Adulterants and substitutes.

The presence of an adulterant in an already inherently toxic street drug leaves both the user and the emergency physician with a harsh predicament. Both may be in the dark as to the true nature of the active ingredients, or as to the clinical effects produced by these substances or combinations of substances. This creates a diagnostic and therapeutic dilemma for the treating physician, as he or she wrestles with the often contradictory clinical signals and the inescapable possibility that prescribed therapy may interact adversely with the compounds already exerting their effects. The only defense we have is an open and constantly probing thought process, which maintains an awareness of the current street drug culture, and then channels this information into the clinical decision process.

Acute dystonic reactions from "street Valium".

Four patients presented to the emergency department with acute dystonic reactions 36 hours after the ingestion of "Valium tablets" they purchased on the street. Complete reversal of the symptomatology was achieved with the use of intramuscular diphenhydramine. The pathophysiology, epidemiology, and treatment principles for dystonic reactions are discussed.

Iron poisoning: report of three cases and a review of therapeutic intervention.

Although the acute ingestion of iron-containing preparations can produce very serious consequences, the majority of reported exposures are not associated with significant morbidity or mortality. We present 3 cases of acute iron ingestion and review the aspects of general management, with an emphasis on the appropriate choice of a gastrointestinal decontamination procedure.

Methanol inhalation toxicity.

Significant toxicity can result from intentional methanol inhalation. We report seven cases, involving four patients, of intentional inhalation of CARB-MEDIC carburetor cleaner containing toluene (43.8%), methanol (23.2%), methylene chloride (20.5%), and propane (12.5%). Patients arrived at the emergency department with central nervous system depression, nausea, vomiting, shortness of breath, photophobia, and/or decreased visual acuity. Treatment included correction of acidosis, leucovorin and/or folic acid, ethanol infusions, and supportive care. Hemodialysis was necessary in three cases. Measured blood methanol levels ranged from 50.4 to 128.6 mg/dL. Blood formic acid levels were 120, 193, and 480 micrograms/mL, respectively, in three patients. Ophthalmic examinations revealed hyperemic discs and decreased visual acuity in one patient. One individual was found pulseless with several CARB-MEDIC cans nearby. Attempts at revival were unsuccessful. Clinicians should be aware that significant blood methanol and formic acid levels may occur after inhalation of methanol.

Florida Poison Information Network. Saving lives and money.

A highly sophisticated network of poison information centers exists in Florida, one each in the northern, central and southern regions of the state. These 24-hour-a-day centers are staffed by nurses and pharmacists who provide assessment, triage and management advice about a wide range of exposures. Toxicologists are available when in-depth consultation is needed. As most cases can be safely managed at home, costly visits to the emergency room are averted, resulting in significant overall health-care savings. These centers also provide educational programs for the public and health professionals and compile epidemiologic statistics.

Survival following massive arsenic ingestion.

A case of a 30-year-old man who ingested a massive quantity of arsenic (approximately 2,150 mg) in an apparent suicide attempt is presented. Aggressive initial therapy, including fluid resuscitation, chelation therapy, and hemodialysis, resulted in the patient's survival. The successful management of arsenic intoxication requires both prompt recognition and the initiation of specific and aggressive therapeutic modalities.

Naloxone.

Naloxone hydrochloride, a synthetic N-allyl derivative of oxymorphone, is an effective agent for the reversal of the cardiovascular and respiratory depression associated with narcotic and possibly some non-narcotic overdoses. It is essentially a pure narcotic antagonist, is relatively safe, and is a useful diagnostic and therapeutic agent. Due to naloxone's pharmacokinetic profile, a continuous infusion protocol is recommended when prolonged narcotic antagonist effects are required. The complex pharmacodynamics of naloxone, specifically relating to endorphin receptor sites, focus its potential use in a variety of clinical situations as continuing research illustrates the association of endogenous opioid compounds with various disease states.

Management of neuroleptic malignant syndrome with anticholinergic medication.

Neuroleptic Malignant Syndrome (NMS) is a life-threatening adverse reaction arising from the use of neuroleptic medications. While dopaminergic agonists, dantrolrene and supportive care are traditionally utilized in the stabilization and management of NMS, anticholinergic medication may also prove effective therapy. Treatment with anticholinergic medication has been suggested in cases of NMS associated with mild hyperthermia. We describe a case of 17-y-old female, who was brought to the emergency department for a possible "acute dystonic reaction". The patient received 50 mg diphenhydramine i.v., which resulted in improvement in mental status. The patient was readmitted to the emergency department 1 d following discharge with symptoms similar, but now considering the diagnosis of NMS. Diphenhydramine 50 mg i.v. was again administered and resulted in significant improvement.

Multiple-dose activated charcoal compared to urinary alkalinization for the enhancement of phenobarbital elimination.

BACKGROUND: Urinary alkalinization and multiple-dose activated charcoal are modalities advocated for the enhancement of phenobarbital elimination in poisoned patients. However, no studies exist comparing the efficacy of these two means of elimination enhancement. We compared their effects on the pharmacokinetic disposition of intravenously administered phenobarbital. METHODS: Ten healthy volunteers participated in each of three randomly ordered study phases. During each phase, 5 mg of intravenous phenobarbital per kilogram of body weight was administered. During phase I, no interventions were made in attempt to enhance phenobarbital elimination. In phase II, participants underwent 24 hours of urinary alkalinization. Throughout phase III, volunteers received six doses of activated charcoal and two doses of sorbitol over 24 hours. RESULTS: The phenobarbital elimination half-life was 148 hours, 47 hours and 19 hours during the control, alkalinization and charcoal phases, respectively. Statistically significant differences in the elimination of phenobarbital were detected when each of the following phases were compared: I vs II, I vs III and II vs III. CONCLUSIONS: Both urinary alkalinization and multiple doses of activated charcoal are effective for the enhancement of phenobarbital elimination but multiple-dose charcoal was superior to urinary alkalinization in our study population.