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Metformin overdose may result in vasodilatory shock, lactic acidosis and death. Hemodialysis is an effective means of extracorporeal elimination, but may be insufficient in the shock setting. We present a case of a 39 yo male who presented with hypotension, coma, hypoglycemia, and lactate of 6.5 mmol/L after ingesting an unknown medication. Metformin overdose was suspected, and he was started on hemodialysis. He developed profound vasoplegia refractory to high doses of norepinephrine, vasopressin, epinephrine and phenylephrine. Venoarterial extracorporeal membrane oxygenation (VA ECMO) was initiated and he had full recovery. Serum analysis with high resolution liquid chromatography mass spectrometry revealed a metformin level of 678 μg/mL and trazodone level of 2.1 μg/mL. This case is one of only a handful of reported cases of metformin overdose requiring ECMO support, and we report the highest serum metformin levels in the literature to date. We recommend early aggressive hemodialysis and vasopressor support in all suspected cases of metformin toxicity as well as VA ECMO if refractory to these therapies.ObjectiveWe present a case of vasodilatory shock secondary to metformin overdose requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) support. This case is one of only a handful of reported cases of metformin overdose requiring ECMO support, and we report the highest serum metformin levels in the literature to date.Data sourcesUniversity of San Francisco, Fresno.Study designCase report.Data extractionClinical records and high resolution liquid chromatography mass spectroscopy analysis.Data synthesisNone.ConclusionsVenoarterial ECMO provided an effective means of hemodynamic support for a patient with severe metformin toxicity.

Deaths associated with the party drug, 3,4-methylenedioxymethamphetamine (MDMA), over the 20-year period from 2000 to 2019 in San Francisco are presented to identify shifting demographic trends. Of the 148 cases, 129 (87.2%) were male with mean and median ages of 30 and 28 years, respectively. The most common manner of death (MOD) in males was homicide (65 of 129) and accident (49 of 129). The most common MOD in females was accident (15 of 19). Regarding racial demographics, Black homicide deaths accounted for 59 of 67 (88.1%) total homicides. The most prevalent cause of death for homicides was gunshot wounds (63 of 67, 94.0%). Homicide prevalence was high in the first decade of the study (53 of 88, 60.2%), sharply dropping off after 2011. White accidental deaths made up most of the accidental deaths (45 of 64, 70.3%). Since 2015, accidental deaths with MDMA began to rise (40 of 60, 66.7%)—most with other coingestants. Similar MDMA concentrations (median, mean ± SD) were observed between homicide (290, 450 ± 490 ng/mL) and accidental (250, 680 ± 1,120 ng/mL) deaths. MDMA concentrations were elevated in central blood compared to peripheral blood from unmatched cases. MDMA was detected in a variety of decedents during the two decades within 2000-2019, with primarily young Black male gunshot wound homicide victims in the first decade and primarily young White male accidental polydrug victims in the second decade. This study demonstrates that MDMA is no longer confined to a party setting, but can also be found in different socioeconomic strata, including its association with violent homicidal deaths. [ABSTRACT FROM AUTHOR]

The article presents abstracts on medical topics which include an online poison information web resource, Russell's viper envenomation, and alcohol-related emergency department visits.