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The author discusses the common causes of pediatric poisoning due to ingestion of toxic substances. Nurses are advised on the best methods to deal with individual cases and safety tips are recommended to parents to prevent accidental ingestion.

The young mother heard a cry and ran into the kitchen to find her 18-month-old daughter on the floor next to a spilled container of liquid drain opener. The toddler [...]

Ten-year-old Tim P. presented at a local emergency room complaining of bloody diarrhea. Despite treatment, his diarrhea continued with additional symptoms of nausea, raspy voice, headaches, abdominal pain, tingling of the feet and hands, lethargy, and eczema. Do you recognize the health risks and clinical aspects of arsenic, and could you assist Tim and his family?, Environmental exposure in our children's world to known and unknown toxins is an evolving area of concern and research. Over the past several years the heavy metal arsenic (As) has [...]

We describe a case of a 43-yr-old female with severe multiorgan injury after accidental poisoning with Colchicum autumnale, which was mistaken for wild garlic (Allium ursinum). Both plants grow on damp meadows and can be confused in the spring when both plants have leaves but no blossoms. The autumn crocus contains colchicine, which inhibits cellular division. Treatment consisted of supportive care, antibiotic therapy, and granulocyte-directed growth factor. The patient was discharged from the hospital after three weeks. Three years after recovery from the acute poisoning, the patient continued to complain of muscle weakness and intermittent episodes of hair loss., INTRODUCTION Autumn crocus (Colchicum autumnale) and wild garlic (Allium ursinum), both members of the same subclass (Liliidae), have very similar leaves that can easily be mistaken for each other during [...]

Introduction: The following case report demonstrates the severe consequences of refractory convulsive status epilepticus from an unfamiliar imported toxin, tetramethylenedisulfotetramine (TETS), and the difficulties of identifying the offending agent. Case Report: A previously healthy 15-month-old girl was found by her parents playing with a white rodenticide powder brought from China. Fifteen minutes later, the child developed generalized seizures and was brought to an Emergency Department (ED). Her initial fingerstick blood glucose was 108 mg/dL. In the ED, the child was intubated for status epilepticus. Despite aggressive therapy with lorazepam, phenobarbital, and pyridoxine, she had 4 h of intermittent generalized seizure activity. She was extubated on the third hospital day, but appeared to have absence seizures and cortical blindness. Continuous electroencephalogram monitoring, performed weeks later, revealed severe diffuse cerebral dysfunction with multiple epileptogenic foci. The child remains developmentally delayed and is on valproic acid therapy for seizure control. Translation of the Chinese package labeling did not clarify its contents. Tetramethylenedisulfotetramine was finally confirmed by gas chromatography-mass spectrometry (GC-MS) in this rodenticide product and then quantified against a TETS standard that was synthesized in our laboratory. Conclusion: Tetramethylenedisulfotetramine is grouped with other 'cage convulsants,' such as picrotoxin, since they have a similar intercalating cyclical molecular structure and cause seizures through non-competitive [gamma]-aminobutyric acid (GABA) antagonism. The oral lethal dose 50% (LD50) in humans is estimated to be as low as 100 [micro]g/kg. Our patient has severe diffuse cerebral dysfunction likely secondary to prolonged seizure activity after exposure to TETS. Key Words: Cage convulsant; Tetramine; Seizures; Status epilepticus., INTRODUCTION Seizures are caused by a multitude of toxins although few have a propensity to cause status epilepticus. Most patients with status epilepticus present with brief episodes of convulsions intermixed [...]

