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Background: Simple asphyxiation due to [CO.sub.2] is uncommon despite the widespread use of dry ice. Dry ice, or compressed carbon dioxide snow, sublimates under standard conditions and liberates [CO.sub.2]. Since [CO.sub.2] is denser than air, it descends upon release and displaces oxygen from the ground upward. In addition, the ambient concentration of [CO.sub.2] rises. Symptoms in exposed patients are related to both a reduced fraction of inspired oxygen ([FIO.sub.2]) and an elevated fraction of inspired [CO.sub.2] ([FICO.sub.2]). Case Report: A 50-year-old medical researcher was discovered dead in a refrigerated room (8'W x 14'D x 8'H) that contained 15 new blocks (10' x 10' x 10') of dry ice. The dry ice had been stored in the refrigerator (4 [degrees] C) at approximately 9 a.m. that day to reduce their sublimation. The researcher had last been seen at approximately noon, indicating that at least three hours had elapsed between storage and exposure. It appeared that at the time of death the descedent was crouching to store samples in a container several inches from the ground. There were no signs of struggle and the descedent had no history of psychiatric disorders, recent personal crises, or medical illnesses. The external ventilation system in the cold room was nonfunctional, although internal air movement occurred via the cooling fan. The blocks of ice appeared grossly intact. Post-mortem examination of the descedent was unrevealing, as was the toxicologic evaluation. A blood p[CO.sub.2] was not performed due to its well described rapid post-mortem rise. In order to confirm the cause of death, the conditions at the time of the event were reproduced exactly using the same cold room. Air was sampled serially at several heights; the [O.sub.2] concentration fell and the [CO.sub.2] concentration rose within 20 minutes, and peaked by 3 hours. The [FIO.sub.2] three hours after dry ice storage was 13.6%, and the [CO.sub.2] concentration was 27.6%, both at a height of 9 inches. The temperature of the room had fallen to - 15 [degrees] C, Conclusions: Cold storage at 4 [degrees] C does not prevent the sublimation of dry ice. Closed space storage of dry ice may lead to rapid incapacitation and death due either to a deficiency of ambient oxygen or an excess of [CO.sub.2]., Ely S, Rao RB, Heller M, Nelson LS, Hoffman RS. New York City Poison Control Center, New York, [...]

Background: While most patients in AW normalize their vital signs with small doses of benzodiazepines (BZ), a subgroup is refractory to standard therapy. These resistant patients require excessive doses of BZ, additional sedatives, and extended ICU stays. Hypotension, prolonged unconsciousness and ventilatory insufficiency complicate their course. This observational study was designed to identify early predictors of resistant AW (RAW). Methods: 19 adults admitted to an inner city hospital for AW who required 50 mg of diazepam (DPM) IV in the first hour of treatment were prospectively enrolled and followed for 24 hours. Age, sex, EtOH level, and maximal CIWA-Ar score (when available) were recorded. Hourly and total doses of IV DPM with concurrent vital signs were recorded at specified intervals. Patients were classified as having RAW if they required barbiturates (Barbs) to control their AW symptoms, or had persistent vital sign abnormalities at 24 hours, or as having non resistant AW (NRAW) if their vital signs normalized within 24 hours with BZ only. Results: 4 patients had NRAW, and required DPM in an hourly (and total) mean dose of 62 mg (62 mg), 32 mg (95 mg), 31 mg (128 mg), 20 mg (146 mg), 28 mg (174 mg), 10 mg (184 mg) at 1, 2, 3, 6, 12, and 24 hours, respectively. The 15 RAW patients required DPM in an hourly (and total) mean dose of 60 mg (60 mg), 45 mg (105 mg), 115 mg (220 mg), 156 mg (376 mg), 189 mg (565 mg), and 113 mg (678 mg) at 1, 2, 3, 6, 12, and 24 hours respectively. 14/15 of the RAW patients required Barbs, 7 were intubated and there were 5 episodes of hypotension. EtOH levels, CIWA-Ar scores, signs and symptoms, and vital signs were similar on admission. Neither hourly nor total BZ doses were statistically different at 1, 2, 3 hours. Both hourly and total BZ doses were significantly different at 6 and 12 hours. At 24 hours only the total dose was different (all by ANOVA). All NRAW patients had normal vital signs by 3 hours with a total DPM dose [is less than] 200 mg. 14/15 RAW patients had abnormal vital signs at 3 hours despite DPM (range: 60-440 mg). Conclusion: At 3 hours, persistently abnormal vital signs or requiring a total DPM dose [is greater than] 200 mg may be early predictors of RAW. RAW patients receiving Barbs may have hypotension, require intubation, and therefore need ICU monitoring. Prospective validation is warranted., Hack JB, Buschmann D, Hoffman RS, Nelson LS. New York City Poison Control Center, New York, [...]

