Iatrogenic pediatric hydroxocobalamin overdose.

INTRODUCTION: Hydroxocobalamin, a precursor molecule to vitamin B12, has emerged as the preferred empiric treatment for patients rescued from enclosed-space fires with concern for inhalational injury and potential concomitant cyanide toxicity. Limited data exist on the effects of hydroxocobalamin toxicity, particularly in pediatric patients. CASE REPORT: We report a case of a healthy three-year old girl who was rescued from an apartment fire and electively intubated by prehospital providers. Due to concern for potential cyanide toxicity, she received 5 g (373 mg/kg) of intravenous hydroxocobalamin, an amount equivalent to one standard adult dose but over five times the appropriate weight-adjusted dose for this 13.4-kilogram child. On hospital arrival, patient was noted to have chromaturia and diffuse erythroderma without cutaneous burns. She was extubated 4 h after prehospital intubation and discharged home the following morning in good condition with persistent erythroderma. Skin color returned to normal within two days. DISCUSSION: We believe this to be the first reported case of iatrogenic pediatric hydroxocobalamin overdose for the treatment of suspected cyanide toxicity. Erythroderma and chromaturia are expected side effects of hydroxocobalamin, even at therapeutic levels. Along with minor airway burns, the only other finding was a transient and hemodynamically neutral bradycardia, which began shortly after prehospital intubation. As this bradycardia occurred prior to hydroxocobalamin administration, more likely culprits include vagal nerve stimulation from direct laryngoscopy, and sinoatrial muscarinic receptor stimulation caused by repeated doses of succinylcholine. In all, we were unable to appreciate any complications due to excess hydroxocobalamin administration.

Hemodialysis for the treatment of pulmonary hemorrhage from dabigatran overdose.

Dabigatran is an oral direct thrombin inhibitor indicated for thromboembolism prophylaxis in patients with nonvalvular atrial fibrillation. Since its approval in the United States in 2010, dabigatran-associated hemorrhages have garnered much attention because bleeding rates were higher than initially expected. Additionally, reversing anticoagulation remains challenging. Traditional modes of reversing warfarin-associated coagulopathies are ineffective in reversing anticoagulation from dabigatran. Although hemodialysis is proposed as a method to accelerate dabigatran elimination, evidence supporting its clinical utility remains unproved. We report the case of an 80-year-old man who presented with worsening hemoptysis in the setting of unintentional ingestion of excess dabigatran. Despite transfusion of 2 units of fresh frozen plasma, he continued to bleed, although his international normalized ratio improved from 8.8 to 7.2. He underwent hemodialysis, and serum dabigatran concentration decreased from 1,100 to 18 ng/mL over 4 hours, with an initial extraction ratio of 0.97 and blood clearance of 291 mL/min. Although his serum dabigatran concentration rebounded to 100 ng/mL 20 minutes after the cessation of dialysis, his bleeding stopped and he improved clinically. Hemorrhage in the setting of dabigatran anticoagulation remains a therapeutic predicament. Hemodialysis may play an adjunct role in accelerating the elimination of dabigatran in bleeding patients.

Performance in appropriate Rh testing and treatment with Rh immunoglobulin in the emergency department.

