[A suicide attempt with oral verapamil: a case report]

We report a case of a 29-years-old patient who tried to commit suicide by taking a high dose of verapamil (22 pills containing 240 mg, each, equivalent to 5.28 g). Ten hours after the ingestion he presented a complete atrioventricular heart block which was resolved with medical treatment presenting a normal ECG 36 hours later. To our knowledge this is the only published case of intoxication caused by such a high dose of verapamil.

Emergency management of drug overdose

Successful management of patients presenting after intentional, accidental, acute or chronic overdose depends on prompt identification of drugs ingested, an organized approach of care that centers around stabilization, patient assessment, gastric evacuation, GI/systemic elimination, patient education and psychiatric evaluation.

Sensory and motor neuropathy caused by excessive ingestion of vitamin B6: a case report

We describe a patient who developed a severe sensory and a mild motor neuropathy. This syndrome was due to massive and prolonged ingestion of vitamin B6 (10 g daily for 5 years). To our knowledge this is the first published case of motor neuropathy caused by chronic abuse of vitamin B6.

"He's probably overdosed on something!"

A 16 year old boy presented with extreme violent behaviour requiring physical restraint. Acute drug intoxication was mooted as a probable cause of his condition. The case illustrates that the causes of altered consciousness and aggressive behaviour are many and varied and that life-threatening conditions need to be considered and excluded in cases of this nature.

Pathophysiological studies of neuromuscular function in subacute organophosphate poisoning induced by phosmet

A 51 year old man developed progressive cranial and proximal muscle weakness, hyperreflexia and mental change. The disorder progressed over 9 days following the fifth weekly spraying with the organophosphate (OP) insecticide, phosmet, with limited symptoms of acute toxicity. Marked decremental responses of 50-80% on slow and fast rates of stimulation were improved to 15% by edrophonium or neostigmine. Intracellular recordings at the endplate region of intercostal muscle revealed small miniature endplate potentials (mepps), reduced mean acetylcholine sensitivity and normal membrane potentials. Electronmicroscopy revealed degeneration and regeneration of the endplates. This study demonstrates that OP poisoning due to phosmet can produce a subacute postsynaptic neuromuscular syndrome without marked symptoms of acute toxicity.

Intentional massive insulin overdose: recognition and management

A case of intentional massive insulin overdose requiring prolonged glycemic support is presented. Suicidal insulin overdose may be more common than generally appreciated. Because hypoglycemic reactions are evaluated routinely in the ED, emergency physicians should maintain a high degree of suspicion regarding suicidal intent or foul play in diabetics with hypoglycemia who respond minimally to the administration of concentrated glucose solutions or in hypoglycemic presentations by nondiabetics who have access to diabetic medications. Fingerstick glucose evaluations or serum glucose levels should be obtained routinely at 15 to 30 minutes after glucose administration in any hypoglycemic patient to gauge the intensity of glucose use. Inability to maintain euglycemia following glucose administration suggests excessive insulin and requires further workup. Evaluation of serum insulin and C-peptide levels is useful in confirming intentional overdoses in cases that are not clear-cut. Glucose infusion rates must be tailored individually to each overdose situation as great individual variability exists in insulin absorption and effects. The clinician should anticipate the possible need for prolonged glycemic support in this setting.

The lithium toxic patient in the medical hospital: diagnostic and management dilemmas

OBJECTIVE

Patients with lithium toxicity can pose difficulties in diagnosis and management in the general hospital setting. The authors examined patients who were referred to the Psychiatric Consultation-Liaison Service with suspicion of lithium overdose to delineate and characterize medical and psychiatric risk factors for toxicity and to follow the course and resolution of their toxicity.

METHOD

The authors reviewed the charts of patients with lithium levels > 1.5 mEq/L who were admitted consecutively to a general hospital over an 18-month period.

RESULTS

Of twelve patients, eight were found to have developed lithium toxicity due to incidental and iatrogenic factors. These patients presented with a variety of confusing signs and symptoms. Hypothyroidism and coexisting organic illness contributed to the lack of clarity in their clinical picture.

