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Case Notes

London/Burundi/South Africa Cases

 

May 2015

 

Case 1

 

4 yo has been bitten by this: 

GETUP_widow_spider_.jpeg

 

 

 

Presents with priapism.

Picture was of a red back spider. Priapism is an uncommon consequence of envenomation.

 

Case 2

 

69 yo presents with respiratory symptoms after inhalation of toxic gas.

Phosphine gas is a pulmonary irritant. It is also a byproduct of methamphetamine manufacturing. This is distinguishable from phosgene gas which can have minimal initial effects and late pulmonary oedema.

 

Case 3

 

13 yo camping find this on hand:

GETUP_Funnel_Web_Spider.jpeg

 

Becomes hypoxic with saturations of 88%.

This picture was of a funnel web spider. Patients presents with pain, autonomic symptoms and a catecholamine excess which can lead to cardiomyopathy and pulmonary oedema. Presents similar to some scorpion envenomations.

 

Case 4

 

20 yo man presents after ingestion of paint thinner with abdominal bloating.

Consider toluene as a cause for renal failure (renal tubular acidosis) post overdose.

 

Case 5

 

30 yo presents with valproate OD and awake. Valproate concentration was 14,000 micromol/L.

 

Always correlate lab results with clinical state. This presentation had a lab error.

 

Case 6

 

From Fiji, patient presents after being stung by this: 

GETUP_Stonefish.jpeg

 

Discuss mechanisms of toxicity and management.

 

This was a picture of a stonefish. Possible mechanisms of toxicity include calcium influx into cortical neurons. Patients present with pain, sweating nausea and occasionally reports of syncope, hypotension and pulmonary oedema. Good debridement of wound and consideration prophylactic antibiotics can prevent wound infections.

Case 7

2.8g Carbamazepine OD from Fiji.


In the absence of blood concentrations, expect erratic absorption from CBZ. Risk assessment >50mg/kg can expect severe toxicity. Clinical state can guide management including airway support. Multidose activated charcoal can be used given enterohepatic recirculation of CBZ. Also consider dialysis if hypotension, prolonged coma, arrhythmias. Slow release preparations can prolong toxicity.

 

March 2015

 

Case 1

 

2 yo has ingested formalin in pea juice given to by the sibling.

 

Formalin for lab use can contain up to 10% methanol as a stabilizer.

 

Case 2

 

A therapeutic error of a 35 yo lady with preeclampsia.

 

Hypermagnesemia can occur with therapeutic errors. Check for reflexes, bradycardia, decreased conscious state and hypocalcemia (QT prolongation).

 

Case 3

 

58 yo patients presents with muscle spasms.

 

Strychnine is a rodenticide working as a competitive glycine receptor antagonist. Causes muscles spasms and can lead to respiratory failure. Supportive care. Has also been used as adulterant in illicit substances. Think tetanus as differential.

 

Case 4

 

2 patients present after inhaling substance, one has started ECMO.

 

Inhalation of illicit substances can lead to acute pulmonary damage/insult. Ie crack lung with cocaine.

 

Case 5

 

A case from Fiji – 4 occupants painting at bottom of yacht. 1 patient suffers a cardiac arrest, the others present with respiratory symptoms and also the first responders. Name potential toxicants.

 

This case involved an explosion with hydrocarbon fumes (from paint) and secondary trauma. In general, think CO with prolonged fire exposure and cyanide if products such as nitriles in plastic manufacture is involved.

 

February 2015

 

Case 1

 

A 24 yo male has swallowed 4 plastic bags containing a recreational substance.

 

Plastics bags can often be fragile and prone to leakage.

 

Parachuting was mentioned as a different form of drug delivery.

http://www.ncbi.nlm.nih.gov/pubmed/20938324

 

 

Case 2

 

45 yo presents with rapidly progressive dementia.

 

There are many causes of toxic leukoencephalopathy including CO, methanol, MDMA, toluene, ethylene, oxycodone, cocaine, high dose IV methotrexate, inhalation heroin and also non tox causes.

 

Case 3

 

20 month old child found playing with pills, episodes of bradycardia to 65.