GUIDELINE SUMMARY All substances are capable of producing toxicity, so nothing is completely non-toxic. Minimally toxic substances are those which produce little toxicity, minor self-limited toxicity, or clinically insignificant effects at most doses. Examples include silica gel, A&D ointment, chalk, lipstick, and non-camphor lip balms, watercolors, hand dishwashing detergents, non-salicylate antacids (excluding magnesium or sodium bicarbonate containing products), calamine lotion, clay, crayons, diaper rash creams and ointments, fabric softeners/sheets, glow products, glue (white, arts, and crafts type), household plant food, oral contraceptives, pen ink, pencils, starch/sizing, throat lozenges without local anesthetics, topical antibiotics, topical antifungals, topical steroids, topical steroids with antibiotics, and water-based paints. Minimally toxic exposures have the following characteristics: (1) The information specialist has confidence in the accuracy of the history obtained and the ability to communicate effectively with the caller. (2) The information specialist has confidence in the identity of the product(s) or substance(s) and a reasonable estimation of the maximum amount involved in the exposure. (3) The risks of adverse reactions or expected effects are acceptable to both the information specialist and the caller based on available medical literature and clinical experience. (4) The exposure does not require a healthcare referral since the potential effects are benign and self-limited. However, decisions regarding patient disposition should take into account the patient's intent, symptoms, and social environment. In addition, individual patient circumstances (e.g., pregnancy, pre-existing medical conditions, therapeutic interventions) need to be considered. Minimally toxic exposures may vary in route (dermal, inhalation, ingestion, ocular), chronicity (acute, chronic), and substance composition (single or multi-ingredient, single or multiple product). Future categorization of substances as 'minimally toxic' should be based on a process involving review of current knowledge, a thorough analysis of poisoning experience, and prospective validation. Key Words: Poisoning; Triage; Guideline; Minimally toxic substance; Poison center., PREAMBLE This document describes the characteristics of and process for determining a minimally toxic exposure. The primary purpose of this document is to assist poison center directors and information specialist [...]

Background: Skin contact with hydrofluoric acid (HF) may cause serious burns and life-threatening systemic poisoning. The use of hemodialysis in fluoride intoxication after severe dermal exposure to HF has been recommended but not reported. Case report: A 46-year-old previously healthy man had 7% of his body surface exposed to 71% HF. Despite prompt management, with subsequent normalization of the serum electrolytes, recurrent ventricular fibrillation occurred. On clinical suspicion of fluoride-induced cardiotoxicity, acute hemodialysis was performed. The circulatory status stabilized and the patient fully recovered. High fluoride levels in the urine and serum were confirmed by the laboratory. Discussion: There is no ultimate proof that the favorable outcome in this case was significantly attributable to the dialysis. However, most reported exposures of this magnitude have resulted in fatal poisoning. As our patient had normal serum electrolytes and no hypoxia or acidosis at the time of his arrhythmias, it was decided that all efforts should be focused on removing fluoride from his blood. The rationale for performing hemodialysis for this purpose is clear, even though such intervention is more obviously indicated in patients with renal failure. Conclusion: Hemodialysis may be an effective and potentially lifesaving additional treatment for severe exposure to HF when standard management has proven insufficient. Key Words: Dermal exposure; Fluoride intoxication; Hemodialysis; Hydrofluoric acid., INTRODUCTION Hydrofluoric acid (HF) is a highly corrosive inorganic acid that is used widely in the etching and frosting of glass and pickling of metals; in manufacture of graphite and [...]

The temporal association of symptoms consistent with ephedrine toxicity after ingestion of ephedrine-containing dietary supplements is heavily relied upon to confirm exposure. Few reports in the literature attempt to associate toxicity with serum levels of these drags. We report a case of ephedrine-induced cardiac ischemia confirmed by a plasma level. A 22-year-old woman ingesting an ephedrine- and caffeine-containing product for 2 days presented with multiple symptoms, including palpitations, nausea, tremulousness, abdominal pain, and vomiting. The initial electrocardiogram (ECG) revealed a normal sinus rhythm with 1 mm of ST segment depression in leads V3 and V4, along with inverted T waves in leads V1-V4. Her symptoms and ST segment depression resolved over several hours with medical management. The amplitude of her T wave inversions notably diminished with therapy; however, they did not completely resolve. Troponins at presentation and the following morning were negative, and an echocardiogram showed only trace tricuspid regurgitation. A serum ephedrine level, drawn approximately 6 to 7 hr after ingestion, was 150 ng/mL. She was discharged from the hospital after being instructed to avoid ephedrine-containing products. Key Words: Ephedrine; Cardiac; Ischemia., INTRODUCTION Ma huang, an herbal source of ephedrine, is a common ingredient of many dietary supplements sold as stimulants, weight reduction aids, or athletic performance enhancers. It is estimated that [...]

