Medical Toxicology

In Response to "Impact of Targeted Temperature Management on ED Patients with Drug Overdose–Related Cardiac Arrest"

Self-Analysis: Do I Comprehend Case Series and Cohort Studies? A Fellow's Perspective

Gadolinium Aspiration Following Inadvertent Endotracheal Tube Cuff Injection in a Pediatric Patient Abstract Introduction Gadolinium-based contrast agents (GBCA) are frequently used for MRI contrast studies. We report a case of pulmonary aspiration secondary to inadvertent GBCA injection. Case Report A 12-year-old female with a past medical history significant for mitochondrial disorder, bronchial asthma, autism, recurrent urinary tract infection, epilepsy, developmental delay, dysautonomia, and thrombocytopenia was scheduled for a contrast-enhanced MRI study using gadoterate meglumine for urinary incontinence. The patient was sedated and intubated in preparation for the study, during which 10 mL of gadoterate meglumine was inadvertently injected into the endotracheal tube cuff pilot line instead of intravenously. The patient remained intubated and was admitted to the intensive care unit with continuous monitoring for signs of pulmonary injury or gadolinium toxicity. She was successfully extubated approximately 24 hours later without complication. Discussion A variety of adverse effects attributable to parenteral GBCA exposure have been reported ranging from mild irritation to life-threatening anaphylaxis. Gadolinium deposition and storage have been implicated in a number of those adverse effects and multiple treatments modalities have been suggested, but no scientifically guided management exists. Conclusion This case of pulmonary aspiration secondary to inadvertent GBCA injection in a pediatric patient demonstrated no acute  side effects or complications within the first 24 hours. With the wide range of adverse effects attributed to gadolinium use in the medical literature, it is difficult to predict potential future adverse effects.

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Does Lidocaine Cause False Positive Results on Cocaine Urine Drug Screen? Abstract Background Individuals who have tested positive for cocaine have claimed that lidocaine, or its primary metabolite, norlidocaine (monoethylglycinexylidide (MEGX)), have caused false positive results for the cocaine metabolite benzoylecgonine (BE) on urinary immunoassay testing. Objective The goal of the study was to determine if lidocaine exposure from routine medical procedures can result in false positives on a commercially available cocaine immunoassay urine drug screen (UDS). Methods We performed a cross-sectional observational study of patients receiving lidocaine as part of their regular care. Standard immunoassay drug screens and confirmatory liquid chromatography-mass spectrometry (LC-MS) were performed on all urine samples to assess for MEGX and BE. Results In total, 168 subjects were enrolled; 121 samples positive for lidocaine were ultimately included for analysis. One hundred fourteen of the 121 were also positive for MEGX. None of the 121 were positive for cocaine/BE on the UDS (95% CI), 0–3.7% for the full sample and 0–3.9% for the 114 who tested positive for MEGX. Conclusion The present study found no evidence that lidocaine or norlidocaine are capable of producing false positive results on standard cocaine urine immunoassays.

Adverse Effects of Physostigmine Abstract Introduction Physostigmine is a tertiary amine carbamate acetylcholinesterase inhibitor. Its ability to cross the blood-brain barrier makes it an effective antidote to reverse anticholinergic delirium. Physostigmine is underutilized following the publication of patients with sudden cardiac arrest after physostigmine administration in patients with tricyclic antidepressant (TCA) overdoses. We completed a narrative literature review to identify reported adverse effects associated with physostigmine administration. Discussion One hundred sixty-one articles and a total of 2299 patients were included. Adverse effects occurred in 415 (18.1%) patients. Hypersalivation (206; 9.0%) and nausea and vomiting (96; 4.2%) were the most common adverse effects. Fifteen (0.61%) patients had seizures, all of which were self-limited or treated successfully without complication. Symptomatic bradycardia occurred in 8 (0.35%) patients including 3 patients with bradyasystolic arrests. Ventricular fibrillation occurred in one (0.04%) patient with underlying coronary artery disease. Of the 394 patients with TCA overdose, adverse effects were described in 14 (3.6%). Adverse effects occurred in 7.7% of patients treated with an overdose of an anticholinergic agent compared with 20.6% of patients with non-anticholinergic agents. Five (0.22%) fatalities were identified. Conclusions In conclusion, significant adverse effects associated with the use of physostigmine were infrequently reported. Seizures were self-limited or resolved with benzodiazepines, and all patients recovered neurologically intact. Physostigmine should be avoided in patients with QRS prolongation on EKG, and caution should be used in patients with a history of coronary artery disease and overdoses with QRS prolonging medications. Based upon our review, physostigmine is a safe antidote to treat anticholinergic overdose.

The Recommendation and Use of Extracorporeal Membrane Oxygenation (ECMO) in Cases Reported to the California Poison Control System Abstract Introduction Antidotes are available to treat some specific poisonings; however, the mainstay of treatment for the poisoned patient remains supportive care. Extracorporeal membrane oxygenation (ECMO) is one of the most aggressive supportive measures available to manage poisoned patients. Objective To characterize the recommendation and use of ECMO in cases reported to the California Poison Control System (CPCS). Methods This retrospective chart review queried the CPCS database from 1997 to 2016 for cases containing the American Association of Poison Control Centers (AAPCC) code for ECMO, and "ECMO" and "ECLS" free-text searches. The collected data included year, age, gender, substances involved, route of exposure, clinical effects, treatments, and medical outcome. Results A total of 94 cases discussed ECMO as a supportive option with 16 cases utilizing ECMO. Cases where ECMO was discussed rose from one case in 1997 to 13 cases in 2016. Of the 94 cases where ECMO was discussed, 38 cases (40%) involved toxicity from a cardiovascular agent(s) and 33 cases (35%) involved exposure to hydrocarbons. Of the 16 cases where ECMO was performed, 13 (81%) involved males. The median age was 17 years (range 1 month–54 years). Ten cases (63%) involve patients under the age of 18. In this series, 13 of 16 ECMO-supported patients survived (81%). Conclusions ECMO is being recommended more often for treatment of acute poisoning cases by the CPCS. All caregivers involved in the treatment of poisoning should gain a working knowledge of the potentially lifesaving technology of ECMO, its indications for use, adverse effects, and drug or poison interactions.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
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6948891480

alsfakia@gmail.com