CONCLUSION

The widening scope of indication for lithium therapy leads to increased risk of toxic reactions which challenge the diagnostic skills of the consulting psychiatrist in a general hospital setting.

Acute aspirin overdose: mechanisms of toxicity

The case history described herein illustrates many of the salient clinical and laboratory features of acute salicylate overdose. Aspirin overdose remains a commonly used means of attempting suicide in young adults. This case demonstrates the role of the laboratory in the management of salicylate overdose. Medical treatment of several critical concurrent metabolic responses was dependent on frequent evaluations of serum electrolytes, blood and urine pH, blood PO2, blood PCO2, and blood HCO3- concentrations. In addition, essential to her excellent medical care was the ongoing close interaction between the clinical toxicology laboratory and the clinical staff.

Prognostic score for kerosene oil poisoning

Ninety five consecutive children with kerosene oil poisoning were studied, the first 70 retrospectively (internal group) and the rest 25, prospectively (external group) over a period of 3 years and 8 months. Based on clinical features and severity of illness in initial 70 cases, a weighted scoring system to determine the outcome was evolved. This included: (i) fever--absent 0, present 1; (ii) severe malnutrition--absent 0, present 1; (iii) respiratory distress--absent 0, present 2, with cyanosis 4; and (iv) neurological symptoms--absent 0, present 2, with convulsions 4. The scores ranged from 0 to 10 in the internal group. Using discriminate function analysis, a score of 4 or more was found to be associated with prolonged hospital stay and complications. The risk of dying increased if the score was equal to or more than 8. The predictive value of the score was 85.7%. For validation, this scoring was applied to the external group as well and 84% of cases could be correctly predicted.

[Severe digitalis poisoning after the ingestion of 1 g of digoxin]

A 50-year-old, previously healthy, woman swallowed 1 g digoxin powder, dissolved in water, with suicidal intent. On admission to hospital one hour later, having vomited three times at home, the prominent signs were somnolence and hypersalivation. Serum digoxin level was 3.37 ng/ml. There followed repeated episodes of asystole alternating with ventricular fibrillation requiring cardiopulmonary resuscitation over 90 min and adrenaline administration. Repeated electrical defibrillation, administration of dopamine, phenytoin and lidocaine, as well as transitory transvenous electrical stimulation became necessary. Anti-digoxin antibody fragments were administered, initially 80 mg, to a total of 3,280 mg over 24 hours. After 3 days of intensive care and a further 21 days in hospital she was discharged and referred to psychiatric treatment. This case demonstrates that even severe digoxin poisoning can be successfully treated without sequelae by the appropriate administration of digoxin antidote. The main problems in this case were regulation of the dosage and acquiring the necessary amount of antidote which greatly exceeded the hospital's own depot.

A fatality due to propofol poisoning

This report describes a suicide by self-administration of propofol in a 29-year-old female radiographer. This is the first published report of death by overdosage with propofol. Propofol was detected in tissues using high performance liquid chromatography. Post mortem femoral blood and liver concentrations of propofol were 0.22 mg/L and 1.4 mg/kg, respectively. The scene suggested that a dose of 400 mg was used.

A high endrin concentration in a fatal case

Gas chromatography coupled to mass spectrometry was employed to quantify endrin in biological fluids in a death attributed to endrin overdose. The blood concentration of endrin was 544.9 mg/l. Results are discussed in the light of the existing literature.

Measurement of digitalis-glycoside levels in ocular tissues: a way to improve postmortem diagnosis of lethal digitalis-glycoside poisoning? I. Digoxin