Background. In combination with other traditional Chinese medicines, Breynia officinalis, a species of Euphorbiaceae, has long been used to treat contusions, heart failure, venereal diseases, growth retardation, and conjunctivitis. B. officinalis, regarded as a poison, was mistaken for a similar plant, Securinega suffruticosa, and cooked in a soup used for the treatment of muscle soreness, lumbago, and as a tonic in this outbreak. Case series. Nineteen patients, 11 males and 8 females (average age 49.2 [+ or -] 9.1 years) consumed an average of 130 mL (30-900mL) of soup containing B. officinalis stems. Fourteen patients developed diarrhea, 10 experienced nausea and chilly sensations, 9 had sensations of abdominal fullness, and 7 suffered from vomiting. The results of liver function tests (LFTs) indicated that the observed maximum median level of alanine aminotransferase (ALT) was 647 U/L (range 89-9440 U/L), aspartate aminotransferase (AST) 314 U/L (range 47-7756 U/L), alkaline phosphatase 251 U/L (range 224-278 U/L), and gamma glutamyl transpeptidase 106 U/L (range 84-313 U/L). The median time to the observed median peak levels was 3 days for ALT, 2 days for AST, 5 days for alkaline phosphatase, and 12 days for gamma glutamyl transpeptidase. With supportive treatment, the majority of abnormalities in 14 of the cases resolved within 6 months of exposure. Conclusions. The consumption of a soup containing B. officinalis Hemsley resulted in dose-related toxic effects. Clinical toxicity consisted primarily of gastrointestinal symptoms and signs and hepatotoxicity. Hepatocellular liver injury rather than cholestatic liver injury was observed. Marked jaundice did not develop. Key Words: Breynia officinalis; Hepatotoxicity., INTRODUCTION Breynia officinalis, a species of Euphorbiaceae, carries the Chinese proprietary name 'Chi R Yun,' which means 'dizziness or vertigo for 7 days.' In daily practice, it has been used [...]

Background. Poison Control Centers follow the acetylsalicylic acid (ASA) treatment guideline to manage unintentional ingestions of topical methyl salicylate liniments. For example, one teaspoon of 30% methyl salicylate cream such as Ben Gay[R] provides an 'ASA equivalent dose' of 180 mg/kg for a 10 kg child. The ASA treatment guideline advises emesis with syrup of Ipecac and 24 h home followup for this dose. Both the ASA conversion factor to yield the ASA equivalent dose and the treatment guideline assume 100% bioavailability of the salicylate. The nature of this topical dosage product led the investigators to expect less than complete absorption of methyl salicylate. Objective. To compare plasma concentrations of salicylate from ingested methyl salicylate cream with plasma concentrations of salicylate from ingested oil of wintergreen. Methods. Four adult volunteers consented to an open label, four-way crossover design, with randomization to the following treatments: 1 mL Oil of Wintergreen, U.S.P., 6.7 g of Ben Gay[R] 15% and 20 g of Ben Gay[R] 15% and also to hold 5 g of Ben Gay[R] 15% cream in the buccal cavity for 1 minute and then expectorate. Plasma was collected for salicylate determination, and the results analyzed with a noncompartmental pharmacokinetic model. Results. No plasma salicylate was detected after buccal treatment phase. Relative bioavailability for the low-dose treatment was 0.5 compared to oil of wintergreen. Conclusion. Plasma salicylate concentrations from methyl salicylate cream are not equal to those achieved after ingestion of oil of wintergreen. Dosage formulation must be considered when predicting toxicity. Key Words: Salicylate; Methyl salicylate; Oil of wintergreen; Pharmacokinetics; Bioavailability., INTRODUCTION Methyl salicylate is on the short list of medicines causing pediatric death in small doses (1-3). The high morbidity and mortality is caused by a form of methyl salicylate [...]

