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Suicide attempts in humans due to injections of the veterinary drug pentobarbital sodium have been rarely reported. Herein, we present a case of a suicide attempt by intramuscular injection of pentobarbital sodium into the rectus abdominis muscle, which was suggested by computed tomography (CT). A 73-year-old man was brought to the emergency department with GCS 3 (E1V1M1) and an incised wound on the right side of the neck. A bottle of Somnopentyl

Background Agonal respiration following out-of-hospital cardiac arrest is associated with favorable neurological outcomes. Resuscitation using extracorporeal membrane oxygenation could contribute to achieving favorable neurological outcomes in patients with refractory cardiac arrest. Case presentation We report two cases of refractory cardiac arrest with non-shockable rhythms and agonal respiration; both patients were successfully resuscitated through extracorporeal cardiopulmonary resuscitation (ECPR). Both patients were breathing spontaneously upon arrival. One patient was asystolic and the other experienced pulseless electrical activity followed by ventricular fibrillation. Agonal respiration was observed in both and ECPR was implemented, leading to a favorable neurological outcome at discharge. Conclusion The presence of agonal respiration has the potential to confer a favorable neurological outcome in patients with refractory cardiac arrest if maintained, even when the initial cardiac rhythm is not shockable. In these cases, resuscitation should not be abandoned, and ECPR should be considered.

Whether central apnoea or hypopnoea can be induced by organophosphorus poisoning remains unknown to date. By using the acute brainstem slice method and multi-electrode array system, we established a paraoxon (a typical acetylcholinesterase inhibitor) poisoning model to investigate the time-dependent changes in respiratory burst amplitudes of the pre-Bötzinger complex (respiratory rhythm generator). We then determined whether pralidoxime or atropine, which are antidotes of paraoxon, could counteract the effects of paraoxon. Herein, we showed that paraoxon significantly decreased the respiratory burst amplitude of the pre-Bötzinger complex (p p

Background The effect of venoarterial extracorporeal membranous oxygenation (V‐A ECMO), plasma exchange (PE), and direct hemoperfusion (DHP) for fatal cibenzoline succinate poisoning is unclear. We report a rare case of severe cibenzoline succinate poisoning along with cardiac arrest, wherein the patient was managed with V‐A ECMO, PE, and DHP. We also measured the blood levels of cibenzoline succinate frequently. Case Presentation A 51‐year‐old woman had a refractory cardiac arrest after cibenzoline succinate ingestion. We initiated V‐A ECMO, PE, and DHP. Plasma exchange did not improve clinical manifestations. Her clinical condition improved during DHP, but there was no evidence about removal of drugs. On day 3, DHP and ECMO were terminated. On day 9, she was transferred to another hospital without arrhythmia recurrence. Conclusion Venoarterial ECMO is effective in cases of cibenzoline succinate poisoning‐related cardiac dysfunction or cardiac arrest. No evidence was obtained for the effects of PE and DHP., A case report of cibenzoline succinate poisoning treated with extracorporeal cardiopulmonary resuscitation and direct hemoperfusion.

Case Sibutramine is a weight loss agent that was withdrawn from the market in the USA and European Union because it increases adverse events in patients with cardiovascular diseases. However, non-prescription weight loss pills containing sibutramine can be still easily purchased over the Internet. A 21-year-old woman without history of cardiovascular diseases developed cardiac arrest. She was a user of a weight loss pills, containing sibutramine and hypokalemia-inducing agents, imported from Thailand over the Internet. Outcome She was successfully resuscitated without any neurological deficits by using extracorporeal membrane oxygenation for refractory ventricular fibrillation. Conclusion This case indicates that sibutramine can cause cardiac arrest even in subjects without pre-existing cardiovascular disease when combined with agents that promote QT prolongation.

Background: Topical antimicrobial formulations containing neomycin are commonly used to prevent and treat burn infections. However, Pseudomonas aeruginosa shows rapid acquisition of adaptive resistance to neomycin. This study aimed to evaluate the survival of P. aeruginosa during exposure to neomycin at high concentrations comparable to those used in topical formulations, and to investigate the effect of adaptive resistance to neomycin on the susceptibility to other aminoglycosides. Methods: Strain IID1130 [neomycin minimal inhibitory concentration (MIC) = 4 µg/ml] was incubated on an agar medium containing neomycin at high concentrations (8-4,096 µg/ml), and growing colonies were macroscopically observed. Acquisition of adaptive resistance was examined for 5 P. aeruginosa strains. Cells were sequentially passaged on agar medium containing neomycin with step-wise increased concentrations (8-2,048 µg/ml). To assess reversion of antibiotic susceptibility, the resulting colonies were repeatedly subcultured on antibiotic-free agar plates. Results: Growing IID1130 colonies were macroscopically detected on a neomycin-containing (2,048 µg/ml) agar plate for 48 h. These cells showed increasing MIC for not only neomycin, but also gentamicin and amikacin; the MIC values were occasionally higher than the breakpoints. When the adapted cells were subcultured on antibiotic-free agar, several passages were required for reversion of susceptibility. Conclusions: Our findings suggest that P. aeruginosa can survive in the presence of neomycin with a concentration typically used in topical dosage forms, and that the acquired adaptive resistance is persistent and is accompanied by cross-resistance to other aminoglycosides.