 

Although unsual for a child to ingest many tablets this case had a digoxin concentration >6.4 nmol/L with symptomatic bradycardia. Controversies behind digoxin fab dosing was discussed.

http://www.ncbi.nlm.nih.gov/pubmed/25089630

 

Also a question on the use of calcium with digoxin overdose:

http://www.ncbi.nlm.nih.gov/pubmed/19201134

 

Case 4

 

Patient presents delirious with chronic renal failure and a wide complex QRS on ECG.

 

Clinical state, old ECGs will help to determine progression in tricyclic overdoses with unknown dose or time ingestions. Toxic metabolites can persist in renal failure.

 

Case 5

 

44 yo presents with overdose of valproate and ammonia of 580 micromol/L. Discuss indication for haemodialysis.

 

The decision for dialysis needs to be made based on a consideration of clinical state, trends in drug concentrations, labs and risk-benefit analysis rather than a single elevated ammonia concentration.

 

August 2014

 

Case 1

30/42 pregnant lady is referred by an obstetrician. She has basophilic stippling on a her blood film. What could this be due to and how would you manage her?

 

Basophilic stippling and anaemia on blood film may be secondary to lead toxicity. Other differentials include arsenic and thalassemia. An interesting case of chelation in pregnancy and of the neonate was discussed. Beware ayurvedic medication as a source of heavy metal poisoning.

 

Case 2

19 yo presents with epigastric pain and acute renal failure. She had taken modified release paracetamol 2/7 earlier

 

 

Late onset nephrotoxicity secondary to paracetamol treated with NAC and no hepatotoxicity has been described. Pathologically, this is thought to be due to acute tubular necrosis. Supportive treatment.

 

Case 3

 

43 yo male found on the floor with empty packets of his antiepileptic.

 

Use of multidose activated charcoal for  carbamazepine is useful via interruption of enterohepatic circulation and “GI dialysis” especially if no dialysis facilities are available. Contraindicated with signs of bowl ileus.

 

Case 4

50 yo male presents following an old fridge explosion. Has had multiple cardiac arrests.

 

Old fridge explosions may contains CFCs and liberate F- ions at high temperatures. Think systemic fluorosis with hypocalcemia, hypomagnesemia and hyperkaelemia in arrest.

 

Case 5

Our Fiji ED docs presented an interesting of hypotension and bradycardia associated with ciguatera poisoning. There was an interesting unvalidated surrounded by flies = good fish vs not = bad fish theory. There are available kits to test ciguatoxin in fish but large reef fish have been implicated.

 

 

July 2014

 

Case 1

A 38 yo male and 24 yo female represent 48hrs with vomiting and diarrhea stating they had a potato and mushroom soup bought with ingredients from the supermarket.

 

The Amanita phalloides mushroom can lead to hepatotoxicity by amatoxin uptake within the liver. This case demonstrated the differentials that need to be thought of with a high anion gap metabolic acidosis, public health issues and an atypical history that can be presented which may not fit with the likely diagnosis.

 

Case 2

16 yo presents having overdosed on paracetamol, oxycodone/naloxone. Her 4 hr paracetamol concentration is 2362 micromol/L and 15 hr is 2612 micromol/L.

 

Extended release paracetamol/acetaminophen product overdoses especially in large overdoses will need regular concentration monitoring and likely a prolonged course of NAC. If there is lack of paracetamol assays, then treatment is safest option with monitoring of liver function tests and coagulation.

 

Case 3

20 yo presents comatose having drunk a liquid slurry.

 

Methaemoglobinaemia can result from sodium nitrite ingestion. Cooximetry can help determine degree of MetHb if available. Treatment is with methylene blue and in severe cases, exchange transfusion should be considered.

 

Sodiumnitrite from cyanide antidote kits as a potential cause of methaemoglobinaemia which may become an issue in Fiji.

 

Case 4

43 yo male presents with fluctuating agitation and drowsiness. Trying to wean off substance bought off the internet.

 

Multiple substance are unregulated and can be bought over the internet. Phenibut is a GABA mimetic at GABA B. Potential for use of baclofen in dependent patients in withdrawal states.

 

 

June 2014

 

Case 1

 

Pt with metastatic lung cancer has been taking 8 of these/day for last month

 GETUP_apricot_kernals.png

 

The picture were apricot kernels which contain amygdalin. Taken in large amounts these can produce symptoms of cyanide toxicity.