Plant poisoning is normally a problem of young children who unintentionally ingest small quantities of toxic plants with little resulting morbidity and few deaths. In some regions of the world, however, plant poisonings are important clinical problems causing much morbidity and mortality. While deaths do occur after unintentional poisoning with plants such as Atractylis gummifera (bird-lime or blue thistle) and Blighia sapida (ackee tree), the majority of deaths globally occur following intentional self-poisoning with plants such as Thevetia peruviana (yellow oleander) and Cerbera manghas (pink-eyed cerbera or sea mango). Antitoxins developed against colchicine and cardiac glycosides would be useful for plant poisonings--anti-digoxin Fab fragments have been shown to be highly effective in T. peruviana poisoning. Unfortunately, their great cost limits their use in the developing world where they would make a major difference in patient management. Therapy for some other plant poisonings might also benefit from the development of antitoxins. However, until issues of cost and supply are worked out, plant antitoxins are going to remain a dream in many of the areas where they are now urgently required., INTRODUCTION Globally, plants are an uncommon cause of significant poisoning. However, unintentional poisoning with plants is common in small children. Surveys of calls to Poison Information Centres in Germany and [...]

Introduction. The home administration of ipecac syrup remains a recommendation in some guidelines for the management of specific pediatric poisonings. A common challenge for poison specialists is how to approach the situation when ipecac syrup is indicated but not kept in the home. This study examines whether or not ipecac syrup can be administered and produce timely emesis in this situation. Methods. Over a 6-month period, a prospective observational study was undertaken to determine if ipecac syrup can be administered in a timely manner when it is indicated but not available in the home. Cases where ipecac syrup was indicated but not kept in the home were included if parents stated that they could obtain ipecac within 15 minutes. Timely administration and the onset of emesis were defined as Key Words: Poisoning; Ipecac, Poison centers; Telemedicine., INTRODUCTION Although its use is decreasing, the home administration of ipecac syrup is still recommended by many poison centers for the management of specific pediatric poisonings (1). A challenge facing [...]

Faced with a child who has been exposed to mercury, would you recognize the signs and symptoms? Would you know what questions to ask, which lab tests to draw, and [...]

Objectives To describe the presentations, characteristics, and follow-up care of children and adolescents aged 10 to 18 years who present to emergency departments (EDs) with acute alcohol intoxication/self-poisoning. Design: Retrospective medical record review. Setting: Five EDs in Western Sydney, Australia. Participants: Patients aged 10 to 18 years who presented to EDs with acute alcohol intoxication/self-poisoning between January 1, 1996, and December 31, 2000. Main Outcome Measures: Frequency of presentations; presentation characteristics; psychosocial characteristics; and presence or absence of follow-up. Results: Two hundred twelve children and adolescents presented to EDs 216 times. Of the 212 patients, 49 (23%) were 14 years or younger, and the youngest was aged 10 years. The majority (82%) came after hours and were brought in by emergency services (77%). In 13% of presentations, verbal and/or physical aggression was present, and a threat of self-harm was present in 2% of cases. A mental health worker was consulted about the child or adolescent in only 6% of presentations. Most children and adolescents (85%) were discharged from the ED. Of concern, in 56% of presentations, a follow-up plan was not recorded. There was documentation of mental health follow-up in only 14% of presentations and follow-up from drug and alcohol services in only 1%. Forensic history, school functioning, and a history of past mental health problems were not documented in more than 60% of the medical records examined. Conclusions: When children or adolescents present to an ED with acute alcohol intoxication/self-poisoning, their risk factors for psychosocial dysfunction appear to be inadequately assessed, documented, and followed up. Clear guidelines for assessment and referral pathways must be established in EDs. Arch Pediatr Adolesc Med. 2002;156:345-348

