Radiopacity of clomipramine conglomerations and unsuccessful endoscopy: report of 4 cases.

BACKGROUND: The radiopacity of ingested substances may serve as a clue to the presence of particular compounds, as this characteristic varies considerably among medications and household products. Tablet conglomerations are also variably radiopaque. We report 4 cases of clomipramine poisoning associated with formation of radiopaque masses, believed to be clomipramine, in the area of the stomach. CASE REPORTS: Four patients were admitted to the Toxicological Intensive Care Unit after ingestions of, respectively, 8.5 g (180 tablets of mixed strength), 7.5 g (100 tablets), 10.5 g (140 tablets), and 4.5 g (60 tablets) of clomipramine, along with other sedatives and antipsychotics. In each case, a rounded density was observed in the gastric area on plain chest radiograph. The hospital courses of each patient were marked by tachycardia, hypotension, QRS and QT prolongation, seizures, and decreased mental status. Three of 4 patients underwent unsuccessful endoscopy to remove tablet fragments and subsequently suffered gastrointestinal hemorrhage requiring transfusion. All patients were discharged recovered from the hospital. DISCUSSION: Clomipramine, a potent tricyclic antidepressant, has been previously reported to be nonradiopaque, and has not been reported to induce formation of concretions. These cases suggest that massive ingestions of clomipramine may form bezoars which are radiopaque and may be associated with serious toxicity. Careful consideration should be given prior to the use of gastric endoscopy for the retrieval of tablet fragments since significant hemorrhage, attributed to the procedure itself rather than to clomipramine toxicity, may ensue.

Relation of body position at the time of discovery with suspected aspiration pneumonia in poisoned comatose patients.

OBJECTIVE: The left lateral decubitus position is generally accepted as the position of choice to protect against aspiration pneumonia in comatose poisoned patients. We studied the relationship between initial body position during coma and subsequent development of suspected aspiration pneumonia (SAP). DESIGN: Observational, descriptive study. SETTING: Toxicology intensive care unit in a university hospital. PATIENTS: Acutely poisoned comatose patients admitted to our intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Glasgow Coma Scale score (GCS) and body position were recorded in poisoned patients on discovery. Chest radiographs were examined for infiltrates suggesting SAP within 24 hrs of hospitalization. The prone positioned patients had a lower incidence of SAP than patients in the lateral decubitus and supine positions, despite similar GCS scores. Patients in the semi-recumbent position had an incidence of SAP similar to prone patients, but with higher GCS values. CONCLUSIONS: The prone position appears to be associated with a lower incidence of SAP than the lateral decubitus position in comatose poisoned patients.

Intubation difficulty in poisoned patients: association with initial Glasgow Coma Scale score.

OBJECTIVE: To determine whether the initial Glasgow Coma Scale (GCS) score is predictive of intubation difficulty in out-of-hospital airway management of poisoned patients. METHODS: A prospective, observational study was performed in a toxicological intensive care unit of a university hospital and in a physician-based out-of-hospital care system. Subjects included consecutive poisoned patients intubated during their airway management by out-of-hospital medical teams before hospitalization. The intubating operator (emergency physician or nurse anesthetist) completed a 1-page checklist concerning the clinical parameters and circumstances (nature of sedation and difficulty) of endotracheal intubation upon hospital arrival. RESULTS: Forms were completed for all 394 consecutive out-of-hospital intubations. The patients ranged from 15 to 95 years of age (median age 38 years). Most (96%) of the intubations were via the oral route. Intubation difficulty was related to GCS values. Intubation difficulty was seen more often in patients with 7 < or = GCS < or = 9 (36%) than in patients with GCS < 7 (15%) or > 9 (10%). Not surprisingly, perceived intubation difficulty was least for those patients undergoing rapid-sequence intubation rather than administration of sedation alone. CONCLUSION: Maximum difficulty of intubation is encountered in poisoned patients with 7 < or = GCS < or = 9. Intubation of such patients appears to be facilitated by appropriate sedation and/or neuromuscular blockade.

A survey of sedation protocols used for emergency endotracheal intubation in poisoned patients in the French prehospital medical system.

The purpose of this study was to evaluate prehospital sedation protocols used by several French mobile intensive care units for difficult intubations in poisoned patients. This prospective, descriptive study was performed within the toxicological intensive care unit in a university hospital. Consecutive poisoned patients intubated during their airway management by prehospital medical teams were included. Intubating physicians completed a one-page checklist concerning the circumstances of endotracheal intubation. Intubation difficulty was significantly related to the nature of sedation protocols. The use of etomidate alone as an intubation sedative agent was associated with significantly poorer intubating conditions (47.2% difficult) than other sedative agents or neuromuscular blockade). Neuromuscular blockade with sedation in our series was associated with the lowest incidence of difficult intubations in poisoned patients. Sedation alone for intubation appears to be inadequate to achieve good intubating conditions in a significant proportion of patients.