Background: MDMA, XTC, or 'Ecstasy,' has been a popular drug of abuse for two decades. Until recently, cases of MDMA exposure in our region had been relatively uncommon. As the use of MDMA became widespread in our area, and since the majority of published data on clinical toxicity consists mainly of isolated case reports, we designed the following study to record systematically our experience with MDMA toxicity. These data now represent the largest collection of MDMA cases reported to date. Methods: Our poison center database was searched for the years 1993 to 1999 inclusive. Patient demographics, coingestants, and symptoms were recorded. Outcome was scored according to AAPCC criteria. The annual incidences of MDMA cases were compared using linear regression and calculation of a Pearson's correlation coefficient. Results: There were 137 cases reported in this 5.25-year period. 86 males and 50 females were exposed; the gender of one patient is unknown. The median age was 22 years ([IQ.sub.25-75] = 17-26 years). 43 cases (31%) experienced moderate to major toxicity, including 1 death due to hyperthermia. 94 cases (69%) experienced minor or no toxicity. The most commonly reported symptoms were agitation (25%), tachycardia (25%), and nausea and vomiting (13%). Hyperthermia and hyponatremia, the most serious complications of MDMA use, were reported in 6 patients and 1 patient, respectively. Urinary retention was reported in 3 patients, all of whom also reported concurrent ketamine use. Coingestants included cocaine, ethanol, heroin, marijuana, phencyclidine, and psilocybincontaining mushrooms. Beginning in 1997, ketamine and GHB were newly reported as common coingestants. MDMA reports increased with time (r = 0.85, p [is less than] 0.05). Conclusion: Increasing MDMA exposures in our region occurred predominately in a young population, of whom nearly a third met AAPCC criteria for moderate to severe effects. Although hyperthermia and hyponatremia occurred infrequently, we advocate rapid initial screening for these potentially devastating complications, while providing appropriate supportive care., Rella JG, Nelson LS, Hoffman RS. New York City Poison Control Center, New York, [...]

Background: 'Body packers' or 'mules' smuggle narcotics internationally by ingesting large numbers of packets filled with illicit drugs. An initial plain abdominal radiograph is often used to confirm the presence of multiple packets. Clinical criteria or radiographic studies may evaluate subsequent adequacy of GI decontamination. No study has confirmed whether computed tomography (CT) scan is superior to traditional contrast radiography. This case report suggests that the conventional radiograph with contrast may be more sensitive for detecting a single packet after decontamination. Case Report: A 28-year-old female stated she had swallowed 55 packets of heroin 2 days earlier. She passed 50 packets spontaneously prior to incarceration and arrival in the emergency department. She was asymptomatic. On physical examination, she was calm and alert with normal vital signs and physical examination, including reactive mid-size pupils and a soft non-tender abdomen with normoactive bowel sounds. Laboratory studies and 12-lead ECG were normal. Radiographs of the abdomen revealed 3 diagnostic densities and 2 possible densities. The patient received whole bowel irrigation (WBI) with polyethylene glycol (PEG-ELS) at 2 liters/h for 2 hours and evacuated 4 packets. Failure to pass the fifth packet raised questions about the patient's history. A helical abdominal CT with oral contrast, interpreted by the CT radiology attending, did not reveal any abnormal densities even though the contrast filled the entire small and large intestine. An uptight abdominal radiograph was subsequently obtained that clearly demonstrated the last packet in the right lower quadrant. The patient received more WBI and passed the last packet within one hour. She remained asymptomatic and was discharged. Subsequently, the CT radiology attending reviewed the CT with the plain radiograph and remained unable to detect the last packet. Conclusions: Computed tomography with contrast missed the single body packet whereas the plain radiograph with contrast did not. Until further study, we suggest using oral contrast plain radiography with bowel follow-through to evaluate the GI tract after WBI., Hahn I, Hoffman RS, Nelson LS. New York City Poison Control Center, New York, [...]

Background: Illicit drugs are smuggled by the intentional ingestion of drug packets. Current recommendations for cocaine 'body packers' include treatment with activated charcoal, whole bowel irrigation (WBI), and surgical removal if any symptoms of cocaine toxicity develop. This case report highlights the limitations of WBI and surgery. Case Report: A 30-year-old woman stated that two days prior to presentation she had swallowed approximately 40 packets of cocaine in an attempt to smuggle them into the US. She was asymptomatic and cooperative and had a normal physical exam. Initial abdominal radiograph revealed multiple packs in the bowel with no signs of obstruction. A urine toxicology screen was positive for cocaine. The patient received whole bowel irrigation with polyethylene glycol (PEG) at 2 L/h for 3 days and passed 25 packets. Due to the failure to pass additional packets, an abdominal CT without contrast was performed which identified remaining packets in the sigmoid colon. Several hours after the CT, the patient developed precipitous hypotension and coma. Following resuscitation, the patient underwent laparotomy and removal of 29 drug packets via an enterotomy. Two of the extracted packets had ruptured. Careful inspection and palpation of the entire GI found no abnormalities. Post-operatively the patient had persistent tachycardia and fever. On post-op day four, a repeat abdominal CT performed to exclude intra-abdominal abscess, located two additional packets in the sigmoid colon. These packets were removed by colonoscopy and appeared to be intact. After treatment for wound dehiscence and cellulitis, the patient was discharged with residual memory deficits. Conclusion: Prolonged whole bowel irrigation may not be effective for total evacuation of drug packets. Although intra-abdominal surgery is the gold standard of diagnosis and treatment of 'body packers,' it may also fail to detect intraluminal drug packets. History obtained from the patient and the associated packet count are unreliable., Olmedo RE, Hoffman RS, Nelson LS. New York City Poison Control Center, New York, [...]