Background: Chronic arsenic toxicity, producing various clinical manifestations, is currently epidemic in West Bengal, India, Bangladesh, and other regions of the world. 2,3-Dimercapto-1-propanesulfonate, a chelating agent, increases excretion of arsenic in urine to several times the prechelation concentration but the therapeutic efficacy of 2,3-dimercapto-1-propanesulfonate in the management of chronic arsenic toxicity has been incompletely evaluated. We investigated the clinical use of 2,3-dmercapto-1-propanesulfonate in such patients. Methods: Twenty-one consecutive patients with chronic arsenicosis were individually randomized into 2 groups: 11 patients (9 males and 2 females, age 30.63 [+ or -] 11.4 years) received 2,3-dimercapto-1-propanesulfonate 100-mg capsules 4 times a day for 1 week and repeated in the 3rd, 5th, and 7th week with no drug during the intervening period. The other 10 patients (5 males and 5females, age 34.4 [+ or -] 14.41 years) were given placebo capsules (resembling 2,3-dimercapto-1-propanesulfonate) in the same schedule. The consumption of arsenic-contaminated water was terminated by all 21 subjects. Initial and posttreatment urinary arsenic excretion was determined in all cases. Sequential excretion of urinary arsenic was determined during the treatment of 2 drug- and 1 placebo-treated cases. The clinical features were evaluated by an objective scoring system before and after treatment. Routine investigation including liver function test and skin biopsy were also done before and after the treatment. Drug-associated toxicity was tabulated. Results: Therapy with 2,3-dimercapto-1-propanesulfonate caused significant improvement in the clinical condition of chronic arsenicosis patients as evidenced by significant reduction of total clinical scores from 8.90 [+ or -] 2.84 to 3.27 [+ or -] 1.73; p < 0.0001. Exposure cessation alone with placebo treatment also reduced clinical scores (8.50 [+ or -] 1.96 to 5.40 [+ or -] 2.12; p < 0.003), but the posttreatment total clinical score of 2,3-dimercapto-1-propanesulfonate-treated patients (3.27 [+ or -] 1.73) was significant(v lower than that of placebo-treated patients (5.40 [+ or -] 2.12; p < 0.01). The most significant improvement was noted in regard to the clinical scores of weakness, pigmentation, and lung disease. No difference was noted between groups in the hematological and biochemical parameters (which were normal) and skin histology before and after treatment. No 2,3-dimercapto-1-propanesulfimate-related adverse effects were noted. Total urinary excretion of arsenic in 2,3-dimercapto-1-propanesulfonate-treated cases increased significantly following drug therapy, with no increase in placebo-treated cases. Conclusion: 2,3-Dimercapto-1-propanesulfonate treatment caused significant improvement in the clinical score of patients suffering from chronic arsenic toxicity. Increased urinary excretion of arsenic during the period of therapy is the possible cause of this improvement., BACKGROUND Chronic arsenic (As) toxicity due to drinking of As-contaminated water has been reported from many countries, but the number of affected people in West Bengal, India, and Bangladesh is [...]

Background: Thermopsis species have been suspected of causing livestock losses. One human case series of Thermopsis poisoning was located in the literature. We report 23 suspected cases of Thermopsis exposures, some resulting in significant toxicity. Methods: Retrospective chart review of all calls involving 'buffalo beans' received by the Regional Poison Centre from 1990-1995. Results: There was a total of 23 exposures, 21 of which involved children [is less than] 12 years of age. Amounts ingested varied as did the plant part ingested. Eighteen of the patients developed symptoms within a few hours and symptoms lasted up to 12 hours. Symptoms included vomiting (14), dizziness (S), abdominal pain (3), drowsiness (2), nausea (2), headache (1), oral irritation (1), tachycardia (1), tremors (1), and other general signs (3). Of the 23 cases, 15 were managed at home but eight were referred to a health care facility, with two requiring admission. In one of the admissions, laboratory data revealed an elevated creatine kinase which remained elevated for 48 hours. Management was symptomatic and included decontamination, fluids, and observation. Plants were not professionally identified, but were referred to by the name 'buffalo bean' or 'buffalo pea.' However, in some cases, relying on the name 'buffalo bean' lead to misidentification of the plant and possible underestimation of toxicity. Conclusion: Ingestion of Thermopsis can be associated with significant morbidity. Gastric ravage may be of value in large ingestions prior to symptoms but effectiveness of activated charcoal is questionable. Patients should be observed for several hours for symptoms and supportive treatment instituted as required., INTRODUCTION The Thermopsis species have been suspected of causing cattle and horse losses, and the seeds have been thought to be poisonous to children in Western Canada.[1] However, only one [...]

