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Introduction: Clenbuterol hydrochloride is a selective beta-2 adrenergic agonist with uses in both humans and animals. Ingestions occurring within the United States are generally due to incidental ingestion of a veterinary product, use as a cutting agent for illicit substances, or illegal use for performance-enhancing purposes. Case Report: A four-and-a-half year-old male presented approximately two-and-a-half hours after an accidental ingestion of an unknown quantity of clenbuterol. Initial laboratory results and electrocardiogram were remarkable for hyperglycemia, hypokalemia, and hypophosphatemia, with an electrocardiogram demonstrating sinus tachycardia. Heart rate ranged from 126 to 147 beats per minute while other vitals remained within normal limits. The patient was observed for 24 hours and discharged with normalized vital signs, laboratory results, and electrocardiogram. Discussion: Clenbuterol hydrochloride is a beta-agonist with high potency, extended half-life, and bioavailability of 70% to 80%. Tachycardia occurs due to beta-1 receptor stimulation, as well as a homeostatic reflex to peripheral vasodilation. Hyperglycemia is not uncommon in exposures and intracellular shifting of potassium causes hypokalemia. Treatment is primarily supportive in nature, with hemodynamic management representing the primary focus of initial triage.

Purpose:The purpose of this work was to retrospectively review patient cases presenting to the University of Kentucky Chandler Medical Center (UKCMC) emergency department (ED) with symptoms of suspected synthetic cannabinomimetic (SC) intoxication. These drugs, currently undetected by standard urine drug screen tests, comprise a structurally diverse group of compounds designed to mimic the psychoactive effects of Δ9-tetrahydrocannabinol (Δ9-THC), the primary psychoactive cannabinoid in marijuana.Summary:Fourteen cases of suspected SC intoxication were identified between July 1, 2015, through September 30, 2015. The median patient age was 25.5 years (range: 13-45 years), and most (64%) patients were males. The most common psychoactive symptom was agitation (n = 6, 42.9%), while the most common physical symptoms were altered level of consciousness (n = 9, 64.3%) and mydriasis (n = 3, 21.4%). Most cases resolved without complication in 24 hours; 2 patients required hospitalization.Conclusion:Recent legislation has failed to curb the public health concerns emanating from SC misuse. Education about the risks of SC use along with additional regulation may be required to remove the false sense of safety that some individuals, especially adolescents and young adults, may associate with these compounds, which are often misconstrued as “herbal marijuana.” Clinicians need to be prepared to identify and treat symptoms of SC intoxication as incidents of toxicity continue to rise.

Rabson-Mendenhall syndrome is a rare genetic disorder resulting from mutations in the insulin receptor and is associated with high degrees of insulin resistance. These patients are prone to complications secondary to their hyperglycemia including diabetic ketoacidosis (DKA). We report the case of a 19-year-old male with Rabson-Mendenhall syndrome presenting with DKA who required doses of up to 500 U/h (10.6 U/kg/h) of insulin. The patient’s insulin infusion was originally compounded with U-100 regular insulin, although to minimize volume, the product was compounded with U-500 insulin. The DKA eventually resolved requiring infusion rates ranging from 400 to 500 U/h. Although numerous opportunities for medication errors exist with the use of U-500 insulin, this case outlines the safe use of concentrated intravenous insulin when clinically indicated for patients requiring extremely high doses of insulin to control blood glucose.