In vitro adsorption of lithium by bentonite.

BACKGROUND: Lithium poisoning is currently managed using a combination of supportive care and urgent haemodialysis in severe cases. Activated charcoal as a gut decontaminant has been found to be ineffective. The use of Sodium Polystyrene Sulphonate (SPS) as an adsorbent has been found to be effective in some studies. However, there have been case reports of gut necrosis and perforation occurring when SPS was used for the treatment of hyperkalaemia in post operative patients or patients with renal failure. Bentonite is a known adsorbent that has been used in the management of paraquat poisonings. The purpose of this study was to determine the ability of bentonite to adsorb lithium. METHOD: 4.5 g of lithium carbonate was dissolved in 1.5 L of deionised water to form the stock solution. 50 mL aliquots of this stock solution were added to 50 mL of either distilled deionised water (pH 7) or simulated gastric fluid (pH 1.2). Bentonite of either 0.75, 1.5 or 4.5 g was then added to simulate 5:1, 10:1 and 30:1 ratio of adsorbent-to-drug. Controls were made with no bentonite added. The resulting mixture was placed on a shaker for five minutes before being filtered. The filtrate was diluted and batch analysed for lithium using atomic absorption spectrophotometry. RESULTS: Bentonite decreased the concentration of lithium recovered from the filtrate by 20.55% in deionised water compared to 48.09% in simulated gastric fluid at a bentonite:lithium ratio of 30:1 (p value 0.005). CONCLUSION: This study shows that bentonite is an effective adsorbent for lithium. The effect is enhanced in simulated gastric fluid. In vivo studies are being planned for clinical correlation.

Catfish spine envenomation: a case report and literature review.

Catfish spine envenomations are common injuries, reported in both freshwater and saltwater. Such injuries are complex puncture wounds, often complicated by severe infection. Signs and symptoms range from simple local pain and bleeding to systemic manifestations with hemodynamic compromise. Care and treatment involve aggressive pain management, judicious wound cleansing, prophylactic antibiotics, and close follow-up. A case of catfish spine envenomation from a freshwater catfish is presented here.

Report on envenomation by a Gila monster (Heloderma suspectum) with a discussion of venom apparatus, clinical findings, and treatment.

Human envenomations by Heloderma species are a rare but clinically important medical problem. We report a case of an adult male bitten on the left hand by a 50-cm male, captive specimen of Heloderma suspectum (Gila monster). Immediate signs and symptoms included pain at the bite site radiating into the arm and axilla and swelling of the hand and forearm. Systemic complaints of nausea, diaphoresis, and dizziness (without a decrease in blood pressure) lasted approximately 1 hour, and laboratory studies were normal. The patient's course was uneventful except for persistent hyperesthesia, which eventually abated. Two types of helodermatid bites produce distinct clinical pictures. The chewing bite potentially causes more envenomation than the slashing bite. The venom contains a number of protein and nonprotein components including serotonin, a bradykinin-releasing substance, protease, hyaluronidase, helodermin, and gilatoxin. The clinical presentation of a helodermatid bite can include pain, edema, hypotension, nausea, vomiting, weakness, and diaphoresis. No antivenin is commercially available. Treatment is supportive, and although first aid measures such as suction or compression may impede venom movement, they are unproved. Cryotherapy, tourniquet, and excision are dangerous and should not be used.

Severe rhabdomyolysis following a viral illness: a case report and review of the literature.

Rhabdomyolysis is a syndrome often associated with alcohol and drug abuse. It may also be seen following viral infections, but is a complication not often considered. We report a case of severe rhabdomyolysis following an influenza-like illness. Despite the extreme elevation of creatinine phosphokinase, 230,600 IU/L, this patient did not develop acute renal failure in contrast to most of the previously documented case reports of rhabdomyolysis associated with influenza virus. This case report illustrates the difficulty in predicting which patients are at risk for developing acute renal failure and emphasizes the need for aggressive treatment of any patient suspected of having rhabdomyolysis.

Use of amrinone and glucagon in a case of calcium channel blocker overdose.

Hypotension resulting from calcium channel blocker ingestion often is refractory to standard therapeutic modalities. Amrinone and glucagon have been used separately and in combination with other agents in the treatment of calcium channel blocker overdose. We report the successful use of both amrinone and glucagon in the treatment of a 30-year-old woman who ingested 3.6 g of verapamil and presented with refractory hypotension. The use of the two agents together may provide improved inotropic support with minimal increases in myocardial oxygen consumption. In this case, the combination of amrinone and glucagon was safe and effective in the management of the hemodynamic instability associated with calcium channel blocker overdose.

Acute myocardial infarction in chest pain patients with nondiagnostic ECGs: serial CK-MB sampling in the emergency department. The Emergency Medicine Cardiac Research Group.

