Medical outcome of cocaine bodystuffers.

To describe the clinical course of cocaine "bodystuffers" presenting to regional emergency departments, a descriptive retrospective analysis was performed on all cases of cocaine bodystuffers received by a metropolitan poison control center and associated toxicology service from January 1993 to May 1994. We identified 46 cases of patients classified as bodystuffers. Of these, 34 patients (74%) remained asymptomatic. Eight patients (18%) had mild symptoms including hypertension and tachycardia that resolved with no treatment beyond decontamination or benzodiazepines (one patient). Two patients (4%) had moderate symptoms including agitation and fever that resolved with no treatment beyond decontamination or benzodiazepines (one patient). Two patients (4%) had severe symptoms including seizure and cardiac dysrhythmia. Both died. Radiographs of the abdomen were negative for foreign body in all 23 examinations performed. Mild cocaine intoxication is common in cocaine bodystuffers. Severe intoxication can occur, resulting in death. Abdominal radiographs are not of value for stuffers ingesting cellophane-wrapped packets. More experience is needed to determine the length of intensive care monitoring that these patients require.

False-negative abdominal CT scan in a cocaine body stuffer.

Computed tomography (CT) imaging has been touted as one of the best techniques to detect body packets in body packers and stuffers. The majority of experience has been with body packers. We describe a case of a body stuffer who presented with abdominal pain after ingesting a large packet containing multiple small packets, with a falsely negative abdominal CT scan without contrast. This case raises questions regarding the best method of detection of body packets in body stuffers.

Emergency department use of flumazenil prior to poison center consultation.

We studied the frequency of use of flumazenil by emergency departments in our region and compared it to recommendations made by specialists in poison information at our poison control center. For a 5-mo period, we prospectively collected cases involving benzodiazepines or zolpidem. Data was documented only from calls from emergency departments. Emergency department personnel were asked the following: If given, the dose and frequency, contraindications, and adverse reactions. Each case was followed to completion. Flumazenil was not given in 55 cases. Of the remaining 14 cases in which it was given, 10 of the cases received flumazenil prior to poison control center consultation. We noted 1 case of dizziness. Ten cases given flumazenil had contraindications (eg ethanol abuse or possible seizurogenic coingestants). Despite possible contraindications, flumazenil was given 10/14 times (71%) prior to calling the poison control center. These results point to potential overuse of this antidote where contraindications or cautions are suspected in the overdosed patients. Our study suggests that when flumazenil use is contemplated by an emergency department physician, a poison control center consult may have a contrary recommendation.

Environmental injuries.

Environmental injuries and illnesses can happen in home, work, or recreational settings. The variety and severity of these injuries might require the clinician to call on skills from internal medicine, emergency medicine, and toxicology. Diseases of thermoregulation are hypothermia and hyperthermia. In each instance, treatment is based on the need to restore the patient's core temperature to normal and on monitoring for complications. The victim of a fire might suffer inhalation injury in addition to burns, and it is more likely that the inhalation injury will be fatal. Oxygen deprivation and inhalation of irritant or asphyxiant chemicals contribute to injury. Toxic plants can be the source of poisoning emergencies, especially in children. Misinformation and myths that surround common plants can create diagnostic problems (i.e., which plants really are toxic and require emergency measures). Venomous marine organisms can cause a wide range of injury, from cutaneous eruption to fatal envenomation. Most are encountered in a recreational setting, such as water sports, but keepers of home aquariums are subject to stings from venomous fish. Lightning injury can present many diagnostic and treatment dilemmas. An important point in this regard is that lightning injury and high-voltage electrical injury are different in pathology and require different approaches for treatment. A discussion of electrical, chemical, and thermal burns makes such differences apparent.

Late increase in acetaminophen concentration after overdose of Tylenol Extended Relief.

We report a case demonstrating a late increase in acetaminophen concentration after ingestion of Tylenol Extended Relief (extended-release acetaminophen; McNeil Consumer Products) along with drugs known to slow gastrointestinal motility. Coingestants that slow gastrointestinal motility are known to affect the interpretation of serum drug concentrations. However, this case illustrates potentially significant differences between extended-release and immediate-release acetaminophen and demonstrates an exception to the current manufacturer recommendation for the use of the Rumack-Matthew nomogram in this setting.

Drug use patterns at major rock concert events.

