[Severe pulmonary complications of massive intoxication with calcium channel blockers and isosorbide mononitrate--a case report]. / Ciezkie plucne powiklania zatrucia antagonistami kanalów wapniowych i monoazotanem izosorbidu--opis przypadku.

A 22-year-old man was admitted to the acute intoxication unit after suicidal intoxication with 100 tablets of verapamil, diltiazem and isosorbide mononitrate. He developed shock, paralytic ileus and adult respiratory distress syndrome (ARDS). The patient required high doses of catecholamines and mechanical ventilation with high inspiratory pressure. Pulmonary barotrauma (pneumothorax, pneumomediastinum, pneumoperitoneum and soft tissue emphysema) was a secondary complication to mechanical ventilation. It is well known that alveolar epithelial type II cells synthesize and secrete all components of the surfactant. Surfactant secretion in epithelial type II cells is inhibited by calcium channel blockers and it predisposes to develop ARDS. This case illustrates the possibility of ARDS in the verapamil and diltiazem intoxication and the need for a heightened awareness of this potential complication.

[Vasopressin analogue injection as ultimate measure for counteracting severe catecholamine-refractory poisoning by several vasodilators taken with suicidal intent]. / Vasopressinanaloga als Ultima ratio bei einer schweren Intoxikation mit Vasodilatanzien.

HISTORY AND CLINICAL FINDINGS: A 78-year-old woman was admitted to the intensive care unit 9 hours after ingestion of 2 g of isosorbitmononitrate, 430 mg of amlodipine, 250 mg of benazepril and 600 mg of mirtazapin in suicidal intent. INVESTIGATIONS: Clinical findings and invasive monitoring showed signs of a hyperdynamic hemodynamic cardiovascular failure caused by toxic vasodilatation. TREATMENT AND COURSE: Despite of primary detoxication, intravenous volume infusion with calcium gluconate, glucagon and naloxone and administration (norepinephrine up to 2 micro g/kg/min) no hemodynamic stabilization was achieved. Only when the vasopressin-analogue argipressin was given peripheral vasodilatation was overcome and hemodynamic stabilization resulted. 10 hours after discontinuing argipressin and norepinephrine the patient developed a mesenteric ischemia, and she finally died on the third day after admission. CONCLUSION: In circulatory shock due to toxic vasodilatation the use of vasopressin analogue argipressin can be helpful as an ultima therapeutic measure in catecholamine refractory shock caused by vasodilatation. Attention must be paid to overwhelming vasoconstrictor effects resulting in mesenteric ischemia.

Massive ingestion of isosorbide-5-mononitrate and nitroglycerin: suicide attempt by an adolescent girl without previous heart disease.

High plasma levels of isosorbide-5-mononitrate were found in a young girl who had ingested 1.6 g of the drug plus 20 mg of nitroglycerin. These concentrations produced no disturbance of the patient's state of consciousness and no serious haemodynamic effects appeared except for a tachycardia in relation to peripheral vasodilatation.

[Intoxication with beta-receptor blockers (author's transl)]. / Intoxikation mit Beta-Rezeptorenblockern.

Beta-blockers are increasingly often used with suicidal intent, but are also sometimes swallowed accidentally by small children. Beta-blockers available in the Federal Republic of Germany differ in their pharmacodynamics and pharmacokinetics. After analysing 49 cases of intoxication, no certain relationship was found between the different substances and specific symptoms. Cardiovascular signs such as sinus bradycardia, arrhythmia, hypotension (30 cases), as well as dizziness and drowziness (17) were the most frequent ones. Loss of consciousness and hallucination (13), as well as seizures (3), also occurred frequently. Hypoglycaemia or symptoms due to it (12) were noted especially in young children. In addition to primary removal of the drug, repeated administration of charcoal and sodium sulphate are recommended with most of the drugs for interrupting the enterohepatic circulation. Administration of atropine for bradycardia and hypotension was usually not effective. Dopamine is recommended; glucagon for definite signs of shock. Haemodialysis is indicated only in exceptional instances and is effective for only a few of the drugs. Forced diuresis should not be practised.