Background: Quetiapine (Seroquel[R]) is a new dibenzothiazepine antipsychotic that was introduced in the US in 1997. It is similar to clozapine, and indicated for psychotic disorders. The proposed mechanism of action is through dopamine (D2) receptor and serotonergic type 2 (5-HT2) receptor antagonism. The effects of quetiapine in overdose have not yet been established. Since the patients prescribed this medicine are at high risk for intentional overdose, the following study was designed to help elucidate the effects of quetiapine in overdose. Methods: Records of all patients with a history of quetiapine ingestion reported to a regional poison center from 1997-1999 were reviewed. Clinical and demographic data, co-ingestants, and interventions were recorded. Outcomes were scored according to accepted AAPCC criteria. Results: 22 cases were reviewed. 17 were intentional ingestions in adults. The 5 cases excluded comprised 4 home calls regarding adults, and an ADR in a 10-year-old boy. Ingested doses were poorly reported, but ranged to a potential maximum of 8 grams. 13/17 patients had a history of co-ingestants which included benzodiazepines, SSRI, antipsychotics, divalproate sodium, Ritalin, terazosin, acetaminophen, ethanol, and codeine. These patients presented most commonly with sedation (10) and tachycardia (4). In the 4 patients with isolated quetiapine ingestion, symptoms included agitation (1), tachycardia (3), sedation (2). One of these 4 patients had QRS prolongation on the ECG and PVCs were noted in 2 patients. Decontamination measures included: orogastric lavage followed by activated charcoal and a cathartic (6); activated charcoal and a cathartic alone (8); none (2); syrup of ipecac (1). All patients recovered without complications. Outcomes were scored as minor or moderate (12), severe (3), none (2). Conclusion: Central nervous system depression and tachycardia seem to be the most common findings in patients with quetiapine ingestions. Some potential for cardiotoxicity was also noted. Although these preliminary data can not exclude more serious toxicity following a massive ingestion, this early experience suggests a relatively benign outcome. Further evaluation including increased sampling and blood levels is required to completely categorize the toxicity of quetiapine., Lynch S, Fill S, Hoffman RS. New York City Poison Control Center, New York, [...]

Background: Lead crosses the human placenta and placental lead levels correlate well with those in maternal plasma. Increased placental lead levels are associated with congenital abnormalities as well as neonatal lead encephalopathy. We report two cases of pregnant women with elevated peripartum lead levels due to pica. Case 1: An asymptomatic 32-week pregnant 17-year-old woman had a lead level of 130 mcg/dL and EP of 36 mcg/dL on her first prenatal visit. She admitted to eating an imported clay pot 3 days earlier. Her hematocrit was 30.7% and basophilic stippling was noted on her blood smear. An abdominal radiograph revealed lead fragments in her GI tract. The remaining pot was densely opaque radiographically and had a lead content of 22%. She received WBI with PEG-ELS at 2 L/h for 4 hours and Ca[Na.sub.2]EDTA IV (1000 mg/m2/d). After treatment with steroids for 2 days for fetal lung maturation a 2.4 kg child was delivered. The child's cord blood lead level was 78 mcg/dL and the mother's blood lead level was 48 mcg/dL at delivery. The child was treated with BAL IM (300 mg/m2/d) x 1 day and Ca[Na.sub.2]EDTA IV (1000 mg/m2/d) for a total of 7 days and the lead level fell to 21 mcg/dL. The mother was treated with Ca[Na.sub.2]EDTA for two more days and succimer x 2 days. The blood lead level decreased to 27 mcg/dL. Case 2: A 16-week pregnant 22-year-old woman had a lead level of 55 mcg/dL on routine screening tests. She stated that she had been eating soil from her yard. She was asymptomatic and fetal development appeared normal. No chelation therapy was initiated at that time. At term, the patient delivered a 5.4 kg child. A cord blood lead level of 78 mcg/dL and an EP level of 800 mcg/dL were found. The mother's lead level was 48 mcg/dL. The next day, the child's lead level decreased to 44 mcg/dL without therapy. Beginning the third day, both mother and child began lead chelation with Ca[Na.sub.2]EDTA IV (1500 mg/m2/d) x 5 days. Both appeared clinically normal. Conclusion: Pica during pregnancy may be associated with increase in both maternal and fetal lead levels. There is no consensus on therapy for pregnant mothers with elevated lead levels. Both sets of patients tolerated the treatment regimens well. Post-partum neonatal lead levels fall rapidly without treatment although the clinical implications of this fall are unclear., Olmedo RE, Rella JG, Hoffman RS, Nelson LS. New York City Poison Control Center, New York, [...]

