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Despite conflicting data, intravenous lipid emulsion has emerged as a potential antidote. The "lipid sink" theory suggests that following intravenous administration of lipid, lipophilic drugs are sequestered in the vascular compartment, thereby reducing their tissue concentrations. This study sought to determine if survival is associated with the intoxicant's degree of lipophilicity. We reviewed all cases in the Toxicology Investigators Consortium's lipid sub-registry between May 2012 through December 2018. Information collected included demographics, exposure circumstances, clinical course, management, disposition, and outcome. The primary outcome was survival after lipid emulsion therapy. Survival was stratified by the log of the intoxicant's octanol-water partition coefficient. We also assessed the association between intoxicant lipophilicity and an increase in systolic blood pressure after lipid emulsion administration. We identified 134 patients, including 81 (60.4%) females. The median age was 40 years (interquartile range 21-75). One hundred and eight (80.6%) patients survived, including 45 (33.6%) with cardiac arrest during their intoxication. Eighty-two (61.2%) were hypotensive, and 98 (73.1%) received mechanical ventilation. There was no relationship between survival and the log of the partition coefficient of the intoxicant on linear analysis (P = 0.89) or polynomial model (P = 0.10). Systolic blood pressure increased in both groups. The median (interquartile range) systolic blood pressure before lipid administration was 68 (60-78) mmHg for those intoxicants with a log partition coefficient < 3.6 compared with 89 (76-104) mmHg after lipid administration. Among those drugs with a log partition coefficient > 3.6, the median (interquartile range) was 69 (60-84) mmHg before lipid and 89 (80-96) mmHg after lipid administration. Most patients in this cohort survived. Lipophilicity was not correlated with survival or the observed changes in blood pressure. The study did not address the efficacy of lipid emulsion. [ABSTRACT FROM AUTHOR]

Buprenorphine in sublingual formulation was recently introduced to the American market for treatment of opioid dependence. We report a series of 5 toddlers with respiratory and mental-status depression after unintentional buprenorphine exposure. Despite buprenorphine&apos;s partial agonist activity and ceiling effect on respiratory depression, all children required hospital admission and either opioid-antagonist therapy or mechanical ventilation. Results of routine urine toxicology screening for opioids were negative in all cases. Confirmatory testing was sent for 1 child and returned with a positive result. The increasing use of buprenorphine as a home-based therapy for opioid addiction in the United States raises public health concerns for the pediatric population. Key Words: buprenorphine, unintentional ingestion, respiratory depression, opioid, pediatric, exploratory behavior Abbreviations: ED, emergency department; CNS, central nervous system, BUPRENORPHINE, ALONE OR in combination with naloxone, has been approved in the United States for the treatment of opioid addiction. Unlike traditional methadone-maintenance therapy, buprenorphine is prescribed for outpatient administration [...]

Dear Editor, In this retrospective IRB-approved case series, we describe two acetaminophen (APAP) toxic patients reported to a regional poison center who manifested arterial acidemia after fluid resuscitation, a marker for poor prognosis (likely death without liver transplantation). Initial laboratory values included APAP concentration 298 mg/L, AST 245 IU/L, ALT 366 IU/L, undetectable ethanol and salicylate. Fomepizole pretreatment in human supratherapeutic acetaminophen ingestions decreased toxic oxidative urinary acetaminophen metabolites [[4]]. [Extracted from the article]

Acute-onset hearing loss of unknown cause may be the result of a tranverse temporal bone fracture. CT imaging is indicated for patients with acute focal neurologic deficits of uncertain cause. [ABSTRACT FROM AUTHOR]

Our interest in fomepizole as an adjunct therapy for severe acetaminophen toxicity is grounded in preclinical investigations and initial human reports. We also feel strongly that fomepizole warrants further prospective study, stated such in our conclusion, and only recommend fomepizole in very limited cases of severe acetaminophen toxicity, such as our three patients, all of which had biomarkers suggesting increased risk for death without liver transplantation. However, in a situation where significant morbidity and mortality to the patient are at stake, repurposing of an already approved drug with preliminary evidence base and appropriate risk-benefit profile is indeed ethical and encouraged by the United States Food and Drug Administration (FDA). [Extracted from the article]

Introduction: While the opioid crisis has claimed the lives of nearly 500,000 in the U.S. over the past two decades, and pediatric cases of opioid intoxications are increasing, only sparse data exist regarding risk factors for severe outcome in children following an opioid intoxication. We explore predictors of severe outcome (i.e., intensive care unit [ICU] admission or in-hospital death) in children who presented to the Emergency Department with an opioid intoxication., Methods: In this prospective cohort study we collected data on all children (0-18 years) who presented with an opioid intoxication to the 50 medical centers in the US and two international centers affiliated with the Toxicology Investigators Consortium (ToxIC) of the American College of Medical Toxicology, from August 2017 through June 2020, and who received a bedside consultation by a medical toxicologist. We collected relevant demographic, clinical, management, disposition, and outcome data, and we conducted a multivariable logistic regression analysis to explore predictors of severe outcome. The primary outcome was a composite severe outcome endpoint, defined as ICU admission or in-hospital death. Covariates included sociodemographic, exposure and clinical characteristics., Results: Of the 165 (87 females, 52.7%) children with an opioid intoxication, 89 (53.9%) were admitted to ICU or died during hospitalization, and 76 did not meet these criteria. Seventy-four (44.8%) children were exposed to opioids prescribed to family members. Fentanyl exposure (adjusted OR [aOR] = 3.6, 95% CI: 1.0-11.6; p  = 0.03) and age ≥10 years (aOR = 2.5, 95% CI: 1.2-4.8; p  = 0.01) were independent predictors of severe outcome., Conclusions: Children with an opioid toxicity that have been exposed to fentanyl and those aged ≥10 years had 3.6 and 2.5 higher odds of ICU admission or death, respectively, than those without these characteristics. Prevention efforts should target these risk factors to mitigate poor outcomes in children with an opioid intoxication.

Acute-onset hearing loss of unknown cause may be the result of a tranverse temporal bone fracture. CT imaging is indicated for patients with acute focal neurologic deficits of uncertain cause.