Aminophylline reversal of antihypertensive agent toxicity.

Hypotension occurred following a combined beta blocker (atenolol), angiotensin converting enzyme inhibitor (quinapil) and selective serotonin reuptake inhibitor (fluvoxamine) overdose. In another instance heart block and hypotension was noted in association with a diltiazem and atenolol adverse interaction. Crystalloid infusion was ineffective in both cases, but toxicity was rapidly reversed with aminophylline administration. Aminophylline's recognized inotropic and chronotropic properties make it a potentially valuable therapeutic agent in the treatment of antihypertensive medication toxicity.

Acute myocardial infarction and renal failure following naphtha ingestion.

We present a case of a non-Q wave myocardial infarction and acute renal failure following an ingestion of naphtha, a petroleum distillate composed primarily of hydrocarbons. The patient's renal, metabolic, and cardiac status improved over several days with aggressive volume replacement and bicarbonate therapy. Acute cardiotoxic effects of hydrocarbon exposure generally manifest as dysrhythmias, secondary to myocardial sensitization to circulating catecholamines, or, possibly, coronary vasospasm. Ischemia from associated hypotension or direct myocardial toxicity are other potential causes of naphtha-related cardiac injury.

Vaginal pessary-induced mechanical bowel obstruction.

We present a case of a mechanical bowel obstruction secondary to an impacted vaginal pessary. As the elderly segment of the population continues to grow, pessary use is increasing in absolute numbers, and clinicians must consider these medical devices when evaluating abdominal, gynecological, and urological complaints in elderly women.

Prolonged coma and loss of brainstem reflexes following amitriptyline overdose.

Severe tricyclic antidepressant (TCA) overdose is generally manifested by cardiovascular and/or central nervous system toxicity. Although the majority of patients who are comatose following these overdoses regain consciousness within 24 h, this case had 5-days of coma with associated loss of brainstem reflexes. Severe central nervous system depression can occur as a sole manifestation of TCA overdose without concomitant cardiovascular toxicity.

Corneal bee sting with retained stinger.

Bee stings of the cornea are rarely reported, but have the potential for causing serious ophthalmologic injuries. We present a case of corneal bee sting with retained stinger apparatus and associated iritis and discuss the pathologic mechanisms of injury, evaluation, and treatment of these uncommon presentations.

Diarrhea-associated over-anticoagulation in a patient taking warfarin: therapeutic role of cholestyramine.

We present a case of significant over-anticoagulation temporally associated with a bout of protracted diarrhea in a patient on warfarin therapy. Cholestyramine was utilized to interrupt the enterohepatic recycling of warfarin and for its antidiarrheal effects to prevent gastrointestinal vitamin K wasting. Cholestyramine enabled the use of very low doses of sc vitamin K1 (2 mg total) with subsequent attainment of a therapeutic International Normalized Ratio in 39 h.

Congestive heart failure and toxic digoxin levels: role of cholestyramine.

We report 2 patients with congestive heart failure and concomitant toxic serum digoxin levels in whom cholestyramine administration increased clearance of digoxin and decreased serum digoxin elimination half-lives. Cholestyramine's gastrointestinal binding of enterohepatically-recycled and enterally-secreted digoxin enhanced elimination, allowing a more rapid return to therapeutic drug levels.

Transdermal drug delivery system exposure outcomes.

Transdermal drug delivery systems are increasingly popular, yet few data exist regarding medical outcomes after exposures. Using data collected through a Regional Poison Information System, this retrospective study identified 61 cases of transdermal drug delivery system exposures reported over a recent 5-year period. Exposure routes included dermal (48 patients), oral (10 patients), combined oral and dermal (one patient), parenteral use of gel residue (one patient), and combined oral and parenteral (one patient). Forty-four exposures (72%) were managed by home telephone consultation only. Eleven of 17 patients (18%) evaluated in health care facilities were admitted, including eight (13%) to intensive care units. Hospital admission correlated statistically with clonidine and fentanyl exposures, oral exposures, and drug abuse. Clonidine exposure also correlated statistically with intensive care admission. One fatality was recorded, and all other patients recovered uneventfully. Transdermal drug delivery system exposures are infrequently reported to our regional poison information center but are associated with a significant hospital use and admission rate.

Flumazenil reversal of carisoprodol (Soma) intoxication.