Background: Arsenic compounds have been used as medicinal agents in the treatment of psoriasis, syphilis, and at present only for trypanosomiasis involving the CNS. In addition, they are well respected poisons used for homicide and suicide. In the past three years clinical studies have reported that arsenic trioxide ([As.sub.2][O.sub.3]) treatment can induce complete remission of patients with acute promyelocytic leukemia (APL) who have failed chemotherapy treatment with all-trans-retinoic acid. The most recent study in which 11 patients received an average cumulative dose of 360 mg of arsenic trioxide (range, 160 to 515) taken orally as outpatients reported a median duration of remission of only 5 months (range, 1 to more than 9). Acute arsenic poisoning manifests with symptoms of vomiting and diarrhea as well as ventricular dysrhythmias, myocardial dysfunction, and hypotension. We report a fatality which is suggestive of arsenic poisoning in a patient with APL who was treated with this newly approved experimental chemotherapeutic agent. Case Report: A 29-year-old man with a history of APL that had been refractory to retinoids and cytotoxic chemotherapy was treated in the hospital with [As.sub.2][O.sub.3] 20 mg orally daily for 35 days (cumulative dose of 700 mg). The patient had no previous history of cardiac disease, had a normal admission ECG and electrolytes, and was not reported to be on cardiotoxic medications. Three days after the [As.sub.2][O.sub.3] regimen was stopped the patient had multiple episodes of refractory ventricular tachycardia including Torsades de Pointes. Despite treatment with lidocaine, bretylium, magnesium, and cardioversion the patient died approximately 24 hours after onset of dysrhythmia. Although a forensic autopsy was refused, a postmortem blood arsenic level of 69 mcg/L was detected in a sample that was taken during the cardiac arrest. Conclusion: The association of arsenic trioxide therapy with a lethal dysrhythmias and the absence of an alternative cause of death raises the concern of causality of arsenic in this case. Future studies using arsenic to treat APL should systematically evaluate the potential for cardiac and systemic toxicity., Olmedo RE, Hoffman RS, Nelson LS. New York City Poison Control Center, New York, [...]

Background: EMLA cream, a mixture of lidocaine and prilocaine, is a topical anesthetic used for minor procedures. Although EMLA-induced MetHb has been reported in children, toxicity in adults is unreported. We describe the first adult to develop MetHb and simultaneous lidocaine toxicity from dermal exposure to EMLA for an elective procedure. Case Report: A 30-year-old female presented to the emergency department 4 hours after a laser epilation treatment. For the procedure, 150 g of EMLA cream (5 tubes) had been applied to her lower extremities under occlusive dressing for 1 hour. About 1 hour later, she began to experience lightheadedness, dyspnea, tongue numbness, muscular twitching, and formication on her legs/back. She denied visual/auditory hallucinations. Her only medications were sertraline and an oral contraceptive. On examination she was alert, but noted to have mild respiratory distress and perioral/acral cyanosis, which did not resolve with supplemental oxygen. Her vital signs were significant for a respiratory rate of 20/ min and her pulse oximeter read 84% saturation while on 100% oxygen. Her lungs were clear and her heart sounds were normal. Bilateral pretibial first degree burns were still present from a prior laser treatment 1 week ago. The remainder of her physical examination was normal. An ABG was: pH, 7.45; p[CO.sub.2], 36 mm Hg; [PO.sub.2], 385 mmHg, and her MetHb was 20% by co-oximeter. The patient received methylene blue, 50 mg IV, over 5 minutes and improved within 1 hour. A repeat MetHb level was 2.7%. Her lidocaine level (drawn at that time but measured 1 week later) was 0.68 mcg/mL confirming systemic absorption from the EMLA cream. Symptoms never recurred and the patient was discharged. Conclusion: MetHb and clinical lidocaine toxicity probably resulted from inappropriate EMLA application to damaged skin. The low lidocaine level may have resulted from the delay between acquisition and measurement. As more patients receive EMLA for minor cosmetic procedures, clinicians should be aware of the potential for adverse effects for this drug and the contraindications to its use., Hahn I, Hoffman RS, Nelson LS. NYC Poison Control Center, New York, [...]

Background: ASA poisoning and death are fairly common events. In ASA poisoning, however, severe muscle rigidity, known as paratonia or rapid rigor mortis, is rarely reported and poorly documented. The following case report describes paratonia in a severely ASA poisoned patient. Case Report: A 42-year-old female with a history of schizo-affective disorder and multiple psychiatric admissions was found disturbed and shouting. When EMS arrived she had a systolic blood pressure of 130 mm Hg and a pulse of 70/min recorded at 4:30 PM. She was brought to the hospital where she was noted to be alert with pressured speech, unable to concentrate, somewhat confused, and with alcohol on her breath. She was restrained and sent to psychiatry. At 7:05 PM, the patient was given lorazepam 2 mg and haloperidol 2 mg, both intramuscularly for agitation. At 10:00 PM, an order was written for lorazepam 2 mg PO, and diphenhydramine 50 mg PO. At 12:15 AM, the patient was transferred to the medical emergency department for respiratory distress. On arrival she was noted to have deep breaths at 12-14/min, a systolic blood pressure of 95 mm Hg, and desaturation by pulse oximeter. Skin was normal to touch, but a temperature was not reported. Shortly thereafter, two myoclonic events were noted and the patient stopped breathing. A cardiac arrest ensued. Because of a clenched mouth and severe rigidity, succinylcholine (100 mg IV) was given for intubation. However, the patient remained rigid and required cricothyrotomy. Resuscitation was unsuccessful. Blood drawn on arrival to the medical emergency department revealed a serum salicylate level of 150 mg/dL. Postmortem evaluation was notable for multiple partially digested enteric coated ASA pills throughout the gastrointestinal tract. No other toxin was identified. The failure to respond to succinylcholine excludes a diagnosis of NMS in this case, and malignant hyperthermia is unlikely given the clinical history. Rapid rigor mortis can be produced in animals when conditions of impaired glycolysis, low ATP and high lactate are present. This results in hyperthermia and irreversible myosin insolubility. Conclusions: Paratonia and the failure to respond to succinylcholine, in the absence of malignant hyperthermia, should raise a suspicion of salicylism., Rao RB, Smiddy M, Nelson LS, Howland MA, Hoffman RS. New York City Poison Control Center, OCME, New York, [...]