Background: The common garden plant autumn crocus contains colchicine and its derivatives. Colchicine poisoning causes abdominal cramps and diarrhea within hours. Several days later, multiorgan failure, pancytopenia, and cardiovascular collapse occur. 1,2 Severe colchicine poisoning is associated with high mortality. Case report: A 63-year-old woman who accidentally ingested an autumn crocus, which contained ~0.38 mg colchicine, had severe vomiting and was taken to an emergency center. She presented with symptoms of gastroenterocolitis within 1 hour of ingestion, and bone marrow hypoplasia with pancytopenia developed on the 3 rd day after ingestion. We continued administration of granulocyte colony-stimulating factor (300 mg) for 5 days until we confirmed that the patient's white blood cell count was increasing. Also, there was focal and segmental intestinal ischemia and some cakes of charcoal remained in the intestinal tract. Therefore, we presumed that nonocclusive mesenteric ischemia was caused by hypotension with severe dehydration, although pseudo-obstruction due to the activated charcoal may have been a contributing factor. We were able to promptly intervene to treat paralytic ileus and gastrointestinal edema before anticipated worsening of abdominal compartment syndrome, by conducting open peritoneal drainage. Despite severe poisoning, our patient survived with intensive care. Conclusion: Colchicine intoxication may lead to a sudden and extreme critical course. Therefore, as there is no means to predict prognosis from initial severity of symptoms at onset, we suggest that all patients suspected of colchicine intoxication should be managed in hospital with continuous vital sign monitoring and frequent laboratory testing for at least a few days after ingestion. Copyright © 2015, Taiwan Society of Emergency Medicine. Published by Elsevier Taiwan LLC. All rights reserved.

A 13-year-old boy developed tetanus, although he had protective antitoxin antibody raised by three doses of tetanus toxoid vaccine. Four days after injury, he presented with muscle rigidity of his posterior neck, excessive diaphoresis, and risus sardonicus and was subsequently diagnosed with tetanus. Tetanus is rare in developed countries, particularly during childhood, but must be promptly diagnosed based on clinical symptoms.

要旨 高インスリン血症性低血糖症は，その多くが新生児期から小児期にかけて発症する疾患である。我々は，重症頭部外傷後に特発性の小児持続性高インスリン血症性低血糖症を来した症例を経験したので報告する。症例は1歳6か月の女児。集合住宅の窓より誤って転落し，約8m下のアスファルトの地面に頭部を打撲し，当施設へ搬送された。頭部CT所見で右硬膜下血腫を認め，搬入当日に緊急開頭血腫除去術を施行した。患児は第21病日より治療抵抗性の低血糖を呈するようになり，大量のブドウ糖持続静注を必要とし，十分なホルモン補充療法でも血糖値は改善しなかった。精査により高インスリン血症を認めたため，膵β細胞からのインスリン分泌を抑制するDiazoxideを投与したが，十分な効果が得られず，全ての膵ホルモン分泌を抑制するOctreotide皮下注に変更した。変更後は速やかに血糖値は上昇し，その後も安定した。先天性代謝異常を除外するためにタンデムマススクリーニングを，また高インスリン血症性低血糖症の原因検索のために遺伝子検査を行ったが，どちらも有意な所見は得られなかった。患児は第108病日に小児科へ転科し，最終的に装具歩行および二語文会話程度にまで回復し退院した。持続性高インスリン血症性低血糖症は遺伝子異常に起因するものが多い。しかし，本症例のように頭部外傷後のストレスが誘引となって発症したと考えられる場合もあるため，治療抵抗性の高度な低血糖症を認めた際には早期に本疾患を疑い，診断および治療を進める必要がある。 ABSTRACT Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) develops primarily during the neonatal and infant periods. Here, we report a case of PHHI after the severe brain injury. The patient was an eighteen–month–old female injured from a fall. She sustained a subdural hemorrhage that necessitated an emergency craniotomy for removal of a hematoma. From the 21st hospital day, although the postoperative course was successful, she needed massive continuous glucose infusions due to the development of treatment–resistant hypoglycemia. She also showed mild hypopituitarism and adrenal insufficiency and hormonal replacement therapy proved ineffective. Hyperinsulinemia was detected and we initially administered Diazoxide. This proved inadequate, so we switched to Octreotide subcutaneous injection. Her blood glucose level subsequently stabilized within a normal range. To rule out congenital dysbolism and search for the true cause of PHHI, we conducted a tandem mass spectrometry screen and genetic testing, neither of which indicated significant results. By the patient’s 120th day, she was able to walk with assistance and form basic sentences. Most instances of PHHI are attributed to gene abnormality and it is often familial. What induces PHHI is unknown; however if treatment–resistant hypoglycemia after a brain injury is noted, PHHI must be considered when making a diagnosis.