Background: In 1993, the nonbenzodiazepine sedative-hypnotic zolpidem tartrate (Ambien[R]) was approved for use in the US. Zolpidem has an imidazopyridine structure and possesses a rapid onset of action and a short half-life. The toxic threshold and profile have not been well established in the pediatric population. Methods: All pediatric zolpidem exposures reported to a regional poison information center over 24 months were reviewed retrospectively from the American Association of Poison Control Centers Toxic Exposure Surveillance System data collection forms. Results: Twelve pediatric zolpidem exposures were reported. Seven were unintentional (ages 20 mon-5 y) and five were intentional misuse/suicide (ages 12-16 y). The regional poison information center was contacted within 1 h in ten cases with onset of symptoms within 10 to 60 min (mean 31.6 min). One child had no effect with 2.5 mg. As little as 5 mg caused symptoms with minor outcome in six unintentional ingestions (5-30 mg). Minor to moderate symptoms were reported 1-4 h after intentional ingestions (12.5-150 mg). The duration of symptoms in the unintentional cases ranged from less than 60 min up to 4 h (mean 2.4 h) and 6-10 h (mean 7.5 h) in the intentional exposures. Treatment consisted of observation (4), syrup of ipecac (1), lavage and activated charcoal (1), activated charcoal alone (5), and unknown (1). Conclusion: Due to the very rapid onset of central nervous system symptoms in children, emesis is not a treatment option. Supportive care, activated charcoal in large ingestions, and observation until symptoms resolve may be sufficient in most pediatric cases., INTRODUCTION Zolpidem tartrate (Ambien), an imidazopyridine derivative, was introduced in the US in 1993 as a benzodiazepine alternative for the therapeutic treatment of insomnia. The benefits of zolpidem over other [...]

Poisonings require a quick response. In fact, treatment often begins before you can identify the accountable toxin. Fortunately, you can usually save lives just by providing supportive care and general [...]

It appears that certain populations may be appropriate targets to educate about the resources available through poison control hot lines. Interviews were conducted with caretakers of 210 children admitted to the emergency room for accidental poison related injuries. Nearly half of these adults had not contacted the poison control center before going to the emergency room. Black adults and those educated in Mexico were more likely not to call poison control before going to the emergency room. Adults using the poison control center's services exhibited a greater knowledge about poison prevention than those not calling.

INTRODUCTION Methanol and ethylene glycol poisonings are closely related in that both occur because of the metabolism of an alcohol moiety via alcohol dehydrogenase (ADH) to produce the metabolites that [...]

Toxicity from toad venom poisoning is similar to digoxin toxicity and carries a high mortality rate. We report on six previously healthy men who developed vomiting and bradycardia after ingesting [...]

Background: Oral hypoglycemic medications are frequently used for Type II diabetes and accidental ingestions by children may occur. There are no comprehensive pediatric studies documenting poison center experiences. Study Objective: To evaluate the toxicity of oral sulfonylurea ingestion in children and the efficacy of treatments instituted in these cases. Method: Retrospective review of all ingestions of oral sulfonylureas reported to a single regional poison control center 1987-1991. Results: Ninety-three cases were identified, one to 16 years old (mean of 3.5 years). Eighty cases (86%) were less than six years of age. Of the six medications used, three, chlorpropamide, glipizide and glyburide made up 88 (95%) cases. Twenty-five patients (27%) became hypoglycemic (glucose < 60 mg/dL). The mean minimum blood glucose in these patients was 46.5 mg/dL (minimum 20 mg/dL). Time of onset of hypoglycemia ranged from 0.5 to 16 h (mean 4.3 h; median 2 h). Only four patients had the onset of chemical hypoglycemia more than four hours postexposure. Persistent hypoglycemia occurred in nine children (10%) despite intravenous glucose therapy. There were no seizures. Mean time to decontamination of patients with and without hypoglycemia was 1.4 and 1.2 h respectively. Intravenous glucose of the following concentrations was administered: 5% (40), 10% (15), 20% (1), and 50% (3). Accidental ingestion of a single tablet of chlorpropamide (250 mg), glipizide (5 mg), and glyburide (2.5 ma) each produced hypoglycemia in childrenages one to four years. Accidental ingestion of 5-10 mg glyburide produced a blood glucose of 57 mg/dL in an 11-year-old child. All patients recovered fully. There were no neurological sequelae noted. Conclusion: Children ingesting oral hypoglycemics should be admitted to a health care facility for 24 h observation. In this series a single tablet produced hypoglycemia., Correspondence: Debra Quadrani, Western New York Regional Poison Control Center, Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222. Tel: 716/878-7657; Fax: 716/878/7857. INTRODUCTION In 1995, diabetes mellitus is [...]

