Fluoride ingestion in children: a review of 87 cases.

All cases of fluoride ingestion in children younger than 12 years old reported to the Rocky Mountain Poison Center between January 1 and December 31, 1986, were retrospectively reviewed. Eighty-seven cases were identified. Eighty-four cases involved accidental ingestion of dental fluoride products in the home (tablets, drops, rinses) in children 8 months to 6 years old. Two older children (8 and 9 years old) became symptomatic after fluoride treatment by a dentist. A 13-month-old child died after ingesting an unknown amount of sodium fluoride insecticide, the only insecticide exposure in our series. Postmortem total serum calcium value was 4.8 mg/dL (normal 8.8 to 10.3). No other patients had serious symptoms or sequelae. Twenty-six (30%) of 87 became symptomatic, with gastrointestinal symptoms (nausea, vomiting, diarrhea, abdominal pain) in 25 patients and drowsiness in 1. Only 3 patients became symptomatic later than 1 hour after ingestion. Analysis of data from 70 cases with sufficient information revealed that as the amount of fluoride ingested increased, the percentage of patients with symptoms increased. Not including the fatal case, 6 patients had serum calcium levels measured, and all were normal. Children who ingested up to 8.4 mg/kg of elemental fluoride in dental products had mild and self-limited symptoms, mostly gastrointestinal.

Granuloma formation induced by spines of the cactus, Opuntia acanthocarpa.

Embedded cactus spines may cause immediate pain due to mechanical damage, be a source of infection, or result in foreign body granulomas. The cholla cacti are particularly tenacious in the manner in which the spines stay embedded in the skin. Pulling away from the cactus may result in a portion breaking away from the main plant and embedding other spines. Granuloma formation has been seen with plant material embedded in the dermis. Onset is generally within a few days, and duration may be as long as 9 mo. Treatment is generally best accomplished with a topical corticosteroid. We present a case of granuloma caused by the cactus Opuntia acanthocarpa which persisted for 8 w despite topical treatment with 0.05% fluocinonide.

Plants and mushrooms of abuse.

The plants described earlier are only a few of those that can be misused. Most have effects similar to those of more popular synthetic drugs but can cause unpleasant side effects and unpredictable results. Identification of the offending botanic agent can be problematic. These plants are still used because most are legal to possess, and they do produce desired hallucinogenic and stimulant effects. Because the active ingredients are similar pharmacologically to agents such as LSD and amphetamine, required treatment is often similar. The challenge for the Emergency Department physician is to recognize the potential for abuse of these botanic agents, their probable side effects, and the need for appropriate, usually supportive, treatment. There are many more plants with abuse potential than can be discussed in detail in an article of this size. Table 1 lists a number of other agents that might be misused. Phenylamine hallucinogens occur in several species and include N,N-dimethyltryptamine (DMT), N-monomethyltryptamine (MMT), 5-methoxy-N-N-dimethyltryptamine (5-MeO-DMT), 5-methoxy-N-monomethyltryptamine (5-MeO-DMT), 5-methoxy-N-monomethyltryptamine (5-MeO-MMT), 5-hydroxy-N-N-dimethyltryptamine (bufotenine or 5-H-DMT), and N,N-dimethyltryptamine-N-oxide (DMT-N-oxide).

Toxic effects of nonsteroidal anti-inflammatory drugs in overdose. An overview of recent evidence on clinical effects and dose-response relationships.

Nonsalicylate, nonsteroidal anti-inflammatory drugs (NSAIDs) can be divided into 4 chemical classes: acetic acids, fenamic acids, oxicams and propionic acids. Most NSAID overdoses result in a benign outcome. Of 50,614 exposures reported to poison centres in the United States in a 2-year period, 131 (0.26%) had a major outcome, with 10 deaths. Despite the generally mild effects reported in large patient series, isolated case reports have documented serious toxicity, such as seizures, hypotension, apnoea, coma and renal failure. The majority of these consequences occur after ingestion of substantial quantities by adults attempting suicide. Rarely, with ibuprofen and piroxicam, children who ingest small amounts in accidental exposure develop serious toxicity. Typical signs and symptoms of NSAID overdose include nausea, vomiting, headache, drowsiness, blurred vision and dizziness. Seizures are rarely documented across all NSAID classes, with the exception of mefenamic acid (where seizures occur in over one-third of cases), or following massive ingestion of other agents. Drugs in the propionic acid group have produced metabolic acidosis, respiratory depression and coma in severe cases. Ibuprofen is the agent with the most published data on overdose, probably because it is available without a prescription in many countries. Symptoms are unlikely after ingestion of 100 mg/kg or less, and are usually not life-threatening unless more than 400 mg/kg is ingested. There is some relationship between plasma concentrations and the potential for development of symptoms, but plasma concentrations have no impact on treatment decisions. Treatment of NSAID overdose is entirely supportive. Recent trends in emergency department procedures regarding gastric decontamination are evolving towards the recommended administration of activated charcoal without gastric emptying in patients presenting more than 1 hour after ingestion, although gastric lavage, followed by administration of activated charcoal, may be advisable in patients who present earlier. Home administration of syrup of ipecac is still recommended if treatment is given shortly after ingestion, with a few exceptions: for example, ipecac is contraindicated after ingestion of mefenamic acid or ibuprofen in amounts greater than 400 mg/kg. Urine alkalinisation and diuresis have been recommended to enhance the elimination of NSAIDs, based on a pKa in the range of 3 to 5. However, because the drugs are universally highly protein bound, with little unchanged renal excretion, this technique is not likely to be beneficial. Haemodialysis is also unlikely to enhance elimination, but may be required if oliguric renal failure develops. Multiple dose activated charcoal may be useful in enhancing elimination of NSAIDs with long half-lives, such as piroxicam and sulindac.