STUDY OBJECTIVE: To describe alcohol and drug use patterns in patients presenting to first aid stations at major rock concerts. METHODS: We retrospectively reviewed all charts generated at the first aid stations of five major rock concerts featuring the rock groups Pink Floyd, the Grateful Dead, and the Rolling Stones. The first aid stations, located at a sports stadium, were staffed by paramedics, emergency medicine nurses, and physicians. We recorded the following data: patient demographics, history of drug or ethanol use, time spent by patient in first aid station, treatment rendered, diagnosis, and patient disposition. RESULTS: A total of 253, 286 spectators attended the five concert events. The rate of use of the first aid station was 1.2 per 1,000 patrons. The average age of the patrons was 26.3 +/- 7.9 years (range, 3 to 56 years). The most common diagnoses were minor trauma 130 (42%) and ethanol or illicit drug intoxication 98 (32%). Of the patients treated, 147 (48%) admitted to using illicit drugs or ethanol while attending the concerts. The median time spent in the first aid station was 15 +/- 22.5 minutes (range, 5 to 150 minutes). One hundred patients (32.5%) were treated and released, 98 (32%) were transported to emergency departments, and 110 (35.5%) signed out against medical advice. CONCLUSION: Minor trauma and the use of illicit drugs and ethanol were common in spectators presenting to first aid stations at these concert events. Physicians and paramedical personnel working at rock concerts should be aware of the current drug use patterns and should be trained in treating such drug use.

Acute renal toxicity after ingestion of Lava light liquid.

A 65-year-old man with a history of alcohol abuse and seizure disorder presented to the emergency department with altered mental status, increased anion gap acidosis, phenytoin toxicity, and acute kidney failure. The patient had ingested the liquid contents of a Lava light, which contained chlorinated paraffin, polyethylene glycol (molecular weight 200), kerosene, and micro-crystalline wax. Gas chromatography-mass spectrophotometry of the patient's blood produced results consistent with the same analysis of the Lava light contents. After 3 days of declining mental status and worsening kidney function, the patient required hemodialysis. After a prolonged hospitalization, the patient was discharged home with residual renal insufficiency. Although multifactorial, the associated renal toxicity was most probably related to the low molecular weight polyethylene glycol content of the lamp's liquid contents.

Acute accidental lindane ingestion in toddlers.

Lindane toxicity has been reported to occur mostly by way of dermal exposure. Cases of ingestion in which blood levels have been determined are rare. We present three such cases, along with a comparison of cases in the literature with respect to blood level half-lives and correlation with signs of toxicity. Emergency physicians can prevent acute ingestion by educating patients on the proper use of lindane and by selecting less toxic scabicidal agents.

Infant involved in a motor vehicle accident.

The authors present and discuss the differential diagnosis for a 7-month-old infant who was seen in the ED after having been involved in a motor vehicle accident. The infant was subsequently found to have an odontoid fracture. Strict attention to the mechanism of injury is emphasized for appropriate evaluation of this patient's condition. An infant who becomes airborne in a car that is extensively damaged deserves an aggressive workup. In a child of this age, examination for subtle or even quite significant injury is difficult. Therefore the focus should be on the potential for injury. This article addresses the rarity of this injury pattern and discusses factors involved in treatment of cervical spine injuries in pediatric patients. The development of the axis and radiography of the cervical spine in pediatric patients are reviewed also. Neurosurgical treatment options are presented. This case also reminds us to ensure parents understand the proper use of a car seat.

Fractional mercury levels in Brazilian gold refiners and miners.