Background: Because of its parenteral formulation, expense and limited use, erythropoietin (EPO) overdose is rare and has only been reported in athletes and one suicidal health professional. We report the first severe complication of unintentional EPO overdose. Case Report: A 42-year-old HIV+ male presented to the hospital complaining of pain in both feet and vague abdominal pain. Several months prior to admission the patient was diagnosed with anemia and required multiple transfusions. Subsequently, he was instructed to self administer EPO 20,000 U/week, in addition to his daily interferon injections for KS. The patient became confused about the instructions and administered EPO 10,000 U/day. He subsequently missed two follow-up appointments prior to presentation. Physical examination was remarkable for plethoric facies, a BP of 128/57 mmHg with a pulse of 113/min, a diffusely tender abdomen, blackened toes bilaterally with decreased pulses and pitting edema. The patient was oriented, but slightly confused. Laboratory studies were remarkable for a hematocrit of 72.3%, a BUN of 47 mg/dL and a creatinine of 2.9 mg/dL. The patient was treated with intravenous fluids and underwent emergent erythropheresis. During hospitalization the patient underwent phlebotomy as needed to maintain his hematocrit below 55%. Pain control was given and he recovered without complication. No specific cause for his abdominal pain was ever established although low-grade mesenteric ischemia was considered. His toes improved although some skin loss occurred. Conclusions: Excessive dosing of erythropoietin can cause thrombosis from hyperviscosity. Although EPO abuse is allegedly responsible for several deaths in athletes, these events are poorly documented. Close monitoring usually prevents significant unintentional overdose. This patient's medication error resulted from confusion about the use of two outpatient parenteral medications. Emergent erythropheresis was used successfully to rapidly reduce his hematocrit. As outpatient use of parenteral medications increase, physicians and pharmacists need to assure that appropriate patient education is provided., Zelman G, Howland MA, Nelson LS, Hoffman RS. New York University Medical Center, New York City Poison Control Center, New York, [...]

Background: Since a massive nerve agent attack may rapidly deplete in-date supplies of atropine, we considered using atropine beyond its labeled shelf life. The following study was designed to assess atropine stability after labeled expiration. Methods: Four atropine solutions (400 [micro]g/mL) (Elkins-Sinn, Inc [n = 3] and American Pharmaceutical Partners, Inc [n = 1]) were stored in a dark, temperature controlled setting according to manufacturers' recommendations. At the time of sampling, these solutions ranged from in-date to 12 years beyond expiration (exp). Standards of atropine sulfate and tropine were prepared and quantified by GC/MS. Study samples were prepared by adding an ammonia buffer to 250 [micro]L of each sample to obtain a pH of 9.5, extracting with a methylene chloride and isopropanol mixture (9:1 ratio), followed by evaporating the organic layer to dryness. Pentafluoropropionic anhydride and pentafluoropropanol were then added as derivatization reagents and the mixture was heated for 20 minutes at 92[degrees] centigrade. The samples were again evaporated and then reconstituted in 100 [micro]L of ethyl acetate for injection into the GC-MS. An additional LC-MS was performed on the oldest sample. Results: All solutions were clear and colorless. Atropine sulfate breakdown products include tropine and tropic acid. Insignificant amounts of these compounds were present in all samples. Atropine concentrations (in [micro]g/mL) were as follows: in-date, 295; 2001 exp, 324; 1999 exp, 342; 1990 exp, 404. Conclusion: The presence of high concentrations of atropine in clear and colorless expired solutions, coupled with the absence of breakdown products suggests their potential utility in times of emergency since dosing is determined by clinical response. Variability in samples may relate to variability in the manufacturing process., Schier JG, Mehta R, Mercurio-Zappala M, Nelson LS, Howland MA, Hoffman RS. NYC Poison Control Center/Department of Health. New York, [...]