Prompted by animal studies reporting the accumulation of digitalis-glycosides in ocular tissues, we investigated whether measurement of digoxin levels in human ocular tissues can improve the postmortem diagnosis of lethal digoxin intoxication. Digoxin was measured in the vitreous humor and choroid-retina of patients who had received in-patient treatment with digoxin prior to death (therapeutic group) and in a single case of suicidal intoxication. The results were compared with the digoxin levels in the femoral vein blood, myocardium, kidney and liver, and evaluated in light of the medical history of each patient. In the therapeutic group the mean digoxin level was higher in the choroid-retina than in other tissues and body fluids. The range of variation in levels in the choroid-retina following therapeutic doses was comparable to that in the other tissues. An extremely high level of digoxin was present in the choroid-retina in the case of suicidal intoxication. In all cases, levels in the vitreous humor were very low compared to those in the choroid-retina. Hence, it is unlikely that significant distortion of choroid-retinal levels occurs due to postmortem diffusion of digoxin into the vitreous body. Our results indicate that measurement of digoxin levels in the choroid-retina can aid the postmortem diagnosis of lethal digoxin intoxication.

Chloral hydrate overdose: trichloroethanol detection by gas chromatography/mass spectrometry

A case is presented where an individual ingested a fatal dose of chloral hydrate. Trichloroethanol (TCE), the metabolite of chloral hydrate, was initially identified by the Fujiwara reaction and quantified by gas chromatography/mass spectrometry in blood )127 mg/l), urine (128 mg/l) and stomach contents (25 mg total).

Distribution of malathion in body tissues and fluids

Six cases of suspected poisoning were studied. The various body tissues and fluids of all the cases were analysed and malathion was found positive. The quantitative analysis was performed using high performance liquid chromatography. The distribution of malathion was studied in lungs, liver, kidneys, spleen, brain, heart, blood, muscles, urine and gastric contents.

[Psychopathologic manifestations of oral administration of endemic nightshade plants]

Psychopathological findings in two cases of oral poisoning with toxins of "Datura stramonium" (thorn apple) and "Hyoscyamus niger" (insane roof) are reported. Toxicological aspects of voluntary ingestion are discussed as well as the forensic importance of criminal poisoning.

[Subacute chloroquine overdosage]

Owing to a misunderstanding a 26-year-old man took for malaria prevention 2 tablets (1.0 g) chloroquine daily instead of the recommended dose of two tablets weekly. After 2 weeks he developed vertigo, generalized weakness and, after sun-bathing, severe bullous light reaction. After 4 weeks generalized hair depigmentation occurred. Two weeks later abnormal accommodation and double vision set in so that he lost distant and near vision. All these signs disappeared after the drug was discontinued (vertigo, weakness and abnormal accommodation within 2 weeks; hair regrew in normal colour after 8 weeks). This case shows the whole spectrum of subacute chloroquine overdosage.

Gas chromatographic-mass spectrometric analysis of buflomedil hydrochloride in biological samples after acute intoxication

Two cases of acute intoxication of buflomedil hydrochloride are reported. The analysis of this compound was performed by an Extrelut extraction followed by a gas chromatographic-mass spectrometric determination. Analytical parameters of linearity, reproducibility and specificity were satisfactory.

The use of hair analysis to document a cocaine overdose following a sustained survival period before death

Hair analysis for cocaine was used in the investigation of a case of accidental cocaine poisoning. A 25-year-old man consumed an entire bottle of Pony Malta, an imported Colombian soft drink. Unbeknownst to him, the 6.2-oz bottle contained a large quantity of cocaine. It was subsequently discovered that this bottle was one of 45 recovered that contained cocaine as part of a smuggling scheme. The subject was hospitalized for acute cocaine intoxication but died 24 days later. The admission blood contained 2.3 mg/L of cocaine and 4.5 mg/L of benzoylecgonine. Subsequent segmental analysis by MS/MS of hair samples taken at the autopsy revealed a peak cocaine concentration in the segment corresponding to the time he ingested the tainted beverage. The use of hair analysis as an adjunct to traditional analytical techniques may help document drug use history and is especially useful in situations have blood and urine specimens have not been collected in a timely fashion.

Toxicity with dextromethorphan-containing preparations: a literature review and report of two additional cases

Dextromethorphan-containing cold/cough preparations are frequently prescribed and bought over the counter for use in children. Although generally considered safe, dextromethorphan has been shown to cause CNS side effects, including hyperexcitability, increased muscle tone, and ataxia. Two deaths have been reported with intentional dextromethorphan overdose. A literature review, brief review of pharmacology, and report of two cases of adverse reactions to dextromethorphan-containing preparations are presented.

