Altered Mental Status at High Altitude.

Intrathecal baclofen pumps are commonly used in pediatric patients with spastic cerebral palsy. Baclofen binds to γ-aminobutyric acid receptors to inhibit both monosynaptic and polysynaptic reflexes at the spinal cord level. The blockade stops the release of excitatory transmitters and thereby decreases muscle contraction. It is commonly used for lower limb spasticity and has been shown to improve postural ability and functional status. The US Food and Drug Administration has approved baclofen for the treatment of spasticity of cerebral or spinal origin in adult and pediatric patients 4 years or older. Various complications of baclofen pumps are described in the literature. Immediately after surgery, problems from infection can arise and range from superficial skin infections to meningitis and bacteremia. Another early complication includes cerebrospinal fluid leak that can be observed by notable swelling beneath the lumbar incision. Additional problems that arise later are usually from the mechanics of the pump and catheter. Pump-related complications include failure, migration, and flipping. Catheter-related complications include disconnection, occlusion, fracture, or kink. Most of these complications typically lead to baclofen withdrawal, although there are a few case reports of overdose due to mechanical causes. Here we describe 2 cases of individuals experiencing complications of excessive baclofen exposure after significant changes in the atmospheric pressure due to travel involving ambient altitude change. These cases reflect the need to discuss this potential complication with families and patients with baclofen pumps before travel to high elevations.

Unintentional fatal phosphine gas poisoning of a family.

OBJECTIVE: The objective of the study was to report the toxicity of phosphine gas after a residential fumigation that resulted in fatal poisoning of a 15-month-old toddler and her 4-year-old sibling. METHODS: This is a case report and a review of literature. RESULTS: A family of 6 members was exposed to phosphine gas after their yard was treated with aluminum phosphide for a rodent infestation. The inhalation of phosphine gas initially caused symptoms of abdominal distress in all of the family members. Within 36 hours of exposure, the 4-year-old sibling died of cardiopulmonary failure in a local emergency department. After an initial presentation of respiratory distress, the 15-month-old toddler progressed to complete cardiopulmonary collapse and did not survive despite aggressive intervention including extracorporeal membrane life support. CONCLUSIONS: Unintentional phosphine gas exposure is rare but has a toxic profile that results in a high fatality rate with no known antidote.