The toxic trio: valproic acid, lithium, and carbamazepine.

Patients with altered mental status and seizure or psychiatric disease often present with an unclear medication history. Commonly prescribed medications include valproic acid (VPA), lithium (Li), or carbamazepine (CZN) of which the regional poison center (RPC) often recommends obtaining these serum concentrations. Regularly ruling out supratherapeutic concentrations without a known history of ingestion may help direct care. Cases from the RPC coded as VPA, Li, and CZN, from January 1, 2006 to December 31, 2008, were searched. All patients with supratherapeutic concentrations (VPA >100 µg/mL, Li >1.2 mEq/L, and CZN >12 µg/mL) were evaluated for the following criteria: (1) those with altered mental status and an unclear history of seizure or psychiatric disorder and (2) a mediation profile not including VPA, Li, or CZN. Twenty-six patients met the inclusion criteria: 8 patients in the VPA group (113-247 µg/mL; mean, 158), 9 patients in the Li group (1.9-5.2 mEq/L; mean, 2.9), and 9 patients in the CZN group (13.4-38.8 µg/mL; mean, 23.2). All patients survived and were treated with supportive care; however, 1 patient had a Li level of 5.2 mEq/L and received hemodialysis. In altered patients potentially being treated for seizure or psychiatric disorders and unknown ingestions or medication lists, obtaining concentrations of VPA, Li, and CZN may help direct care and provide clinically relevant information. The RPC detected 26 patients with supratherapeutic VPA, Li, or CZN concentrations in patients with potential indications for the agent but no available history of drug ingested or medication list. A prospective study is warranted to evaluate the usefulness of obtaining these concentrations in this patient population.

An unusual case of epistaxis-juvenile nasopharyngeal angiofibroma.

BACKGROUND: Epistaxis is a common complaint seen in the younger population. Its etiology is typically from the anterior nares, although we present a case of epistaxis from an uncommon source-juvenile nasopharyngeal angiofibroma. Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular, benign, yet locally invasive tumor that occurs in preadolescent males. OBJECTIVES: To illustrate a case of epistaxis from an uncommon source. CASE REPORT: A 21-year-old man with a past medical history of allergic rhinitis presented to the Emergency Department (ED) after 6 months of intermittent yet worsening epistaxis. He described the bleeding as sudden onset that resolved after 30 min of direct compression of the external nares. He denied any history of digital manipulation, trauma, or bleeding disorders. Upon arrival in the ED, he had brisk bleeding from the right naris that was initially controlled with phenylephrine nasal spray. A small round friable mass was visualized in the right posterior nasal cavity. Further hemostasis of the epistaxis was achieved using a nasal tampon moistened with phenylephrine, and a computed tomography scan of the sinus revealed a soft tissue mass almost completely occupying the sphenoid sinus and extending into the nasopharynx and posterior ethmoids. There was also expansion and bony erosion of the right pterygopalatine fossa. A final diagnosis of JNA was made and the patient was given follow-up with an otorhinolaryngologist, who ultimately surgically resected the mass. CONCLUSIONS: JNA is a highly vascular, benign, yet locally invasive tumor that occurs in preadolescent males. This case illustrates the importance of appreciating the more uncommon cases of epistaxis, especially when conventional methods of treatment have initially failed.

Chemical and traumatic occupational eye exposures in aviation personnel.

INTRODUCTION: The eye is vulnerable to chemical exposure and foreign body infiltration in the occupational setting. Individuals working in the aviation field are prone to these types of exposures. METHODS: We conducted a 28-mo retrospective chart review to document the number of airline workers complaining of chemical or foreign body exposure to the eye at an onsite airport medical clinic. The International Classification of Diseases, Ninth Revision (ICD-9), code for chemical conjunctivitis (372.5), was used to identify patients' charts. We documented the type of treatment that was initiated and whether there was eye damage. We further investigated the chemical composition of the products and whether there was any associated toxicity. RESULTS: Few instances of chemical exposure and foreign body infiltration were found. Patients were exposed to the following products: lubricants (e.g., naphthenic oils), hydraulic fluid (e.g., petroleum or phosphate ester based), jet fuel (e.g., kerosene), and de-icing agents (e.g., propylene glycol). There was no documentation regarding the use of personal protection equipment in the patients' charts. All patients received eye irrigation with normal saline. No sequelae were documented. CONCLUSION: Airline personnel are exposed to a variety of chemical agents in the workplace. None of the agents that workers were exposed to in this small study exhibited toxic effects to the eye. Proper use of personal protection equipment in aviation personnel may limit the number of chemical and foreign body eye exposures.

Massive insulin overdose managed by monitoring daily insulin levels.

We present a case of a significant insulin overdose that was managed by monitoring daily plasma insulin levels. A 39-year-old male with poorly controlled diabetes mellitus presented to the Emergency Department via emergency medical services after an attempted suicide by insulin overdose. In the attempted suicide, he injected 800 U of insulin lispro and 3800 U of insulin glargine subcutaneously over several parts of his abdomen. The patient was conscious upon arrival to the emergency department. His vital parameters were within normal range. The abdominal examination, in particular, was nonfocal and showed no evidence of hematomas. He was awake, alert, conversant, tearful, and without any focal deficits. An infusion of 10% dextrose was begun at 100 mL/h with hourly blood glucose (BG) checks. The patient was transferred to the intensive care unit where his BG began to decrease and fluctuate between 50 and 80 mg/dL, and the rate of 10% dextrose was increased to 200 mL/h where it was maintained for the next 48 hours. The initial plasma insulin level was found to be 3712.6 uU/mL (reference range 2.6-31.1 uU/mL). At 10 hours, this had decreased to 1582.1 uU/ml. On five occasions, supplemental dextrose was needed when the BG was <70 mg/dL. Thirty-four hours after admission, the plasma insulin level was 724.8 uU/mL. Fifty-eight hours after admission, the plasma insulin level was 321.2 uU/mL, and the 10% dextrose infusion was changed to 5% dextrose solution at 200 mL/h. The plasma insulin levels continued to fall daily to 112.7 uU/mL at 80 hours and to 30.4 uU/mL at 108 hours. He was transferred to an inpatient psychiatric facility 109 hours after initial presentation. Monitoring daily plasma insulin levels and adjusting treatment on a day-to-day basis in terms of basal glucose infusions provides fewer opportunities for episodic hypoglycemia. Furthermore, it was easier to predict daily glucose requirements and eventual medical clearance based on the plasma levels.