A Case of Mental Change in a Patient Who Received a Zoletil Injection

Zoletil is a non-opioid, non-barbiturate animal anesthetic and proprietary combination of two drugs, a dissociative anesthetic drug, tiletamine, with the benzodiazepine anxiolytic drug, zolazepam. Zoletil has greater potency than ketamine. Zoletil is abused for recreational purposes, especially by people with easy access to medicine. However, in Korea, it is available over-the-counter. Here we report on a case of an 83-year-old woman who received injection of seven vials of "Zoletil 50" by her daughter and presented with an altered mental change. Her mental state was stupor and vital sign was hypotension, bradycardia. Her blood tests indicated metabolic and respiratory acidosis and hyperkalemia. She was treated with intravenous naloxone and flumazenil but was not responsive. She was admitted to the ICU and treated with supportive therapy. Her mental state showed transient recovery, however, her clinical manifestation worsened and she expired.

Clinical Features of Acute Acetanilide Herbicide Poisoning

PURPOSE: Acetanilide has been in widespread use as an amide herbicide compound. However, available data regarding acute human poisoning is scarce. The aim of this study was to analyze the clinical characteristics of acetanilide poisoning in order to identify the risk factors associated with severity. METHODS: We conducted a retrospective observational study encompassing the period January 2005 to December 2010, including adult ED patients suffering from acetanilide intoxication. Toxicological history, symptoms observed, clinical signs of toxicity, and laboratory test results were collected for each patient. The patients were classified into two groups for analysis, according their poisoning severity score (PSS). Resulting clinical data and prognostic variables were compared between mild-to-moderate poisoning (PSS 1/2 grades), and severe poisonings and fatalities (PSS 3/4 grades). RESULTS: There were a total of 37 patients, including 26 alachlor, 6 s-metolachlor, 4 mefenacet, and 1 butachlor cases. The majority of patients (81.1%) were assigned PSS 1/2 grades. Changes in mental status and observation of adverse neurologic symptoms were more common in the PSS 3/4 group. The median ingested volume of amide herbicide compound was 250 ml (IQR 200-300 ml) in the PSS 3/4 group, and 80 ml (IQR 50-138 ml) in the PSS 1/2 group. Also, the median GCS observed in the PSS 3/4 group was 13 (IQR 10-14), which was markedly low as compared to a median GCS of 15 in the PSS 1/2 group. Overall mortality rate was 5.4%, and profound cardiogenic shock was observed prior to death in all fatalities. CONCLUSION: When compared to previous reports, acute acetanilide poisoning resulted in relatively moderate severity. The presence of neurologic manifestations, hypotension, lower GCS score, and larger ingested volumes was associated with more serious effects and mortalities.

Clinical Analysis of Ocular Trauma Induced by Lawn Trimmers

PURPOSE: Lawn trimmers are widely used to cut the weeds around graves in South Korea, but they can cause ocular injury. We investigate at the emergency room the incidence and the clinical features of ocular trauma induced by lawn trimmers. METHODS: The authors analyzed 106 patients who visited Konyang University Hospital's emergency room from March 1, 2007, to October 31, 2011, because of ocular trauma caused by a lawn trimmer. Patients were sorted into two groups, severe ocular injury and mild ocular injury. RESULTS: Over a 5-year period, 106 patients with ocular trauma caused by a lawn trimmer underwent clinical study. Most of the patient (103 patients) were males, and the average age of the patients was 51.75+/-11.66 years. The incidence of ocular trauma peaked in the sixth decade of life. Most injuries occurred between July and September. Severe ocular injury developed in 46.2% of all patients. As age increased, so did the severity of the ocular injury. The impacting object was a small stone in 43.4% of all patients. Nobody wore protective gear. The most common diagnosis were corneal abrasion, followed by intraocular foreign body, corneal laceration, and sclera laceration. Fifty-four patients were followed up, and thirty-six patients of them had severe injury. The most common complication was a traumatic cataract. CONCLUSION: Ocular trauma induced by a lawn trimmer is more severe than general ocular trauma. We suggest that everyone using a lawn trimmer should wear protective gear and follow safety guidelines.

Comparative Study Evaluating the Accuracy of the Urine Sodium Dithionite Test to Predict Plasma Paraquat Concentration in Poisoning Cases

PURPOSE: Plasma Paraquat level is one of the most important prognostic factors used in identifying Paraquat poisoning. Urine sodium dithionite tests are widely used in clinical settings for detecting the presence of Paraquat chemicals and predicting prognosis, but this test is subjective and qualitative. In this prospective study, we evaluated the correlation between sodium dithionite test results as measured by a colorimeter, versus actual plasma or urine Paraquat levels. METHODS: Plasma and urine sample were taken from patients upon arrival at a local emergency center (ED) within 12 hours after Paraquat ingestion. Urine was tested using sodium dithionite reaction and the resulting urine color was measured by colorimeter to result in an L (lightness) value. RESULTS: A total of 23 patients were enrolled in this study with a mean age of 57 years old, mean Paraquat intoxication volume of 94 mL, and mean Paraquat intoxication prior to ED arrival of 3.2 hours. The patients' mean blood Paraquat concentration was 82.23 microg/ml and urine Paraquat concentration was 169.19 microg/ml. Using the sodium dithionite test, 17 patients were diagnosed as beyond 'strong positive'. L values were correlated with intoxication volumes, blood Paraquat concentrations, and urine Paraquat concentrations. Blood Paraquat concentrations showed significant correlation with L value, poison volume, urine Paraquat volume, and creatinine values. CONCLUSION: The greater the intoxicated Paraquat volume, blood Paraquat concentration, and urine Paraquat concentration, the lower the L value.

A Case of Electrocardiographic and Mental Change in a Patient with a Diphenhydramine Overdose

The antihistaminic drug diphenhydramine is mainly used as a sedative, hypnotic and antiemetic. In many countries it is available over-the-counter, very common, and generally regarded as a harmless drug. However, diphenhydramine overdose can result in cardiotoxicity due to its ability to block fast sodium channels in a manner analogous to classic Vaughan-Williams type IA antidysrhythmic agents. As such, cardiotoxicity from diphenhydramine resembles that of the tricyclic antidepressant agents. Here we report a case of a 52 year old man who ingested 2,000 mg of diphenhydramine and presented with an altered mental state and an electrocardiographic change. His electrocardiogram showed sinus tachycardia with a rate 145 beat/min, a QRS interval of 88 ms, and a QTc of 556 ms. He had a wide anion gap metabolic acidosis. He was treated with intravenous sodium bicarbonate and supportive therapy. His clinical manifestations waned and he was transferred to another hospital nearby his hometown.