Problematic behavior of drug-dependent patients in the general hospital. A clinical and administrative approach to management

Drug-dependent patients in general hospitals behave in ways that are difficult for medical and surgical staff to manage. Common problems include drug-seeking, states of intoxication and withdrawal, poor compliance, and behavior that is disruptive or dangerous to others. The authors describe an approach to these problematic behaviors based upon early recognition, a clinical perspective, and administrative action. Institutional initiatives are needed to overcome the practical and conceptual obstacles to effective management of these patients.

Diagnosis of magnesium-induced diarrhea

BACKGROUND

There is no specific method of diagnosing magnesium-induced diarrhea. Therefore, the frequency and clinical importance of diarrhea caused by magnesium are unknown. The purposes of this study were to establish a method for diagnosing magnesium-induced diarrhea and to apply it to patients with chronic diarrhea.

METHODS

We measured fecal output of soluble magnesium and fecal magnesium concentration in 19 normal subjects with formed stools (15 collection periods), with non-magnesium-induced diarrhea (36 collection periods), and with diarrhea induced by magnesium hydroxide alone (11 collection periods) or in combination with phenolphthalein (3 collection periods), and in 359 patients with chronic diarrhea.

RESULTS

The upper limits of fecal output of soluble magnesium and fecal magnesium concentration in normal subjects were 14.6 mmol per day and 45.2 mmol per liter, respectively. When normal subjects had diarrhea due to the ingestion of magnesium hydroxide alone or in combination with phenolphthalein, fecal magnesium output was always abnormally high. For each millimole increase in fecal magnesium output, fecal weight increased by approximately 7.3 g. The fecal magnesium concentration was very high when magnesium was the only cause of diarrhea but only moderately elevated when diarrhea was induced by magnesium hydroxide plus phenolphthalein. Biochemical and clinical evidence indicated that excessive ingestion of magnesium was an important cause of chronic diarrhea in 15 of the 359 patients with chronic diarrhea (4.2 percent), if not the only cause.

CONCLUSIONS

Quantitative fecal analysis for soluble magnesium is an accurate method of diagnosing magnesium-induced diarrhea. Some patients with chronic diarrhea ingest excessive amounts of magnesium (in antacids or food supplements), and physicians may fail to discover this before embarking on an expensive and invasive diagnostic evaluation.

Accidental and intentional poisonings with ethylene glycol in infancy: diagnostic clues and management

Ethylene glycol has long been recognized as a potentially lethal poison and remains available today as automotive antifreeze and windshield deicer fluids. Ethylene glycol is rapidly absorbed from the gastrointestinal tract, with peak levels measured one to four hours after ingestion. Metabolism of the parent compound and the production of several organic acids are responsible for the metabolic acidosis observed in ethylene glycol poisoning. Target organ cellular damage is seen in the kidney, brain, myocardium, pancreas, and blood vessel walls. Renal tubular deposition of calcium oxalate crystals is felt to be responsible for the development of the severe renal injury which may accompany ethylene glycol ingestion. The clinical course is quite varied and includes inebriation, hematuria, cardiorespiratory compromise, and neurologic effects. Prompt diagnosis and initiation of treatment, including ethanol therapy and hemodialysis, is necessary to ameliorate the effects of ethylene glycol ingestion. Two cases of ethylene glycol poisoning, one accidental and one intentional, are reviewed.