A field study survey of individuals residing in the region of Para, Brazil, was conducted to determine fractional mercury levels in individuals at risk for exposure in the Brazilian Amazon region. Subjects with a history of exposure to mercury either in the gold mining or refining industry, or exposure to these processes through proximity were included. Three groups were identified as either having recent (less than 2 d since last exposure), intermediate (less than 60 d), or remote (greater than 60 d) exposure to mercury vapors. Fractional blood and urinary mercury levels were assessed for these groups. Group I (recent) had the highest geometric mean blood 24.8 (SD 44.1, range 7.6-158.8) micrograms/L and urine 75.6 (SD 213.4, range 6.5-735.9) micrograms/g-cr (microgram mercury per gram of creatinine) mercury; intermediate (group II) geometric mean blood 7.6 (SD 5.5, range 2.2-19.4) micrograms/L and urine levels 23.8 (SD 84.0, range 7.8-297.0) micrograms/g-cr; the lowest levels in remote exposure (group III): geometric mean blood 5.6 (SD 3.3, range 3.1-14.3) micrograms/L and urine 7.0 (SD 9.8, range 3.1 to 32.9) micrograms/g-cr. The fraction of organic was lowest in group I (32.4%), higher in group II (65.7%), and highest in group III (72.2%). While the frequency of symptoms was comparable in the recent and intermediate groups (2.6 mean, SD 2.3, range 0-8, and 3.1 mean, SD 1.9, range 0-7, symptoms per patient), those with remote exposure demonstrated the highest rate of reporting (6.4 mean, SD 4.1, range 0-11, symptoms per patient). There is significant exposure to mercury for those working in or living near the mining and refining industry. Blood and urine levels are a better marker of recent than remote exposure. The fraction of organic mercury increases with time since exposure. Symptoms may be persistent and low levels of blood and urine mercury do not exclude remote or cumulative toxicity.

The pulse oximetry gap in carbon monoxide intoxication.

STUDY OBJECTIVE: Pulse oximetry has been reported to be falsely elevated in the presence of carbon monoxide (CO). However, the degree to which pulse oximetry overestimates measured oxyhemoglobin saturation (O2Hb) has not been investigated in patients with CO exposure. This study quantifies the effect of CO on pulse oximetry and O2Hb in a series of patients with elevated carboxyhemoglobin (COHb) levels. METHODS: A prospective case series of 25 pulse oximetry measurements, with concurrent arterial blood gas sampling, were obtained on 16 adults with CO exposure. RESULTS: COHb levels (mean, 16.1%; SD, 11.6%; range, 2.2% to 44%) did not significantly correlate with pulse oximetry saturation (mean, 97.7%; SD, 1.5%; range 96% to 100%) (r = .45; P = .1 [NS]). Compared with COHb, a pulse oximetry gap (mean, 17.5%; SD, 1.5%; range, 2.3% to 42%), defined as pulse oximetry saturation minus O2Hb, yielded a linear regression model: pulse oximetry gap = 1.82 + 0.94 x COHb (SEM = 0.07; F = 204; R2 = .90; P < .0001). CONCLUSION: Oxygen saturation as measured by pulse oximetry failed to decrease to less than 96% despite COHb levels as high as 44%. Regression between the pulse oximetry gap and COHb suggests that pulse oximetry overestimates O2Hb by the amount of COHb present. Pulse oximetry is unreliable in estimating O2Hb saturation in CO-exposed patients and should be interpreted with caution when used to estimate oxygen saturation in smokers.

The toxic patient as a potential organ donor.

The use of organs from poisoned victims for the purpose of transplantation has been poorly studied; criteria for organ donation is virtually non-existent in such cases. To further elucidate these indications, a retrospective review of all organ transplantation donated by poisoned victims in Northern and Central Illinois was undertaken. From January 1988 to December 1993, 17 poisoned victims were identified as having donated organs to 41 recipients. Eleven of the donors died as a direct result of drug toxicity, whereas six donors had drug-related deaths. The cases were reviewed for toxin involved, organ preoperative function and postoperative function (up to 1 year after transplant). Kidney transplants postoperative function was rated as good if creatinine was less than 1.9, fair if creatinine was 2 to 2.9, and poor if creatinine was 3. Donor age ranged from 2 years to 54 years. Toxins involved in donation included ethanol (n = 8), cocaine (n = 5), carbon monoxide (5), barbiturates (2) and lead (1), six patients had multiple drugs. Two of the nine recipients of livers died intraoperatively, both unrelated to organ function. Thirty-two kidneys were transplanted with 28 having good 10-day postoperative function, three having fair postoperative function, and one (cocaine donor) having poor postoperative function. One kidney transplanted from a cocaine donor had a thrombosed graft 5 days postoperatively. Deaths involving toxins in general does not seem to be a contraindication to donation of liver and kidney for transplantation.

Constraints on the enhancement of elimination of drugs with activated charcoal.