Background: Desiccant packets are widely used within consumer products' packaging to maintain a suitable humidity during storage. Desiccant packets in the United States typically contain non-toxic products such as silica gel. Approximately 1.8% of calls to our poison control center in 2001 were in regard to human desiccant exposures of which only minor outcomes occurred. These included the following: vomiting (1), cough/choke (2), abdominal pain (1), oral irritation (1) and mechanical throat irritation (1). We present a case of a toddler who ingested the contents of a desiccant packet and suffered a caustic injury. Case Report: A 2-year-old male presented to the ED after ingesting the contents of a desiccant packet found in a box of imported Chinese cookies. The child was initially given water by his parents, which he swallowed but then vomited. He presented to the ED with a history of vomiting, drooling and foaming at the mouth. Physical exam in the ED revealed an erythematous tongue and posterior oropharynx. The child's vocal cords and proximal trachea were examined by nasopharyngoscopy and found to be atraumatic. The child was admitted to the hospital with the intention of having upper gastrointestinal endosocopy performed the following day. Over the next 12 hours, the patient began tolerating oral intake. For this reason, endoscopy was not performed and the patient was discharged home following an additional day of observation. The packet itself had both English and Chinese words on it and stated 'DO NOT EAT' and that its main ingredient was 'CAUSTIC LIME.' The pH of the packet' s content was 11. Conclusion: Desiccant packets from other countries may contain toxic ingredients such as strong alkali. A thorough inquiry into the nature of the product and the history of the exposure should always be obtained., Schier JG, Hoffman RS, Nelson LS. NYC PCC/Bellevue Hospital Center. New York, [...]

Background: Body-packers, patients who smuggle contraband in their gastrointestinal tract, are usually treated with whole bowel irrigation (WBI) to promote the passage of packets. We report the safe addition of the promotility agents erythromycin and metoclopramide to WBI in the treatment of two body-packers. Case Series: Patient 1-A 36 year-old female who confessed to body-packing heroin presented for medical clearance. She had no somatic complaints, and her physical examination was unremarkable. An upper GI series (UGIS) revealed one remaining packet in the stomach. She was treated with WBI for 18 hours, and a repeat UGIS indicated that the packet remained in the stomach. She was treated with metoclopromide 10 mg IV, and 8 hours later with a second dose of metoclopromide 10 mg IV and one dose of erythromycin 250 mg IV. 8 hours after the second dose of medication she passed the packet per rectum, just prior to a planned endoscopic removal. Patient 2-A 41 year-old male in custody for suspicion of body-packing heroin presented for medical clearance. He denied body-packing or any somatic complaints. His physical examination was unremarkable. Plain abdominal radiography confirmed the presence of multiple packets. He was treated with WBI, erythromycin, and metoclopromide, and passed a total of 85 packets per rectum over the next 36 hours. Conclusion: In two body-packers, the promotility agents erythromycin and metoclopramide were used safely. In one case, the use of these agents appeared to result in the passage of a single packet that had not progressed after 18 hours and extensive WBI. We believe that the use of promotility agents in the treatment of body-packers deserves further consideration., Traub S J, Su M, Hoffman RS, Nelson LS. NYC Poison Control Center, New York, [...]

Background: Cardioactive steroid poisoning is rarely associated with the use of herbal preparations. Identification of the specific compound is difficult due to the large number of potential agents and limitations of the analytic technique. We describe such a case and the subsequent analytic investigation. Case Report: A 36-year-old woman with no medical history and taking no conventional medication ingested an herbal preparation marketed for 'internal cleansing.' Its ingredients were neither known to the patient nor listed on the accompanying literature. The next morning she developed nausea, vomiting and weakness. In the ED, her pulse was 30/min and BP 110/60 mmHg. Her ECG revealed a junctional rhythm at a rate of 30/min with 'digitalis effect.' After empiric therapy with 10 vials of digoxin-specific Fab, her symptoms resolved and she reverted to a sinus rhythm at a rate of 68/min. Her serum digoxin concentration measured by fluorescence polarization immunoassay (FPIA; Abbott TDx[R]) was 1.7 ng/mL. Further serum analysis by the Tina Quant (Roche[R]) digoxin assay, a more digoxin-specific turbidimetric immunoassay, found a concentration of 0.34 ng/mL and an enzyme immunoassay for digitoxin revealed a concentration of 20 ng/mL (therapeutic 1030 ng/mL). Serum HPLC analysis revealed the presence of active digitoxin metabolites; the parent compound was not present. Conclusion: An empiric dose of 10 vials of digoxin-specific Fab should be given initially in patients poisoned by an unknown cardioactive steroid and then re-evaluate to determine if further administration is needed. Though the diagnosis should be suspected clinically, laboratory analysis involving immunoassays of varying specificity can confirm the presence of cardioactive steroids and perhaps assist with identification., Barrueto F Jr., Jortani SA, Valdes R Jr., Hoffman RS, Nelson LS. New York City Poison Control Center, New York, [...]

Objective: Ferric chloride (Fe[Cl.sub.3]) is used to qualitatively test the urine of patients with presumed salicylate exposure. Fe[Cl.sub.3] testing of an unidentified poison might provide confirmation of salicylate exposure in [...]

Objective: Levo-alpha acetyl methadol (LAAM) is a very long-acting opioid agonist used as an alternative to methadone maintenance therapy for opioid addiction because of its superior dosing profile. LAAM is [...]

Objective: Describe the pharmacology, clinical presentation, assessment and treatment of patients exposed to non-pharmacologic cardioactive steroids. Methods: A review of basic research, clinical material, and original research performed by the [...]