Background Tension gastrothorax is a kind of obstructive shock with prolapse and distention of the stomach into the thoracic cavity. Progressive gastric distension leads to mediastinal shift, reduced venous return, decreased cardiac output, and ultimately cardiac arrest. Therefore, it is crucial to decompress the stomach distension for the initial resuscitation of tension gastrothorax. Case presentation A 75-year-old female was transported to our resuscitation bay due to motor vehicle crash. At the time of arrival to our hospital, the patient developed cardiac arrest. While undergoing cardiopulmonary resuscitation, an unstable pelvic ring was recognized, so we performed a resuscitative thoracotomy to control hemorrhage and to perform direct cardiac massage. Once we performed the thoracotomy, the stomach and omentum prolapsed out of the thoracotomy site and through the diaphragm rupture site and spontaneous circulation was recovered. Neither the descending aorta nor the heart was collapsed. Although we had continued the treatment for severe pelvic fracture (including blood transufusions), the patient died. Given that (1) the stomach prolapsed out of the body at the time of the thoracotomy; (2) at the same timing, spontaneous circulation returned; and (3) the descending aorta and heart did not collapse, we hypothesized that the main cause of the initial cardiac arrest was tension gastrothorax. Conclusions Recognition of tension gastrothorax pathophysiology, which is a form of obstructive shock, makes it possible to manage this injury correctly.

消化管穿孔による後腹膜膿瘍が,大腿輪を経て左側腹部から下腿に波及したために生じた壊死性筋膜炎のまれな1例を経験した。症例は65歳の女性。左側腹部から大腿部にかけての疼痛と皮膚壊死を認めたため壊死性筋膜炎を疑い,当院高度救命救急センターに搬入された。搬入時,呼吸,循環動態は安定していたが,左躯幹から大腿部,外陰部の浮腫,紫斑,硬結,皮膚壊死を認めた。搬入後直ちに,躯幹から下肢にかけての皮膚の壊死部分を筋膜上までdebridementし人工真皮にて被覆した。術中,左鼠径靭帯下部に便の付着と後腹膜方向の交通部があった。開腹したところ結腸脾湾曲部の後腹膜腔への穿孔があり,後腹膜腔には膿瘍が充満した状態であったため,結腸左半切除を行った。穿孔部結腸の病理組織検査では憩室や悪性所見はなかった。術中,術後にわたりショック状態や臓器不全に陥ることなく順調に経過し,第5, 10病日に人工真皮による被覆を行い,さらに第20病日と32病日には,autograftによる植皮術を施行し欠損部を被覆した。下肢壊死性筋膜炎の原因として後腹膜腔への腸管穿孔は非常にまれであるが,原因の一つとして常に可能性を念頭に置く必要がある。本症例では早期かつ広範に壊死した皮膚や皮下組織,筋膜を徹底的にdebridementし,その原因となった腸管に対して処置し得たことが,その後の敗血症の発症や,臓器障害への進展を防止できたと考えられた。

We report a case of laxatives induced severe hypermagnesemia complicated with cardiopulmonary arrest. A 55-year-old woman, with nephritic syndrome and anorexia nervosa, was later transported to our emergency room (ER) because of oliguria and consciousness disturbance. During transfer to the intensive care unit from the ER, cardiopulmonary arrest suddenly occurred. Cardiopulmonary resuscitation was immediately performed, and spontaneous circulation was restored after 3 min. Thereafter, administration of dopamine, norepinephrine, and epinephrine was required to maintain systolic blood pressure at 80 mmHg. Arterial blood gas analysis showed severe metabolic alkalosis, and blood biochemical tests revealed hypermagnesemia (serum magnesium concentration, 18.5 mg/dl) and renal dysfunction. Continuous infusion of diuretics followed by massive hydration and continuous hemodiafiltration (CHDF) was started. Five days after starting CHDF, magnesium concentration was almost normalized and administration of catecholamine was stopped. It was thought that progression of renal dysfunction that occurred in the patient taking a magnesium product for chronic constipation caused reduction in magnesium excretion ability, resulting in hypermagnesemia-induced cardiopulmonary arrest. To avoid a rebound phenomenon following magnesium flux from cells, continuous blood purification seems to be an effective treatment for symptomatic hypermagnesemia.