Both extracorporeal hemoperfusion through charcoal-containing columns and repeated oral administration of charcoal can accelerate clearance of some drugs or toxins from the systemic circulation. The efficacy of these 2 interventions is limited by a variety of factors, and the complex kinetic equations describing charcoal-induced clearance provide little practical clinical guidance about the potential efficacy of charcoal in accelerating clearance of a specific drug or toxin without previous empiric data. We derive here simple rules that place an upper limit on the maximal fraction of an absorbed dose of drug that can be removed (FRmax) by charcoal in terms of the volume of distribution (Vd), a parameter which is known for most drugs. For 4 h of hemoperfusion, a theoretical upper limit of FRmax is (1/Vd), where Vd is expressed in L/kg of body weight, and actual fractional removal (FR) will not exceed [1/(2 x Vd)]. Drug removal by 24 h of repeated po administration of charcoal exhibits similar relationships between FRmax and Vd, when charcoal-induced clearance derives primarily from removal of drug from blood perfusing in gastrointestinal mucosa. These relationships offer a simple means to evaluate the potential efficacy of acceleration of drug clearance by activated charcoal for drugs with a known value for Vd, and the relationships indicate that such interventions are impractical for drugs with very large values for Vd, such as tricyclic antidepressants.

Successful therapy of iron intoxication in pregnancy with intravenous deferoxamine and whole bowel irrigation.

We describe the successful treatment of a severely iron-poisoned adult patient in week 26 of gestation with 10.2 g deferoxamine administered iv over 14 h and whole bowel irrigation (2 L/h of polyethylene glycol-electrolyte solution/nasogastric tube for 12 h) with a good maternal outcome and no adverse effects on the fetus.

The price of gold: mercury exposure in the Amazonian rain forest.

Concern has surfaced over the recent discovery of human mercury exposure throughout the tropical rain forest of South America's Amazon River Basin. The probable source of mercury has been traced to gold mines located within the interior. The mining process involves the extraction of gold from ore by burning off a mercury additive, resulting in vaporization of elemental mercury into the surrounding environment. The purpose of this case series is to document mercury levels in miners and local villagers presenting with a history of exposure, or signs and symptoms consistent with mercury toxicity. Over a five year period (1986-91), the whole blood and urine mercury levels of 55 Brazilian patients demonstrating signs and symptoms consistent with mercury exposure were collected. Thirty-three (60%) of the subjects had direct occupational exposure to mercury via gold mining and refining. Whole blood mercury levels ranged from 0.4-13.0 micrograms/dL (mean 3.05 micrograms/dL). Spot urine levels ranged 0-151 micrograms/L (mean = 32.7 micrograms/L). Occupational mercury exposure is occurring in the Amazon River Basin. Interventions aimed at altering the gold mining process while protecting the workers and surrounding villagers from the source of exposure are essential. The impact of the gold mining industry on general environmental contamination has not been investigated.

Cocaine liberation from body packets in an in vitro model.

STUDY OBJECTIVE: To quantitatively assess cocaine liberation from various body packet materials. DESIGN: 100-milligram cocaine packets (plastic bags with various wrapping techniques, paper, and condoms) were placed in a simulated gastric medium. Samples were also tested in an alkalinized gastric medium, with determination of both cocaine and benzoylecogonine concentrations using high-performance liquid chromatography with ultraviolet detection. RESULTS: Cocaine liberation was greatest in acid medium, with increasing liberation from condom packets to cellophane bags (three wrapping techniques used) to paper packets. The same trend was noted in alkaline medium but with a far lower maximum cocaine concentration accompanied by rapid hydrolysis to its inactive metabolite, benzoylecgonine. CONCLUSION: Cocaine liberation of a known quantity of drug is dependent on the wrapping method and material used; thus, a good history from the "body-stuffer" is essential to predict potential cocaine liberation and toxicity. Rapid hydrolysis of cocaine to its inactive metabolite in an alkaline medium implies a role for gastric alkalinization in the acute management of these patients.

Unusual occupational toxins.

Occupational and environmental medicine affords encounters with many unusual toxins, ranging from exotic metals to rocket fuels. Twelve of the most unusual industrial toxins are reviewed here and their clinical manifestations and treatments explored: acetonitrile, acrylonitrile, boron hydrides, dimethylaminopropionitrile, dimethylformamide, hydrazines, methyl isocyanate, 2-nitropropane, phosphine, Stalinon, tellurium, and vanadium.