A 52-year-old woman presented with central nervous system depression and a Glasgow Coma Score of 9 secondary to ingestion of carisoprodol, a centrally acting muscle relaxant analgesic. After administration of i.v. flumazenil, the patient's neurologic status normalized and she required no further therapy. Carisoprodol and its active sedative-hypnotic metabolite, meprobamate, are gamma aminobutyric acid receptor indirect agonists with central nervous system chloride ion channel conduction effects similar to the benzodiazepines, thus making flumazenil a potentially useful antidote in toxic presentations.

Clinical nuances of pediatric methadone intoxication.

Pediatric methadone intoxication may present with clinically unusual findings which could cause confusion to the inexperienced practitioner. We present a case of pediatric methadone overdose, address clinical nuances pertinent to these overdoses, and discuss measures aimed at limiting these potentially catastrophic exposures.

Rectus abdominis endometrioma.

A 31-year-old woman presented with complaints of increasingly severe right lower quadrant discomfort that had occurred for several days each month over the course of the previous 6 months. A tender mass of the abdominal wall was palpated on physical examination, and subsequent ultrasonography and magnetic resonance imaging disclosed a discrete mass of the body of the right rectus abdominis muscle which was confirmed as endometrial tissue on biopsy. Rectus abdominis endometrioma is a relatively rare cause of abdominal pain which may mimic an acute abdomen. Clinical clues to the diagnosis include previous uterine or gynecological surgery/invasive procedure (with preservation of ovarian function), cyclical nature of the discomfort, and the presence of a palpable mass with or without associated skin color changes.

Perionychial infections associated with sculptured nails.

Two cases of perionychial infections associated with the use of sculptured fingernails are presented. Both patients developed paroncyhia necessitating incision and drainage. One patient, a diabetic, had a concomitant subungual abscess and felon which required repeat drainage and debridement as well as intravenous antibiotics over an extended period for complete resolution. Sculptured fingernails may be risk factors for the development of digit infections through various mechanisms, and users of these cosmetic devices, especially diabetics and immunocompromised people, should be made aware of their potential for infectious complications.

Compartment syndrome after simple venipuncture in an anticoagulated patient.

An excessively anticoagulated 52-year-old man on chronic warfarin therapy developed a forearm compartment syndrome after venipuncture in an antecubital vein. At fasciotomy, active venous bleeding into the forearm from the venipuncture site was noted, and a large forearm hematoma was evacuated. Anticoagulated patients or those with coagulopathies are at risk for compartment syndrome after percutaneous needle punctures and should be warned of this possibility. Such individuals should be instructed to seek immediate medical attention if any signs or symptoms of this complication occur.

Urosepsis associated with vaginal pessary use.

Conservative management of genital prolapse in older women uses vaginal pessaries. Infectious complications of these devices, attributable in some instances to poor routine maintenance, are uncommonly reported. We present 2 cases of genitourinary sepsis associated with unsuspected pessary use and discuss the spectrum of complications reported with these appliances.

Dextromethorphan- and pseudoephedrine-induced agitated psychosis and ataxia: case report.

Pseudoephedrine and dextromethorphan are therapeutic constituents of numerous commonly used, over-the-counter cough and cold preparations. Although this drug combination is generally considered quite safe if utilized in recommended doses, overmedication or overdose can result in serious neurologic and cardiovascular abnormalities that occasionally can be life-threatening. We present a case of a 2-year-old child who developed hyperirritability, psychosis, and ataxia after being overmedicated with a pseudoephedrine/dextromethorphan combination cough preparation, and discuss probable mechanisms of toxicity and risk factors for adverse events.

Cervical spine injury in low-impact blunt trauma.

Few data are available regarding the incidence of cervical spine injuries following relatively low-impact blunt trauma. This prospective level II trauma center study of low-impact blunt trauma found a 1.30% incidence of cervical spine injury. Impressive differences were found in such parameters as population characteristics, modes of injury, elapsed times to emergency department evaluation, and Revised Trauma Scores between this study group and those reported in prospective level I high-impact blunt trauma series. Cervical spine injury in low-impact blunt trauma is significant and often presents less than dramatically, thus emphasizing a need for maintaining a high index of suspicion at all times.

Clonidine and sleep apnea syndrome interaction: antagonism with yohimbine.

A patient with sleep apnea syndrome, concurrently taking clonidine as an antihypertensive, presented with severe respiratory acidosis, hypotension, and associated central nervous system depression. Acidosis was improved by mechanical ventilation, and central nervous system (CNS) depression and hypotension were reversed with yohimbine. Clonidine may have an additive CNS depressive effect in sleep apnea syndrome and should be used with caution in such patients. Yohimbine's sympathetic-enhancing effects may be useful in clonidine toxic states.