Background: 'Chasing the dragon' involves heating heroin on aluminum foil and inhaling the pyrolysate. It is increasingly popular among heroin users as a means to avoid the risks associated with drug injection. Unique to chasing the dragon is the development of a rare neurologic disorder due to a progressive spongiform leukoencephalopathy. Case Report: A 43 year old woman with a history of polysubstance abuse presented with two weeks of bizarre behavior. Her initial evaluation was significant only for a urine toxicology positive for heroin. During her first three days of hospitalization she developed choreoathetoid movements of her upper extremities and restlessness of her legs, her speech deteriorated to a soft mumble (pseudobulbar speech) and she exhibited apathy, memory loss and a paucity of movement. A noncontrast head CT and cerebrospinal fluid (CSF) analysis were normal. On day 5 the patient exhibited spontaneous decerebrate-like posturing and a decreased level of consciousness. A repeat noncontrast head CT revealed diffuse and extensive white matter hypoattenuation. She developed persistent fever of 104-106[degrees]F; multiple blood and urine cultures were negative. The diagnosis of heroin pyrolysate-induced leukoencephalopathy (HIL) was considered and she was empirically treated with coenzyme Q. The family confirmed that 'she did inhale heroin after heating it over aluminum foil with a flame.' The patient expired on day 10. Post mortem findings included a slight softening of the white matter, spongiform degeneration of the white matter, and vacuolation of myelin sheaths and scattered axonal bodies. These findings are considered diagnostic of HIL. Conclusion: The diagnosis of HIL should be considered in a patient with a history of 'chasing the dragon', neurobehavioral changes including confusion, apathy, cerebellar signs, and motor restlessness, and characteristic radiographic findings., Long H, Deore K, Hoffman RS, Nelson LS. New York City Poison Control Center, NY, [...]

Objective: Since many hospitals must send samples for EG out to a reference laboratory, delays in diagnosis and treatment may occur. A qualitative colorimetric test [Ethylene Glycol Test Kit (EGT)], already in use by veterinarians, gives results in 30minutes with little expertise or cost. We sought to determine if the test detects EG, its metabolite glycolic acid (GA), or other alcohols in human plasma. Methods: EG was added to human fresh frozen plasma to yield EG concentrations of 1, 10, and 100 mg/dL. GA was added to separate vials at concentrations of 1, 10, 50, 100 and 500 mg/dL. A control vial with no EG was included. To other vials the following compounds were added to yield a concentration of 100 mg/dL: propylene glycol (PG), ethylene glycol butyl ether (EGBE), ethanol, methanol, and isopropanol (ISOH). The EGT kit was used according to the manufacturer's instructions and includes an internal control. Two blinded study groups, medical toxicologists (n = 3) and EM residents (n = 11)--assessed vials for color change. Inter-rater reliability was assessed with a kappa statistic with a p < 0.05 considered significant. Results: Complete agreement among all observers was obtained on the following: EG at all concentrations: positive; all controls: negative; PG: positive; methanol and ethanol: negative; GA: positive except at a concentration of 1 mg/dL which was negative. Discordant results were obtained for EGBE and ISOH. Overall inter-observer agreement was high, with kappa = 0.87 for the toxicologists and 0.708 for the EM physicians (P < 0.001 for both). Conclusions: The EGT reliably detected the presence of EG at all tested concentrations in human plasma. False positive findings will occur with PG and possibly ISOH and EGBE. The additional ability to detect glycolic acid at clinically relevant concentrations offers a unique advantage over standard testing. Prospective study in patients with suspected EG poisoning is warranted., Long H, Nelson LS, Hoffman RS. New York City Poison Control Center, NY, [...]

Background: Topiramate is a relatively new anticonvulsant. Although metabolic and ocular toxicity are reported with chronic use, there are little data regarding acute toxicity. We report a case of neurological changes in a young girl after isolated topiramate ingestion. Case report: Shortly after returning home from school, a previously healthy 5-year-old girl began acting strangely. She took a nap, and awoke 3 hours later screaming that she 'couldn't feel anything'. Her mother noted 'arching movements' of the child's back. The mother took topiramate for seizures, and the daughter admitted to ingesting some of this medication. On arrival to the hospital, vital signs were: pulse, 96/minute; blood pressure, 116/73mm Hg; respiratory rate, 20/minute; temperature, 99.0 [degrees] F. The patient was alert and oriented. Mild lateral nystagmus was noted. She perseverated in response to simple questioning, giving correct answers but repeating these answers five or ten times in quick succession. She also demonstrated repetitive mouthing movements. The remainder of the physical examination was normal. Routine blood testing, urine toxicology testing for drugs of abuse, and non-contrast computerized tomography of the head were all unremarkable. Electroencephalographic studies were also within normal limits. A serum topiramate level was 10.5 mcg/ml, confirming ingestion. The patient was admitted for observation, and recovered uneventfully. Conclusion: Topiramate ingestion appears to have produced neurological changes in a 5-year-old girl. Physicians should be aware that neurological changes may be part of the toxicity associated with acute topiramate ingestion., Traub SJ (1), Howland MA (1,2), Hoffman RS (1), Nelson LS (1). (1)New York City Poison Control Center, New York and (2)St. John's University College of Pharmacy, Queens, [...]