Toxicity of homeopathic products.

Homeopathy is an alternative form of medicine that employs infinitesimal doses, individualized treatments and the concept of "like cures like". Practitioners are attempting to gain credibility with standard medical practice by making their drug testing (provings) conform more closely to the placebo and double-blind crossover studies done by standard medicine. Overdoses of homeopathic remedies are seldom serious (although all should be evaluated) because of the very small doses employed.

Chlorambucil overdose: accidental ingestion of an antineoplastic drug.

A 22-month-old, 10 kg child ingested 32 mg of chlorambucil and developed irritability, myoclonic-like muscle jerks, an exaggerated startle reflex, vomiting, and EEG changes within a few hours. The neurologic symptoms improved overnight, and the patient was discharged at about 28 hours postingestion. During the three weeks of follow-up, mild bone marrow suppression occurred and resolved. A normal EEG was reported at 33 weeks postingestion.

Five cases of Thermopsis poisoning.

Various Thermopsis species are found in the foothills and plains of the Rocky Mountains. There are no reported cases of human ingestion to Thermopsis reported in the literature. We report 5 cases of ingestion of seeds or flowers where the primary symptoms were nausea, vomiting and headache of several hours duration. As few as 6 seeds produced symptoms. The common names used by parents when calling the poison center could have easily lead to misidentification and a careful history and subsequent professional identification were required to ascertain the actual plant involved.

Cigarette and nicotine chewing gum toxicity in children.

A prospective review of 51 cases of tobacco ingestion and 5 cases of nicotine resin chewing gum exposure was conducted to evaluate the incidence and degree of toxicity caused by these products in children. A dose-response relationship was observed for cigarette exposures. Nine of 10 children ingesting more than one cigarette or three cigarette butts developed signs or symptoms, while 12 of 24 ingesting lesser amounts became symptomatic (P less than 0.01). Severe symptoms (e.g. limb jerking and unresponsiveness) were only seen with the larger amounts. Nicotine resin gum produced toxicity in 4 of 5 children who chewed 1/2 to 4 pieces. Agitation, lethargy, tachycardia, hypotension, abdominal pain, and vomiting were seen within 30 min of exposure to the gum.

Mystery root ingestion.

Patients frequently come to the emergency department or contact a poison center following exposure to plants. These cases are often challenging owing to difficulty in correct identification of the involved plant. A case of two patients who demonstrated anticholinergic syndromes after ingesting an unknown, wild plant is described. Chemical analysis of two suspect plants collected in the same location allowed a probable diagnosis of poisoning from ingestion of henbane (Hyoscyamus niger).

Toxicity of Cyclamen persium (Mill).

Cyclamen spp contain toxic saponins, although the number of serious exposures is very low. The plant was investigated for toxic and pharmacologic properties in the 1950's and 1960's, but there is little current investigation. Cyclamens have been found both as woodland plants and houseplants in Europe for years, and the plant is becoming increasingly popular in the US. Poison centers should be aware of the potential toxicity of this plant, especially that of the rhizomatous tubers. Additional data on exposures reported to poison centers may be helpful in further defining the toxicity of this plant.

Assessing mistletoe toxicity.

To assess the potential toxicity of mistletoe ingestion, data were collected on 14 cases of ingestion of one to three berries or one or two leaves of American mistletoe (Phoradendron sp) from 1982 to 1985. Eleven patients ingested berries and three ingested leaves; none became symptomatic. Nine patients were observed at home without intervention except poison center telephone follow-up. Five had induced emesis, including two who were referred to emergency departments for evaluation, where no findings other than ipecac-induced vomiting were noted. Also reviewed were data on a total of 318 cases of mistletoe ingestion reported to the Food and Drug Administration Poison Control case reporting system between 1978 and 1983 (n = 177) and the American Association of Poison Control Centers national data collection system (n = 141) in 1984. The majority remained asymptomatic and no deaths were recorded. These data allow the conclusion that ingestion of one to three mistletoe berries or one or two leaves is unlikely to produce serious toxicity.

Human overdose with the veterinary tranquilizer xylazine.

Three patients self-injected the veterinary tranquilizing agent xylazine (Rompun). The first patient developed mild bradycardia and hypotension, miosis, and a feeling of disorientation. The other two patients became apneic and required intubation and mechanical ventilation. Initial mild hypertension followed by mild hypotension and a mildly elevated blood glucose was seen in the second patient, whereas both the second and third patients developed mild bradycardia. Xylazine has structural similarity to the phenothiazines and pharmacological activity similar to clonidine. With increasing veterinary use, the availability and potential for human exposures may also increase.