Fentanyl-related deaths: demographics, circumstances, and toxicology of 112 cases

Since 1979, the potent narcotic analgesic fentanyl and its analogs have been synthesized in clandestine laboratories and sold as heroin substitutes. At least 112 overdose deaths have been associated with their use. In this study, toxicology data, autopsy findings, and coroners' investigative reports were reviewed in order to construct a profile of the typical fentanyl overdose victim and to identify any factors that might heighten the risk of death from fentanyl use. The "typical" fentanyl overdose victim was 32.5 +/- 6.7 years of age (range, 19 to 57 years), male (78%, compared with 22% female), and Caucasian (50%, compared with 29% Hispanic, 20% Black, and 0.9% Asian). With the exception of his or her age, the typical fentanyl overdose victim is quite similar to the typical heroin user. Nearly all the deaths (94%) occurred in California, yet within the state they were widely distributed throughout 17 counties and 44 cities. Pulmonary edema and congestion and needle puncture sites were consistent postmortem findings. No preexisting medical conditions were identified as possible risk factors. Although most of the fentanyl victims had a prior history of intravenous drug use, morphine or codeine were not commonly found, which suggests that the victims had little or no opiate tolerance. Ethanol was present in 38% of the cases and is thought to be a significant risk factor. Mean fentanyl concentrations in the body fluids were quite low: 3.0 +/- 3.1 ng/mL (0.3 +/- 0.31 micrograms/dL) in blood and 3.9 +/- 4.3 ng/mL (0.39 +/- 0.43 micrograms/dL) in urine, measured by radioimmunoassay. Although the potency of the analogs and the purity of street samples varies considerably, it is probably the general availability of the drug rather than the potency of a particular analog that determines the incidence of overdose deaths.

Forensic analysis of triazolam in human tissues using capillary gas chromatography

A reliable and sensitive method has been developed to assess the concentrations of the hypnotic drug triazolam in human tissues, including putrefied tissues. The method involves a 3-step solvent extraction, clean-up on a silica gel column and gas chromatography using a nitrogen phosphorus detector and a capillary column. Estazolam was used as an internal standard. The calibration curve was linear over the concentration range 1 ng/g-1 microgram/g and the lower limit of detection was 0.5 ng/g. A forensic study was performed on the toxicological effects of triazolam using putrefied tissues.

Verapamil overdose

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Cyclic antidepressants, lithium, and neuroleptic agents. Pharmacology and toxicology

Cyclic antidepressants, lithium, and phenothiazines are frequently prescribed to psychiatric patients. Emergency department physicians must be familiar with these medications, and the pharmacologic and toxicologic characteristics of them are discussed. Cyclic antidepressants are the primary cause of drug-related death in the United States, with sodium bicarbonate recognized as the treatment of choice. Lithium toxicity may be subtle, and treatment is generally supportive in addition to volume replacement with normal saline and hemodialysis for significant intoxications. A neuroleptic overdose is managed primarily with supportive care. Neuroleptic malignant syndrome must be considered in any psychiatric patient presenting to the Emergency Department.

Burst suppression EEG with baclofen overdose

The article reports the case history of a patient with baclofen intoxication and burst suppression activity in the EEG several hours after baclofen ingestion. With symptomatic treatment the patient recovered within 5 days and the EEG became normal, again.

Plasma catecholamine levels in cyclic antidepressant overdose

Cyclic antidepressant overdose is a major cause of morbidity and mortality in self-poisoned patients. The major cause of mortality with cyclic antidepressant overdose is cardiotoxicity. We determined plasma catecholamine levels in 41 symptomatic acute overdose patients to identify interactions between QRS duration (a marker for cardiotoxicity) and a presumed hyper-adrenergic state. Using a linear multivariable regression analysis, QRS duration correlated with the presence of cyclic antidepressant, plasma norepinephrine levels, the ratio of norepinephrine to epinephrine level, and pulse rate (p less than 0.001, r2 = 0.42). Commensurate physiologic changes were not found in the presence of elevated catecholamine levels in the cyclic antidepressant overdose group. One possible explanation for the blunted systemic response to the elevated catecholamine levels is adrenergic desensitization. Investigation of serial catecholamine levels during cyclic antidepressant overdose may lead to modification of our current theories of cardiotoxicity and therapy.

Is corneal deposition of antimalarial any indication of retinal toxicity?