Metobromuron, a substituted urea herbicide, is widely used for control of grasses and broad-leaved weeds in Taiwan. Major systemic toxicity has not been reported following poisoning. A 22-year-old woman at 36 weeks of gestation was admitted to the emergency department three hours after digestion of a mixture of 25% metobromuron and 25% metolachlor. Though stable initially, she developed central cyanosis 12 hours later. Emergent cesarean section was considered but administration of intravenous methylene blue readily reversed the cyanosis and prevented the operation. Recurrent cyanosis did not develop. Normal vaginal delivery occurred 17 days after the poisoning. Follow-up for four years revealed normal growth of the child. Metobromuron poisoning, like other urea herbicides, may cause methemoglobinemia via its hydrolysis products. Administration of methylene blue is effective treatment and should be considered in the treatment of methemoglobinemia following urea herbicide poisoning., (Key Words: metobromuron: diuron: methemoelobinemia; methylene blue; metolachlor: pregnancy.) INTRODUCTION Metobromuron, a substituted urea herbicide, is effective against grasses and broad-leaved weeds. Though widely used, its effects in humans are [...]

For many physicians an antidote is an antidote. According to the International Programme on Chemical Safety definition, an antidote is a therapeutic substance used to counteract the toxic action(s) of a specified xenobiolic. Given this wide definition, the efficacy of an antidote may vary considerably depending on which toxic action(s) being counteracted and the level of counteracting power. An almost 100% efficacy is seen using specific antagonists, such as naloxone in opiate poisoning or flumazenil in benzodiazepine poisoning, e.g. resulting in complete reversal of opiate toxicity unless complications, such as anoxic brain damage, have developed. At the other end of the efficacy scale, we may place chelating agents for heavy metal poisoning and diazepam for organophosphorus insecticide poisoning which are considered only to be an adjuncts to supportive care. When teaching clinical toxicology or recommending the use of antidotes in poisoned patients, the expected efficacy level of the antidote in question should be stressed. This may be particularly important in severe poisonings when the antidote may only be considered as an important adjunct to supportive care, e.g. deferoxamine in acute iron poisoning. Unless this is stressed, the unexperienced physician may rely too much on the antidote and pay insufficient attention to the supportive care. The varying efficacy levels will be discussed based on the presently ongoing International Programme on Chemical Safety/Commission of the European Communities evaluation program on antidotes., INTRODUCTION Antidotes may play an important role in the treatment of poisoning. While good supportive care and elimination techniques may, in many cases, restore a poisoned patient to good health [...]

A 24-year-old man presented to the emergency department with nausea, vomiting, abdominal pain, and an acute confusional state of 6 hours' duration. Ten hours before admission, he had ingested a mixture of orange juice and six ground leaves, later identified as Nerium oleander (common pink oleander) leaves. His blood pressure was 100/80 mm Hg, and his pulse rate was irregular at 40/min. He was disoriented and his speech was dysarthric. Twelve-lead electrocardiography revealed a complete atrioventricular block, with a nodal escape rhythm of 40/min and diffuse ST depression. The presumptive diagnosis of acute oleander intoxication was confirmed by the detection of digoxin (1.0 nmol/L [0.8 ng/ml]) on radioimmunoassay. Despite intensive therapy, the patient's hemodynamic condition deteriorated. His blood pressure decreased to 70/40 mm Hg; he became oliguric and nonresponsive to external stimuli; and his potassium concentration rose to 6.8 mmol/L. Eighteen hours after admission, an empiric 480-mg dose of digoxin-specific Fab antibody fragments was administered intravenously over 30 minutes. Within minutes of the initiation of immunotherapy, the patient woke up; his blood pressure rose to 90/50 mm Hg; and he regained a sinus rhythm of 68/min with a prolonged PR interval. His potassium concentration decreased to 5.1 mmol/L within 15 minutes and normalized within 1 hour of therapy initiation. One day later, the 1[degree] atrioventricular block disappeared, but the ST depression persisted for an additional 6 days. The value of digoxin-specific Fab antibody fragments in the treatment of plant glycoside and, in particular, oleander intoxication is discussed. (Arch Intern Med. 1995; 155:2121-2125)