Background: Ketamine causes relaxation of bronchial smooth muscles and is used to treat bronchospasm in asthmatic patients who require mechanical ventilation. It increases heart rate, blood pressure, and cardiac output with a resultant increase in myocardial oxygen consumption. Ketamine is considered to have a wide margin of safety, with no adverse outcomes reported even in the setting of profound overdose. We report a death directly attributed to iatrogenic ketamine overdose. Case Report: A 69 year old woman with a history of hypertension and asthma presented with shortness of breath. She was treated for asthma exacerbation with standard therapy, including albuterol and methylprednisolone, with little improvement. Prior to intubation the patient was administered midazolam and ketamine. Within minutes, the patient developed cardiopulmonary arrest and died. It was subsequently discovered that the patient was given 500 mg of ketamine IV instead of the intended dose of 50 mg IV (recommended dose is 1-2 mg/kg). Post-mortem examination revealed 75% stenosis of the left anterior descending coronary artery and hypertensive heart disease. Cause of death was attributed to coronary artery disease exacerbated by ketamine overdose. Conclusion: Although ketamine overdose is not generally life-threatening, serious outcomes may occur, particularly in patients with underlying heart disease. This case also highlights the need for continuing efforts to prevent medication dosing errors., Long H, Nelson LS, Hoffman RS. New York City Poison Control Center, NY, [...]

Background: After the events of September 11, increased border security in the United States has had many effects, one of which is to increase the amount of drugs confiscated at US border crossings. As a result, drug traffickers may be under pressure to use any means possible to deliver their product to the US, including the utilization of children. In conjunction with this hypothesis, we report a 12-year-old body-packer, the youngest such patient ever described. Case Report: A 12-year-old presented to the Emergency Department complaining of rectal bleeding. He had recently arrived in the US from Europe, and had passed through airport security without incident. In the ED he admitted to body-packing 87 packets of heroin, and stated that he had passed several packets before presentation. He had no other somatic complaints. His vital signs were normal. His mental status was normal, and pupils were midrange and reactive. Abdominal examination revealed normal bowel sounds. Abdominal radiography demonstrated multiple foreign bodies, consistent with drug packets. He was treated with whole bowel irrigation and activated charcoal, and ultimately passed the remaining 84 bags of heroin. Barium-enhanced radiography and colonoscopy after the passage of these packets confirmed an empty gastrointestinal tract. The patient was discharged to the custody of law enforcement officials. Conclusion: An increase in airport security after the events of September 11 in the US has led to greater confiscation of smuggled drugs, and smugglers may try previously unutilized and underutilized means to deliver their product to the United States. We report a 12-year-old body-packer, the youngest such patient ever reported, and urge physicians to be aware that body-packing is not confined to the adult population., Traub SJ, Hoffman RS, Nelson LS. New York City Poison Control Center, NY, [...]

Background: Levetiracetam (Keppra[R]), a new anticonvulsant used to treat partial complex seizures, is also being investigated for its mood-stabilizing properties. Although its precise mechanism of action is unknown, levetiracetam does not appear to directly interact with the GABA system. We report the first intentional overdose with levetiracetam including clinical effects and serial serum concentrations. Case report: A 38-year-old woman ingested 60 (500 mg) tablets of levetiracetam that she used as a mood-stabilizing medication for bipolar disorder. She had no other prescription medications available and no other medical history. She vomited four hours after ingestion and presented to the ED two hours later. In the ED, she was obtunded and had diminished deep tendon reflexes. Her presenting vital signs were: BP 105/66 mmHg; P 66/min; R 10/min; T 97.8[degrees]F; [O.sub.2] sat of 70% on 100% [O.sub.2]. She was intubated both for ventilatory assistance and protection of her airway. Orogastric lavage was performed and activated charcoal (50 grams) was administered. A comprehensive urine drug screen was negative as were serum ethanol, lithium, carbamazepine, phenytoin and valproic acid levels. Her levetiracetam serum concentration was 400 [micro]g/mL at 6 hrs, 72 [micro]g/mL at 18 hrs and 60 [micro]g/mL at 20.5 hrs. The steady state therapeutic serum concentration after daily ingestion of 3000 mg is 10-37 [micro]g/mL. Peak levels 1.5 hours after a therapeutic dose are 10-60 [micro]g/mL. She was extubated the next hospital day and recovered without sequelae. Conclusion: In overdose, levetiracetam is sedating and causes respiratory depression. This patient recovered rapidly with supportive care., Barrueto F Jr., Williams K, Howland MA, Hoffman RS, Nelson LS. New York City Poison Control Center, New York, [...]

Case Report: A 63 year old non-English speaking Haitian woman with non-bloody diarrhea and no other constitutional signs or symptoms presented to her health care provider who supplied her with [...]

Objective: Traditional remedies are routinely used both for health maintenance and the treatment of illness. Many of these compounds contain agents that are undisclosed and potentially toxic. We report a [...]