Ninety-five percent of patients on chloroquine demonstrate corneal deposition of the drug with the pupil dilated; less than 10% of patients on hydroxychloroquine show any corneal changes when so examined. I describe one patient on chloroquine and two on hydroxychloroquine who demonstrated large amounts of corneal antimalarial drug, leading to the early diagnosis of definite retinopathy. Examination of the cornea with the pupil dilated may reveal the presence of retinal toxicity in some patients.

[Interpretation of postmortem digoxin levels: evaluating a "corrective factor" for postmortem blood digoxin concentration]

Interpretation of postmortem serum digoxin levels is made difficult above all by a possible prefinal or postmortem rise in digoxin concentrations in the blood. To compensate for this postmortem increase, Eriksson et al. (1984) divided the level of postmortem digoxin in femoral venous blood by a factor of 1.5; in the opinion of these authors, postmortem digoxin levels still exceeding "therapeutic levels" after division by 1.5 are an index of digoxin overdose. The diagnostic value of this "correction factor" was investigated. In 56 cases with documented digoxin medication, samples of postmortem femoral venous blood were taken and the level of digoxin determined. In none of the cases had there been a clinical diagnosis of digoxin intoxication. Fifty percent of the measured values were above "therapeutic levels" (0.7 ng/ml to 2.2 ng/ml). Following division by 1.5, 20% of the cases still showed levels exceeding 2.2 ng/ml; the highest "corrected" value was 4.44 ng/ml. Taking into account the length of time between final dosage and death, individual differences in sensitivity to digitalis glycoside, and the complexity of ante- and postmortem dispersion processes, we concluded for the cases we studied that an (undetected) digoxin overdose was not even likely in those cases whose postmortem values after division by 1.5 lie above "therapeutic levels". The "correction factor" proposed by Eriksson et al. (1984) is only of limited diagnostic value; at best the "corrected" values can give an approximate indication of the corresponding antemortem serum digoxin concentrations. In particular, "corrected" values only a little above "therapeutic levels" could not confirm suspicion of an overdose with sufficient certainty.

Nifedipine poisoning in a child

A 14-month-old child ingested approximately 800 mg (70 mg/kg) of nifedipine. When first examined, the child was unresponsive, markedly hypotensive, and hyperglycemic. According to electrocardiographic results, there was a third-degree atrioventricular block that rapidly progressed to cardiac arrest. Following successful cardiopulmonary resuscitation, mechanical ventilation and resuscitation with intravenous normal saline, calcium chloride and dopamine were required to restore perfusion, reverse metabolic acidosis, and stabilize vital signs. Complications related to nifedipine intoxication included the development of pulmonary edema and possible infarction in the posterior parietal and occipital lobes associated with cortical blindness and the development of seizures with an abnormal electroencephalogram. The patient recovered without clinically apparent residua. Massive nifedipine overdose in infants represents a potentially life-threatening event that requires prompt medical attention. Reported cases of nifedipine intoxication were reviewed and therapeutic interventions were discussed.

Value of initial ECG findings and plasma drug levels in cyclic antidepressant overdose

Electrocardiographic changes and quantitative plasma drug levels associated with cyclic antidepressant (TCA) overdose have been the subject of many reports in the medical literature. Heart rate, QRS duration, QT interval, and most recently, the terminal 40 ms QRS (T40) axis have been reported to be valuable indicators in TCA overdose. The value of plasma drug levels and their ability to predict complications has been debated. To evaluate the discriminant and predictive abilities of ECG parameters and quantitative drug levels in a large series of TCA overdoses, we retrospectively reviewed the charts of all overdose patients admitted to ICU in our facility during a 30-month study period. The TCA-positive group (187) had statistically significant differences (P less than .001) from the TCA-negative group (171) in heart rate, QRS duration, QTc, and T40 axis. However, none of these parameters could correctly classify more than 66% of cases. The sensitivity and specificity of the T40 axis were found to be only 29% and 83%, respectively. Correlation coefficients for plasma quantitative TCA levels by ECG parameter yielded an R of less than .33 in all cases. QRS duration of 100 ms or more and heart rate of 100 or more, or TCA level of 1,000 ng/mL or more, were present in all of a few patients with complications. We conclude that ECG parameters cannot be relied on to include or exclude the diagnosis of TCA overdose and that TCA levels do not correlate with ECG parameters.

