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We report a case of Western Gaboon viper (Bitis rhinoceros) envenomation in which the patient's symptoms progressed despite treatment with North American crotalid antivenom but improved after receiving South African Institute for Medical Research (SAIMR) polyvalent antivenom. A 59-year-old man was hospitalized after reportedly being bitten by a Gaboon viper (Bitis gabonica). On arrival, he had normal vital signs, two puncture wounds on his left hand, and edema distal to the wrist. The hospital contacted the local poison center who conveyed that crotalid antivenom would be ineffective and recommended transfer to a snakebite center for species-appropriate antivenom. However, this recommendation was disregarded. Initial laboratory tests 2 hours after envenomation revealed a platelet count of 77 x 10 9 /L; other parameters were normal. He received six vials of crotalid antivenom (CroFab®) followed by three maintenance doses (total 12 vials). The next morning, swelling had progressed proximal to the elbow and platelets decreased to 37 x 10 9 /L. He was subsequently transferred and received SAIMR polyvalent antivenom. Six hours later, his platelets were 130 x 10 9 /L. The next morning, his swelling had significantly improved. He was discharged the following day. After discharge, it was discovered that the snake was a Bitis rhinoceros. Bitis gabonica and Bitis rhinoceros are popular captive snakes in the United States. Bitis rhinoceros was formerly a sub-species of B. gabonica, and they are often referred to interchangeably. Their venoms cause tissue edema, coagulopathy, and in severe cases, hemorrhage, dysrhythmias, and death. Antivenom is not widely available in the United States often necessitating patient transfer or antivenom delivery. This case addresses the question of whether crotalid antivenom, which is ubiquitous in the United States, can treat B. gabonica and B. rhinoceros envenomations and highlights the need for consultation with a poison center to facilitate administration of species-appropriate antivenom., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Case Report: A 12-month-old (former 24 week gestational age), 8.7 kg male was hospitalized after an uneventful colostomy reversal. In the postoperative unit, the patient unintentionally received 1000 mg IV (114.9 mg/kg) acetaminophen instead of the intended 100 mg IV. Serial acetaminophen concentrations were drawn. The patient received IV Nacetylcysteine and ultimately had no adverse outcomes., Discussion: This case report adds to the existing literature regarding toxicokinetics of IV APAP in infants. Our patient had a calculated ke of 0.263 h-1, correlating with a half-life of 2.63 hours. Based on current available data, the half-life of IV APAP in infants varies (2.6 to 4.9 hours). The reason for this variation is unknown and further research is needed in this area.

Purpose of Review: Kratom (mitragynine) is a commercially available herbal supplement that is gaining popularity in the United States. Kratom is associated with a variety of neurologic effects. This review will discuss kratom's association with seizure through 3 cases and highlight what neurologists should know about kratom's clinical effects and legal status., Recent Findings: Kratom is currently commercially available, unscheduled by the US Drug Enforcement Administration, and a topic of regulatory debate in the United States. Large poison center reviews have suggested that kratom use is associated with seizure. There have been limited case studies to corroborate this finding. We present 3 cases in which seizures were associated with kratom use in patients treated for epilepsy., Summary: Since 2008, kratom use is rising in prevalence in the United States aided by lack of regulation. Neurologists need to be aware of its association with seizure and other neurologic side effects., (© 2020 American Academy of Neurology.)

Background: Prepacked naloxone kits (PNKs) are frequently used to reverse opioid intoxication. It is unknown if the presence of illicitly manufactured fentanyl and its analogs (IMFs) in heroin supply is affecting the PNK doses given by laypersons. We investigated the trend of PNK dose administered to reverse opioid toxicity in suspected/undifferentiated opioid intoxication. Methods: We retrospectively reviewed PNK administrations reported to the Maryland Poison Center between 1 January 2015 and 15 October 2017. Primary outcome was the mean PNK dose administered to reverse opioid-induced central nervous system and ventilatory depression. Secondary outcomes included the reversal rate of opioid toxicity, patient disposition, and survival rate. Results: Our analysis involved 1139 PNK administrations. The mean age of subjects was 34.3 years; 68.8% ( n  = 781) were male. Ventilatory depression was present in 98.2% ( n  = 958) of cases, and 97% ( n  = 1097) were unresponsive. Law enforcement administered the majority of PNK (91.0%; n  = 1035); the primary route was intranasal (97.9%; n  = 1051). Toxicity was reversed in 79.2% ( n  = 886) of overdose victims after a mean PNK dose of 3.12 mg. EMS personnel gave 291 subjects additional naloxone (mean: 2.2 mg), reversing opioid toxicity in 94.2% ( n  = 254). Between 2015 and 2017, the mean PNK dose increased from 2.12 to 3.63 mg ( p  < .0001) while the reversal rate decreased from 82.1% to 76.4% ( p  = .04). One hundred and eighty-two patients (15.9%) refused transport; of those transported to a hospital, 73.4% ( n  = 569) were treated and released and 12.4% ( n  = 96) required hospitalization. Ninety-six percent ( n  = 1092) of the subjects survived. Forty subjects were pronounced dead at the scene. Fentanyl or its analog was detected in 36 of 55 opioid-related deaths (65.5%). Conclusions: PNK administration reversed toxicity in the majority of patients with undifferentiated opioid intoxication. Between 2015 and 2017, increasing doses of PNK were administered but the reversal rate decreased. These trends are likely multifactorial, including increasing availability of IMFs.