 

Case 2

2 day old neonate treated for seizures hours within birth. Na 118. Has had IV phenobarb. Unresponsive for 2 days on ventilator and now looks “brain dead”.

 

This patient likely had a 10 fold error in phenobarbitone administration. Exchange transfusion and dialysis has been used previously. In this case, peritoneal dialysis was used as the patient was deemed to be too unstable for the other methods.

 

 Case 3

 

Patient presents with this ECG post ingestion oxycodone, paracetamol, codeine, 500mg doxylamine and Vit D. Discuss ECG findings.

 

This ECG showed a wide complex QRS likely secondary to Na channel blockade. ECG changes improved with administration of sodium bicarb.

 

Case 4

58 yo female presents ingestion amlodipine and candesartan. Discuss role of methylene blue and high dose insulin.

 

The use of bedside ECHO will be helpful in these cases to distinguish pump failure vs vasoplegia. High dose insulin Euglycemic therapy has been used to improved pump failure and methylene blue to decrease NO production for vasoplegic states.

 

 

Case 5

 

29 yo female has been taking methotrexate 10 mg/day for last week instead of weekly for her psoriasis. Discuss mechanisms of toxicity and duration of treatment.

 

Methotrexate inhibits dihydrofolate reductase (preventing reduction of folic acid to folinic acid) and thymidylate synthetase decreasing RNA and DNA synthesis. Exogenous Folinic acid admin bypasses the inhibition and restores this synthesis. The question of debate was the adequate length of treatment.

 

Case 6

Desmond from PNG discussed a couple of interesting cases of puffer fish poisoning and possible neurotoxic shellfish poisoning.

 

 

May 2014

 

Case 1

30 yo man presents with haematemesis after drinking “xylene”. 2 days later he had no oesophagus.

 

Be cautious of what patient’s tell you if the clinical picture does not fit. In the end further history emerged that he had taken sodium hydroxide (highly corrosive) from his methamphetamine lab and ended up with an oesophagectomy and partial gastrectomy.

 

 

Case 2

A 50 yo man cooked up 5 of this type of fish. What is the mechanism of toxicity? Presents in respiratory arrest and a Sodium of 168 mmol/L.

 

 GETUP_puffer_fish.png

 

 

This picture was of a puffer fish. Tetrodotoxin  is a potent neurotoxin that inhibits firing of action potentials in nerves binding to Na channels and leads to paralysis.

Cranial diabetes insipidus has been reported as a result of cranial insult.

 

Case 3

Call in regards to a 15 yo girl with cerebral palsy having had a 40x therapeutic error of her intrathecal medication.

 

Intrathecal baclofen errors can result in hypotonia, seizures, bradycardia, respiratory depression and coma. Treatment options include CSF lumbar puncture to remove fluid and emptying the pump system. Supportive care also important.

 

Case 4

31 yo man presents having taken an overdose of some TB medications.

 

Ethambutol can lead to ocular toxicity causing a painless central loss of vision, possibly through the binding of intracellular copper with secondary alteration of mitochondrial function and subsequent neuronal injury. Also remember coingestants of other TB medications such as isoniazid.

 

Case 5

64 yo female has taken a handful of these. Discuss mechanism of toxicity and clinical course.

 GETUP_Castor_beans.png

 

 

This picture was of castor beans. Ricin acts by inhibiting protein synthesis. Chewing the seeds can result in gastrointestinal symptoms. More severe ingestion can lead to multi-organ effects.

 

 

 Case 6

 

Consuelo Meneses from the Ecuador poisons centre presented a fatal case of paraquat poisoning after ingestion of 300ml of concentrate. They see around 300 cases per year of paraquat poisoning. Ingestion of >50mg/kg or >0.25ml/kg of 20% solution is fatal.

 

 

 

March 2014

 

 

Case 1

19 yo female has ongoing pain after stung by this creature (March pic 1)

 GETUP_Jellyfish.png

 

 

The Carukia Barnesi jellyfish can cause the Irukandji syndrome – pain, increased catecholamine response, APO, cardiogenic shock. Treatment with vinegar, analgesia, supportive. Evidence for magnesium use is inconclusive but should be considered in patient with refractory pain or systemically unwell not improving with supportive care. Raised troponins investigated on their own merit ie. ECHO for heart failure.