STUDY OBJECTIVES: This study tested the hypothesis that serial creatine phosphokinase (CK)-MB sampling in the emergency department can identify acute myocardial infarction (AMI) in patients presenting to the ED with chest pain and nondiagnostic ECGs. DESIGN: Patients more than 30 years old who were evaluated initially in the ED and hospitalized for chest pain were studied. Serial CK-MB levels were analyzed prospectively using a rapid serum immunochemical assay for identification of AMI patients in the ED. Presenting ECGs showing new, greater than 1-mm ST elevation in two or more contiguous leads were considered diagnostic for AMI. All other ECGs were considered nondiagnostic ECGs. CK-MB levels were determined at ED presentation and hourly for three hours (total of four levels). Patients with at least one level of more than 7 ng/mL were considered to have a positive enzyme study. The in-hospital diagnosis of AMI was determined by the development of typical serial ECG changes or separate standard cardiac enzyme changes after admission. SETTING: Eight tertiary-care medical center hospitals. METHODS AND MAIN RESULTS: Of the 616 study patients, 108 (17.5%) were diagnosed in the hospital as AMI; 69 of these AMI patients (63.9%) had nondiagnostic ECGs in the ED. Of the patients with nondiagnostic ECGs, 55 (sensitivity, 79.7%) had a positive ED serial CK-MB enzyme study within three hours after presentation. Combining serial ED CK-MB assay results with diagnostic ECGs yielded an 88.4% sensitivity for AMI detection within three hours of ED presentation. The predictive value of a negative serial ED enzyme study for no AMI was 96.2% (specificity, 93.7%). CONCLUSION: Serial CK-MB determination in the ED can help identify AMI patients with initial nondiagnostic ECGs. Use of serial CK-MB analysis may facilitate optimal in-hospital disposition and help guide therapeutic interventions in patients with suspected AMI despite a nondiagnostic ECG.

Cinchonism: two case reports and review of acute quinine toxicity and treatment.

Two cases of acute quinine toxicity are presented, one from self-poisoning and the other from an unidentified source. Both patients presented with acute bilateral blindness. They also experienced the classic symptoms of cinchonism, including nausea, vomiting, and tinnitus. Prolongation of the Q-T interval developed in both patients. Serum quinine levels of 5.3 mg/L and 13 mg/L were measured. Although their visual acuity improved, both patients had some residual deficit at follow-up. A review of the literature, including clinical presentation and emergency medicine diagnosis and management, is also presented.

A four-year program to train residents in emergency medical services.

There is general agreement that residents in the field of emergency medicine require extensive training in emergency medical services (EMS). This paper outlines a comprehensive four-year training program in EMS that has been integrated into the emergency medicine residency curriculum of the University of Cincinnati since 1985. The EMS program is comprehensive and makes it possible for the level and type of EMS activities that are provided to match the evolving expertise of the resident. The program provides a significant amount of practical training in ground and aeromedical transport, in disaster work, in telemetry communications, and in other areas. Evaluation of the program is at an early stage but informal reports are strongly positive.

Acute pulmonary toxicity to nitrofurantoin.

Nitrofurantoin is a widely prescribed antibiotic used for the treatment of urinary tract infections. In some patients it can produce an acute pulmonary reaction ranging from mild dyspnea to noncardiogenic pulmonary edema. Symptoms include fever, dyspnea, chills, cough, and chest pain. Physical examination generally reveals an acutely ill, extremely apprehensive patient in varying degrees of respiratory distress. Fever is usually present and there is an increase in heart rate and respiratory rate. Cyanosis, rales, and a maculopapular rash are common findings. Laboratory studies typically demonstrate a leukocytosis with eosinophilia, varying degrees of hypoxia and hypocapnia, and a mild to moderate elevation of the erythrocyte sedimentation rate. The chest x-ray study may be normal but more often demonstrates bilateral lower lobe interstitial infiltrates frequently accompanied by pleural effusions. Treatment in the majority of cases requires only stopping the drug, but steroids, bronchodilators, or antihistamines may be used in selected cases. Once the diagnosis is made and the drug withdrawn, prognosis for full recovery is excellent.

Correlation of initial amitriptyline concentration reduction with activated charcoal therapy in overdose patients.

Plasma amitriptyline concentrations were measured serially in nine overdose patients and correlated with the timing and amount of each patient's initial activated charcoal therapy. A direct correlation was found between the time to initial charcoal therapy (Tc) and the plasma concentration half-life of amitriptyline (T 1/2) calculated for the first seven to 18 hours of hospitalization; T 1/2 = 2.68 + 0.047 Tc (r = 0.78, P less than 0.05). An inverse trend of T 1/2 with the initial amount of charcoal administered was also noted. Nortriptyline, the major metabolite of amitriptyline, decreased in two of three patients who received greater than or equal to 50 gm of activated charcoal within 60 minutes of presentation. These findings support previous in vitro and human volunteer studies advocating the rapid administration of activated charcoal in acute tricyclic antidepressant overdoses.