Acute iron overdose is a serious cause of morbidity and mortality, however, optimal gastric decontamination procedures in iron overdose are unclear. In order to determine the effectiveness of oral deferoxamine mesylate solution in humans to prevent the absorption of iron in acute exposures, the following prospective case control crossover study was designed. Seven informed adult human volunteers were given an oral dose of 5 mg/kg elemental iron alone in a control phase and again in an experimental phase followed by a single equimolar dose of oral buffered deferoxamine solution. Plasma iron concentrations were determined spectrophotometrically for eight hours following administration of iron alone and following doses of iron with deferoxamine. There was no significant difference in peak iron concentration, time to peak iron concentration or area-under-the-curve between the two groups. Based on our results, equimolar doses of oral deferoxamine do not appear to decrease the absorption of low doses of oral iron in humans., (Key Words: deferoxamine; iron, poisoning; gastric decontamination.) INTRODUCTION Acute overdose with iron preparations has been recognized as a serious cause of morbidity and mortality (1)(2)(3)(4)(5), especially in children (1). According [...]

Iron poisoning is the most common cause of overdose mortality in children under six years of age and there are no reports of survival with iron levels > 2687 [mu]mol/L (>15,000,[mu]g/dL). A 22-month-old male was brought to the emergency department by his parents after ingesting an estimated 50 ferrous sulfate tablets (60 mg elemental iron/tablet) several hours earlier. Despite spontaneous emesis and gastric lavage his condition deteriorated and he was found to have a serum iron of 2992 [mu]mol/L (16,706;[mu]/dL). During the first four days in the intensive care unit, he developed coma, metabolic acidosis, hypovolemic and cardiogenic shock, liver failure, coagulopathy and adult respiratory distress syndrome. He was treated with a unique deferoxamine dosage schedule (25 mg/kg/h for 12 h/d x 3 d), mechanical ventilation, Swan-Ganz catheter monitoring, dopamine/nitroprusside therapy, blood product, bicarbonate, electrolyte and volume replacement. After a prolonged hospital course complicated primarily by gastric outlet obstruction he was dismissed on full oral feedings, gaining weight, and neurologically intact. Swan-Ganz catheter monitoring guided the management of this patient's shock, iron-induced cardiac failure, and deferoxamine mesylate induced adult respiratory distress syndrome. Further experience and research is required to determine the most appropriate deferoxamine mesylate dosing schedule and our experience expands the range for possible survival after massive iron overdose. (Key Words: iron poisoning: deferoxamine: cardiogenic shock; ARDS.), INTRODUCTION Prenatal iron supplements are commonly found in the homes of young children, so it is not surprising that poisoning from such preparations is a common occurrence in children. In [...]

A 55 year-old female ingested two bulbs of Urginea maritime (squill) plant as a folk remedy for her arthritic pains. Her past history was significant for Hashimoto thyroiditis and she was hypothyroid upon presentation. Subsequent effects resembling those seen with cardiac glycoside intoxication included nausea, vomiting, seizures, hyperkalemia, atrioventricular block and ventricular arrhythmias resembling digitalis toxicity. A serum digoxin level by an enzyme immunoassay method was 1.59 ng/mL. Despite supportive treatment and pacing, the patient expired from ventricular arrhythmias 30 h after ingestion. Squill has been recognized since antiquity for the clinical toxicity of its cardiac glycosides, but this appears to be the first report of a fatality since 1966. (Key Words: squill: uriginea maritima: cardiac glycosides: poisoning.), INTRODUCTION The most important plant sources of cardiac glycosides are digitalis (foxglove), strophanthus and squill. Squill is Urginea maritima, the sea onion which grows near the Mediterranean shore and in [...]

Aluminum phosphide poisoning is common in the rural belt of Northern India. The release of cytotoxic phosphine gas primarily affects the heart, lungs, gastrointestinal tract and kidneys, although all organs can be involved. The cellular site of action phosphine requires further definition. Diagnosis is made by clinical suspicion, silver nitrate test and biochemical examination of the gastric aspirate and viscera. Treatment consists of early gastric lavage, vasopressors and supportive care. Specific therapy with intravenous magnesium sulphate is recommended., INTRODUCTION Tablet and pellets composed of aluminum phosphide (AlP) ammonium carbonate are used worldwide against rodents and other pests which infest stored grain. In the last few years, an epidemic [...]