 

Case 2

92 yo deliberate ingestion digoxin, HR 17 to 40. Initial Dig concentration 18 nmol/L.

 

This patient also had had renal impairment. It took 2 weeks for her Digoxin concentration to be within the therapeutic range. Age and renal impairment and redistribution need to be ongoing considerations in these large overdoses.

 

Case 3

16 yo presents having taking 100 tablets of paracetamol and 100 tablets of “panadol osteo”.

 

Another large overdose but with paracetamol (acetaminophen). Panadol osteo is a mix of immediate and sustained release paracetamol. Prolonged administration of NAC is indicated in these patients guided by paracetamol concentrations/liver function/clinical state. Other issues such as doubling the NAC dose, role of multidose activated charcoal or measuring the half life of paracetamol to guide management were raised.

 

Case 4

29 yo female presents lithium and an antipsychotic.

 

Amisulpride(Solian) is a newer antipsychotic. Delayed coma, arrhythmias and seizures have been reported. The ECG shows a prolonged QT of 600ms. The risk of torsades was discussed and management.

 

Case 5

A female purchased 2 nicotine cartridges and injected contents into thigh. Blood gas 3 hrs post ingestion. pH 7.36 / CO2 35 / Bic 17 / Lactate 7.6

 

This patient did well, but propylene glycol needs to be considered as a diluent.

 

Case 6

Additional case – Valproate OD 75g

The use of carnitine seems sensible in high risk hyperammonia valproate OD patients with LFT derangement. However, good studies backing its use and overall impact on outcome is questionable.

 

February 2014

 

Case 1

A 30 yo male has injected an unknown amount of insulin glargine. He has had 3L IV therapy and his 50% dextrose infusion is up to 150ml/hr.

-The use of octreotide may be useful in patients with endogenous insulin production to decrease fluid requirments ie. T2DM. The use of C peptides in these large insulin ODs is undefined.

 

Case 2

Patient has ingested unknown amount of this plant. Presents bradycardic.

 GETUP_oleander.png

 

 

Oleander contains cardiac glycosides similar to the effects of digoxin. However ½ life can be prolonged in pods >leave ingestions and symptoms may persist for days. Digifab may be used. If this is unavailable, charcoal may be beneficial. Digoxin concentrations just help confirm ingestion and don’t correlate with toxicity.

 

 

Case 3

A 30 yo snake handler has been bitten by this 1 hour ago.

He is located in a country hospital.

 GETUP_death_adder.png

Picture is of a death adder. Primary mechanism of toxicity is neurotoxic with severe cases of paralysis reported.

 

Cape Cobra envenomation in Namibia- death is often result of respiratory failure.

 

Rattlesnakes envenomation in North America- haemorrhage, shock or angioedema are causes of death.

 

Case 4

A 43 yo female has ingested 300ml of “bute” 90 mins ago.

 

Phenylbutazone is a veterinary preparation on the NSAID type. Overdoses can lead to multiorgan failure.

 

 

Case 5

36 yo male injected oxycontin tablets, presents with pleuritic chest pain.

“Dirty hit” or particular matter a concern in the patients in the pulmonary system. No role for anticoagulation.

 

 

December 2013

 

Case 1

44 yo male with pHx- ETOH abuse presents with chest pain following ingestion of alcohol.

-In addition to the disulfiram reaction with alcohol there have been reports of possible acetaldehyde induced chest pain leading to coronary vasospasm.

 

 

Case 2

72 yo Polypharmacy OD including diltiazem SR 30 x 180mg. Presents with BP70/35 HR 60

- Controversy still remains on whether high insulin dextrose therapy is superior to inotropes for calcium channel blocker overdose depending on your location of practice. But before chucking in the kitchen sink, think of the lipid sink or in vasoplegic states methylene blue.

 

Case 3

20 yo female presents with OD of multiple sclerosis medications. Becomes bradycardic and hypotensive 19hrs post ingestion.

-Fingolimod is a sphingosine 1 phosphate receptor agonist and given its pharmacokinetics and dynamics may lead to delayed bradycardia and hypotension.

http://www.ncbi.nlm.nih.gov/pubmed/24178903

 

30 yo has been given medicine to promote weight loss – presents with chest pain, flushing.