STUDY OBJECTIVE: The quality measure "Rh immunoglobulin administration for Rh-negative women at risk for fetal blood exposure" was recently endorsed by the National Quality Forum. No published data have shown a related performance gap in US emergency departments (EDs). We determine performance in a US ED for appropriate Rh testing and treatment among pregnant ED patients at risk of fetal blood exposure. METHODS: This was a retrospective, observational study in an urban, academic ED with 97,000 annual visits. We performed record review of all pregnant ED patients aged 14 to 50 years and presenting between June 1, 2009, and June 1, 2010, to determine whether a sensitizing event or a potential sensitizing event occurred and whether Rh testing and treatment with Rh immunoglobulin were performed when indicated. Performance rates were calculated under 2 different assumptions for patients without Rh testing ordered in the ED but who had previous data in the electronic medical record: (1) unless explicitly documented by the treating physician, previous Rh data were considered as not having been checked; and (2) when available in the electronic medical record, Rh status was always considered as having been checked. Interrater reliability was assessed for whether a trauma represented a sensitizing event. RESULTS: Among 1,465 patients identified, 808 met inclusion criteria; 560 had a sensitizing event and 248 had a potential sensitizing event. Interrater reliability for determination of sensitizing event or potential sensitizing event in trauma was moderate (κ=0.42). Performance rates for Rh testing among patients with sensitizing events, with potential sensitizing events, and overall were 73% (95% confidence interval [CI] 69% to 76%) (408/560), 36% (95% CI 31% to 43%) (90/248), and 62% (95% CI 58% to 65%) (498/808). Appropriate treatment for patients with a sensitizing event, with a potential sensitizing event, and overall was 56% (95% CI 39% to 71%) (19/34), 0% (95% CI 0% to 49%) (0/5), and 48% (95% CI 33% to 63%) (19/39). Assuming that physicians were aware of previous Rh results yielded performance rates of 96% (95% CI 93% to 97%) (535/560), 73% (95% CI 67% to 78%) (181/248), and 89% (95% CI 86% to 91%) (716/808) and treatment performance rates of 54% (95% CI 38% to 69%) (20/37), 0% (95% CI 0% to 30%) (0/11), and 42% (95% CI 29% to 56%) (20/48). CONCLUSION: In this single-center study, among patients with a sensitizing event, performance was moderate for Rh testing and treatment with Rh immunoglobulin. Despite lack of consensus or uncertainties in certain measure definitions, in at least 1 US academic ED there appears to be an opportunity for further evaluation and performance improvement in this area.

A case report of porphyria variegata management in the emergency department.

BACKGROUND: Porphyria variegata (VP) is one of the hepatic porphyrias that results from the deficiency of protoporphyrinogen oxidase, an enzyme in the heme synthesis pathway. The name porphyria variegata refers to its many presentations, which include various neuropsychiatric and cutaneous manifestations. Emergency department (ED) presentations due to VP are most commonly neuropathic abdominal pain. CASE REPORT: We present the case of a 57-year-old woman presenting to an ED with abdominal pain consistent with prior VP attacks. In addition to analgesics and supportive care, infusion of intravenous dextrose resulted in improvement in her symptoms. CONCLUSION: Intravenous dextrose and heme administration remain the first-line treatment for abdominal pain attributable to known acute hepatic porphyria attacks. Recently, the mechanism of action of carbohydrates in treating porphyria has been elucidated. Current information on this illness and ED management are discussed.

Reversal of Pediatric Opioid Toxicity with Take-Home Naloxone: a Case Report.

BACKGROUND: Take-home naloxone, an opioid antagonist, has become part of a multimodal approach to curbing opioid-related mortality. However, there is little information about the utility of take-home naloxone in pediatric patients. We report a case of opioid toxicity after exposure to methadone in a pediatric patient, which was successfully reversed with take-home naloxone. CASE: A previously healthy 22-month-old girl ingested an unknown amount of liquid methadone. The child became progressively somnolent. The mother administered intranasal naloxone at home with reversal of somnolence. The patient presented to the emergency department and had recurrence of symptoms. The patient was placed on a naloxone infusion and discharged from a tertiary care facility, uneventfully, 2 days after ingestion. RESULTS: To our knowledge, we report the first case of pediatric opioid toxicity reversed by take-home naloxone. In the setting of rising opioid-related mortality, providers and public health officials should consider expanding access of take-home naloxone for children at high risk for opioid overdose.

Flibanserin toxicity in a toddler following ingestion.

INTRODUCTION: Flibanserin is a medication recently approved by the FDA for treatment of generalized hypoactive sexual desire disorder (HSDD) in premenopausal women. Its mechanism of action is not fully understood but is thought to modulate serotonin receptors and increase levels of norepinephrine and dopamine. While much is known about toxicity of other drugs which affect these systems, there is little information about toxicity of flibanserin at this time. CASE: We present a case of a 2-year-old boy who ingested an estimated 600 mg of his mother's flibanserin. Following ingestion, the child developed facial twitching and unresponsiveness to pain, concerning for seizure-like activity. In the emergency department (ED) he was found to have hypertension, mydriasis, slurred speech, and normal labs. He responded well to supportive care including administration of benzodiazepines. Shortly after admission to the hospital, his temperature increased to 38.4 °C. Toxicology testing revealed the presence of 1-(3-trifluoromethylphenyl)-piperazine (TFMPP), a flibanserin metabolite. TFMPP is a recreational drug used as an alternative to 3,4-methylenedioxymethamphetamine (more commonly known as "MDMA" or "ecstasy"). DISCUSSION: This case highlights potential toxicity associated with ingestion of flibanserin.

