cocaine cause tachycardia and vasoconstriction. A smokable, rapidly reacting form of cocaine base, "crack," is highly addictive. Smoking crack introduces a high concentration of cocaine into the bloodstream, rendering it especially dangerous. We report a case that visually demonstrates severe aortic vasoconstriction from the suprarenal aorta and extending to both femoral arteries and beyond, resulting in renal failure and fatal bowel ischemia after a 5-day binge of crack cocaine.

Southern Pacific Rattlesnake bite: a unique clinical challenge.

The Southern Pacific Coast Rattlesnake (Crotalus Helleri) is responsible for most of the snake bites in the coastal area of California from Los Angeles to San Diego. However, Crotalidae polyvalent immune ovine Fab fragments are not made from the venom of C. Helleri. This sheep-derived antivenom is indicated only in moderate snakebite envenomations. Very scant data are available regarding venom-induced thrombocytopenia treated with ovine Crotaline Fab fragments. This is the second reported case of venom-induced thrombocytopenia that followed a "biphasic" pattern with the inability of ovine Crotaline Fab fragments to prevent this toxic effect. This case shows that severe envenomation from Crotalus Helleri associated with a delayed presentation to the Emergency Department does not have a sustained response to the ovine antivenom, and suggests that the use of Wyeth (equine) antivenom may be of greater therapeutic benefit.