-Dinitrophenol uncouples oxidative phosphorylation and can be associated with hyperthermia and end organ toxicity.

 

Case 4

Name this picture (below). What are the toxic mechanisms involved?

See below for answer

GETUP_Conus_shell.png

 

Cone shells depending on the species can release contoxins ranging from local pain to respiratory failure.

 

Case 5

Tres Pasitos (aldicarb) or three step is a carbamate used for poisoning rodents in South America and highly toxic for toddlers.

Also known as Two step in South Africa.

 

Case 6

Thick tailed scorpions in African regions are more toxic than thin tailed scorpions. Effects can range from severe pain to weakness, bulbar paralysis

November 2013

 

Case 1

A 3 yo, 5yo, 6yo has ingested “green liquid” from shed. They are in a rural hospital with minimal facilities.

-Ethylene glycol potentially fatal in small amounts. Treat with ethanol and dialysis. Oral vodka to state of inebriation if IV ETOH and bloods unavailable.

 

Case 2

27 yo presents with back pain and trouble walking. Has taken 30 x ibuprofen in last 24 hours.

Renal tubular acidosis and hypokaelemic periodic paralysis a consequence of NSAID use. Remember to check K, renal function and blood gas if suspected.

 

Case 3

A 20 yo man has taken an unknown amount of amitriptyline. There is a worldwide shortage of sodium bicarb.

Sodium acetate has been suggested as a replacement. Loading dose given slower because of metabolism. Other options include hypertonic Saline, increased minute ventilation.

 

Case 4

Spot diagnosis: What could have caused this (see pic)? Mechanism of toxicity? See below for answer.

 GETUP_Hornet.png

 

This was the consequence of the Asian giant hornet or Vespa mandarinia. Tissue damage is caused by stimulating phospholipase action. Neurotoxin (mandaratoxin) can be lethal.

 

Case 5

Paraquat is not an organophosphate. Have attached article on atropinisation and clinical endpoints in organophosphate poisoning.

 

October 2013

 

Case 1

Patient has been to seafood restaurant and does not feel well. Below is the ECG tracing. Discuss mechanisms toxicity, treatment, duration action.

GETUP_ECGtracing.png

 

 

The ECG tracing of heart block was secondary to somebody with symptoms of ciguatera toxicity. Ciguatoxins blocks Na channels in the open state leading to the symptoms experienced. Bradycardia is rare and mechanism are thought to be due to vagal activation is one of the theories (I have attached an article). Duration of action cardiotoxicity likely shorter than other symptoms (<24hrs) but would manage symptomatically till improves.

Case 2

Spot diagnosis-hint starfish (see pic). Discuss role first aid, toxicity and treatment.

GETUP_Starfish.png

 

Picture was of the crown of thorns starfish. Mechanism of toxicity is by release of saponins. Local haemolytic effect and tissue damage. Problems of foreign body. May be a role for hot water (40 degrees Celsius) first aid and coverage for secondary bacterial infection from saltwater. Otherwise supportive care.

 

Case 3

Person is found slumped in car. “Stay away” is written all over the front windscreen.

 

 

Think of hydrogen sulfide in the person whom is slumped in the car. First responders unlikely to be at risk if not prolonged exposure and good ventilation. Carbon monoxide not usually a problem for first responders.

 

Case 4

Body building drugs to get the heart pumping

 

Clenbuterol and beta agonist has been abused for body building and weight loss. Treatment with diazepam. Short acting beta blocker (ie esmolol) may be an option if not responding.

 

Case 5

Australian brown snake envenoming can be deadly. Collapse usually occurs early, but anecdotes on removal of immobilization bandage.

 

 

Case 6

 

Patient has taken a swig from an unmarked bottle from a farmer friends garden shed. Discuss possibilities, risk assessment and management. There are limited diagnostic facilities.

 

The unmarked bottle from the garden shed- think paraquat, organophosphates as worst case scenario along with other herbicides/pesticides. Urine dithionate test can be helpful in paraquat. If don’t have these manage supportively. Clinical syndrome can help differentiate. Pungent smell of solvents from OPs.

 

 

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