Clozapine Intoxication Mimicking Acute Stroke.

Clozapine is an atypical antipsychotic drug prescribed for treatment-resistant schizophrenia. The risk of adverse hematologic, cardiovascular, and neurologic effects has tempered its use, and reports of overdoses remain rare. We report a case of accidental acute clozapine intoxication in a clozapine-naïve patient, who presented with symptoms mimicking acute stroke and later developed status epilepticus. Clozapine intoxication is a rare presentation in the emergency department with potential for iatrogenic harm if not correctly identified.

Death following intentional ingestion of e-liquid.

CONTEXT: Electronic cigarette (e-cigarette) use is growing within the United States, resulting in both intentional and unintentional exposures to concentrated liquid nicotine or "e-liquid." Nicotine has been culpable for severe poisoning and deaths in the past. However, sources of nicotine have traditionally been from cigarettes, cigars, or pesticides. Fatalities due to liquid nicotine are rare, and fatalities following ingestion of e-liquid are even scarcer. CASE: We present a case of a 24-year-old woman who intentionally ingested up to 3000 mg of liquid nicotine intended for e-cigarette use. She was found in pulseless electrical activity and had return of spontaneous circulation (ROSC) after undergoing approximately 10 min of cardiopulmonary resuscitation with a blood pressure of 74/53 mmHg and a pulse rate of 106 beats/min. Despite aggressive supportive care, she ultimately died after she was found to have multiple acute infarcts, consistent with severe anoxic brain injury, on magnetic resonance imaging. The patient's toxicologic testing, obtained shortly after ROSC, was notable for plasma nicotine and cotinine levels each >1000 ng/mL. DISCUSSION: This fatality highlights the potential toxicity associated with suicidal ingestion of liquid nicotine.

A transient N-O-linked Pauson-Khand strategy for the synthesis of the deschloro carbocyclic core of the palau'amines and styloguanidines.

A stereocontrolled route to the deschloro cyclopentyl core of the palau'amines and styloguanidines has been developed. This strategy makes use of the intramolecular Pauson-Khand cyclization of an enyne with a "transient N-O tether" to construct a five-membered carbocycle in a diastereoselective fashion. [reaction: see text]

Hemorrhagic complications associated with dabigatran use.

OBJECTIVE: Dabigatran is a direct thrombin inhibitor approved for anticoagulation in non-valvular atrial fibrillation and, in some countries, for thromboembolism prophylaxis following select orthopedic surgeries. Despite decreased rates of thromboembolism, bleeding remains a risk due to the inability to conveniently monitor anticoagulant effect and the lack of a reversal agent. CASE SERIES: We present four cases of dabigatran-related bleeding. A 79-year-old man on aspirin, clopidogrel, and dabigatran presented with rectal bleeding and epistaxis. He died despite transfusion and administration of prothrombin complex concentrate. A 73-year-old woman on dabigatran and aspirin survived after transfusion and an emergent sternotomy for cardiac tamponade. An 86 year-old man with kidney disease and thrombocytopenia received packed red blood cells, platelets, and fresh frozen plasma for rectal bleeding while on dabigatran. An 80 year-old man on dabigatran had a subdural hematoma after falling and hitting his head. Serial imaging showed no progression. CONCLUSION: The absence of a reversal agent for dabigatran raises concern for uncontrollable bleeding and death. Dabigatran's listed contraindications include active bleeding and a history of dabigatran hypersensitivity reaction. Wider use may result in bleeding rates higher than anticipated from clinical trials. Risks factors that may have contributed to bleeding in these patients include concomitant bleeding diathesis, antiplatelet agent use, renal insufficiency, advanced age, and fall risks.