Iron poisoning: report of three cases and a review of therapeutic intervention

Although the acute ingestion of iron-containing preparations can produce very serious consequences, the majority of reported exposures are not associated with significant morbidity or mortality. We present 3 cases of acute iron ingestion and review the aspects of general management, with an emphasis on the appropriate choice of a gastrointestinal decontamination procedure.

Ethchlorvynol overdose

Ethchlorvynol remains a drug that frequently surfaces in clinical emergency practice despite safer and more effective pharmaceutical agents on the market. Effects such as poisoning, dependence, ocular damage, and overdose continue to receive attention in the literature. Awareness of complications and treatment in ethchlorvynol exposure requires attention to a drug remaining clinically available without an appropriate clinical indication.

Nonsteroidal anti-inflammatory drugs and coma: a case report of fenoprofen overdose

We present the case of a 17-year-old girl who ingested 24 to 36 g fenoprofen as a suicidal gesture. She presented with coma, hypotension, metabolic acidosis, and respiratory depression within four hours of ingestion. The most common adverse effects of the nonsteroidal anti-inflammatory drugs occur in both therapeutic and toxic doses and include gastrointestinal upset, blood dyscrasias, and analgesic nephropathy. The propionic acid derivatives of nonsteroidal anti-inflammatory drugs, including fenoprofen and ibuprofen, are rarely associated with severe toxic effects. This is the first report of pure fenoprofen overdose presenting as coma and metabolic acidosis.

Use of flumazenil in intoxicated patients with coma. A double-blind placebo-controlled study in ICU

In a double-blind placebo-controlled prospective clinical trial we studied the efficacy and safety of the benzodiazepine antagonist, flumazenil. In 23 patients admitted to the Intensive Care Unit with coma due to overdose with benzodiazepines or other sedatives, flumazenil i.v. (up to 2 mg or placebo) was given. In 13 patients given flumazenil the Glasgow Coma Scale (GCS) increased significantly from 4.9 to 7.8 (p less than 0.05). Six of these 13 patients, including mainly benzodiazepine mono-intoxications, needed only one series of injections (up to 1.0 mg flumazenil); the GCS increased thereby from 4.5 to 10.7 within a maximum of 5 min (p less than 0.01). In the remaining 7 patients, needing two series of injections of flumazenil (up to 2.0 mg), GCS did not rise significantly and coma was related to intoxications with nonbenzodiazepine sedatives, flunitrazepam and in one patient, encephalitis. In the 10 patients receiving placebo, the GCS did not change. A significant increase in the GCS from 5.5 to 10.8 (p less than 0.001) was, however, observed when flumazenil (up to 1.0 mg) was given after placebo. In patients with EEG monitoring the changes in waveform pattern paralleled the clinical response. Effects could be detected within 1-2 min after flumazenil injection and lasted up to 45 min. There were no adverse reactions or benzodiazepine withdrawal symptoms. We conclude that flumazenil is an effective and safe drug in the treatment of benzodiazepine overdose. The use of flumazenil is of diagnostic value in mixed-drug intoxications or coma of unknown origin and is of therapeutic importance for reversal of benzodiazepine intoxications.

Nifedipine overdose accompanied by ethanol intoxication in a patient with congenital heart disease

A 34-year-old female was brought to the emergency department after taking 200 to 250 mg of nifedipine and drinking an unknown amount of ethanol in a suicide attempt. She was hypotensive, acidotic, mildly hyperglycemic, and exhibited a conduction abnormality on the ECG. The patient was treated with IV fluids, thiamine, and calcium infusion. The patient was later found to have an endocardial cushion defect with a patched ventricular septal defect and an atrial septal defect of the ostium primum type. We did not observe any untoward effects due to the combination of drugs and congenital abnormalities that could be explained on an individual basis. Nifedipine overdose associated with alcohol intoxication, to our knowledge, has not been previously reported.