Evaluation of Syva EMIT Toxicological Serum Tricyclic Antidepressant Assay.

Tricyclic antidepressant (TCA) overdose is a common, potentially life-threatening finding in patients seen in emergency departments. There is a need to rapidly differentiate the TCA overdose from others in the emergency unit population. The Syva EMIT Toxicological Serum Tricyclic Antidepressant Assay for serum tricyclic antidepressant levels on 87 patients being evaluated for possible TCA overdose in the emergency department of the University of Cincinnati Hospital was examined. Serum tricyclic antidepressant concentrations were also determined by high performance liquid chromatography (HPLC), and comprehensive urine drug screening was performed by several methods. The EMIT assay correctly identified all 53 negative patients whose TCA levels were less than 300 ng/mL. The remaining 34 patients had positive TCA levels greater than 300 ng/mL by EMIT; however, 22 were confirmed by HPLC. Phenothiazines and phenothiazine metabolites were present in the remaining 12 unconfirmed patients, indicating a cross reaction with this class of drugs. It was concluded that the assay is useful to exclude the presence of serious TCA ingestion when a result of less than 300 ng/mL is obtained. However, a result of greater than 300 ng/mL is not specific for TCAs only, as evidenced by the cross reactions obtained with phenothiazines.

An evaluation of carboxyhemoglobin spot tests.

A number of spot tests for carboxyhemoglobin are described in the emergency medicine literature. Four of these tests were evaluated for specificity, sensitivity, ease of performance, and ease of interpretation. Second- and third-year emergency medicine residents were given samples of blood and asked to perform each of four spot tests on the samples. They were told that the samples may or may not contain carboxyhemoglobin. The reagents and instructions were available, but no technical assistance was given. The residents were asked to record the results of the tests and to answer a questionnaire. The test results were analyzed by linear regression and within-run precision. The available spot tests found in the literature were unable to determine accurately clinically significant levels of carboxyhemoglobin. The evaluators believed that the tests required a minimum of technical expertise and were easy to perform and interpret. None of the evaluators had any prior experience with carboxyhemoglobin spot tests.

Bicarbonate therapy for the cardiovascular toxicity of amitriptyline in an animal model.

The beneficial hemodynamic effects of sodium bicarbonate as treatment for tricyclic antidepressant poisoning were investigated in an animal model. Seven adult dogs (17.5 to 20 kg) were poisoned by an intravenous infusion of amitriptyline. Toxicity was defined as a doubling of the initial QRS width. A continuous infusion was used to maintain toxicity for 30 minutes after which 44.5 mEq of sodium bicarbonate was administered intravenously. Five of the animals survived to completion of the experiment. Three of the surviving animals developed dysrhythmias. All dysrhythmias ceased within one minute of administration of sodium bicarbonate. An increase in mean blood pressure (P less than .05) and serum pH (P less than .05) and a decrease in mean QRS width (P less than .05) occurred following administration of sodium bicarbonate. The maintenance of toxicity for 30 minutes suggests that this model can be used for future studies of tricyclic antidepressant poisoning.

Venomous snakebite in a patient allergic to horse serum.

The management of snake envenomation is a clinical challenge. The definitive therapy, antivenin, is potentially harmful and should not be used indiscriminately. However, the morbidity and mortality from the envenomation usually outweigh any adverse reactions to the antivenin therapy. Most reactions can be divided into two general categories: type I (immediate hypersensitivity) reaction, which may be life-threatening, and the more common type III (immune complex) reaction characterized by serum sickness. It is vital to evaluate the patient's potential for developing adverse reactions from antivenin and to be prepared to provide appropriate therapy. The administration of epinephrine and antihistamines can be lifesaving in type I reactions, while steroids and antihistamines can ameliorate type III reactions.

Blood levels of diazepam after endotracheal administration in dogs.

A pilot study was performed to evaluate the endotracheal administration of diazepam. Five mongrel dogs were anesthetized and orotracheally intubated. Diazepam in a dose of 0.5 mg/kg was delivered through a red rubber catheter placed through the endotracheal tube. Diazepam levels were then measured at 0, 30, and 60 seconds, and at 2, 5, 15, 30, and 60 minutes. Arterial blood gas determinations were performed at 0, 10, 30, 60, and 90 minutes. In all dogs peak serum levels averaged 1,500 ng/ml +/- 541 ng/ml, which is well above therapeutic anticonvulsant levels (150 ng/ml to 600 ng/ml). Arterial pH an PCO2 did not change dramatically from control values during the period of study. Arterial PO2 showed a transient drop of approximately 10 to 30 mm Hg within the first 60 minutes, but returned nearer the control values by the end of 90 minutes. the endotracheal administration of diazepam has been shown to be effective in achieving rapid therapeutic serum levels of the drug. Further study is needed to determine any deleterious effects on the lungs before this method of administration can be recommended for use in humans.