Gluteal compartment syndrome. A report of 4 cases

Four cases of gluteal compartment syndrome are presented, 1 traumatic and 3 after an overdose of sedatives. Associated lesions included sciatic nerve palsy in 2 cases and acute renal failure in 1. Three cases with intramuscular pressure exceeding 60 mmHg underwent emergency fasciotomy. Intramuscular pressure monitoring is useful for evaluating the effect of fasciotomy.

[Coma due to an overdose of valnoctamide]

We report a 27-year-old man, who became comatose after autopoisoning with a high dose of valnoctamide. He was mechanically ventilated for 12 hours and survived without serious side effects. Valnoctamide blood levels were monitored in order to study the pharmacokinetics of oral overdosing of this drug. Serum half-time levels appeared to be approximately 15 hours.

Protracted phencyclidine coma from an intestinal deposit

Phencyclidine is a common drug of abuse that can be taken orally, intravenously, or by inhalation. We describe a massive overdose of phencyclidine in a patient who swallowed a plastic bag containing the drug. Quantitative serum phencyclidine levels remained persistently elevated for several weeks. On hospital day 20, a plastic bag was passed via the rectum. Subsequently, the patient's serum phencyclidine levels fell in accordance with previously described pharmacokinetics. The patient rapidly recovered neurologic function. Persistently elevated serum drug levels should suggest continued drug absorption from a gastrointestinal deposit. We propose that colonoscopy and esophagogastroduodenoscopy be performed early in this setting.

Acute poisonings with ethyle loflazepate, flunitrazepam, prazepam and triazolam in children

Even though acute poisonings with benzodiazepines are extremely common, less is known of the clinical toxicity of recent derivatives, particularly in children. 1,989 cases involving ethyle loflazepate, flunitrazepam, prazepam or triazolam recorded at the Lyons Poison Center and due to 1 compound and associated with clinical symptoms were selected for study. Children less than 16-y of age accounted for 482 cases. Sleepiness, agitation and ataxia were significantly more frequent in the children. Hypotonia was seldom observed but was indicative of severe poisoning. The dangerous toxic dose of these compounds in children is suggested to be 0.78-0.90 mg ethyle loflazepate/kg, 0.26-0.29 mg flunitrazepam/kg, 7.80-9.00 mg prazepam/kg and 0.06-0.07 mg triazolam/kg. These results are in keeping with the relatively low acute toxicity of the older benzodiazepines.

[Iodoform poisoning. 3 cases]

Three cases of iodoform poisoning are described following dressings with 10% iodoform gauze (0.10 x 5 m) on extended wounds. Five, ten and sixteen days after the beginning of dressings, the patients became confuse, hallucinated, and one of them was subsequently comatose. Vomiting, fever, tachycardia with premature ventricular beats and shortening of P-R interval, slight increase of transaminases and proteinuria were observed. Within a few days (3 to 8) after the iodoform dressings were discontinued, the signs of iodoform toxicity disappeared. The toxicity of iodoform is probably unrecognized if the rarity of the observations published and the amount of iodoform gauzes annually sold are compared.

Hyponatremic coma under oxcarbazepine therapy

Oxcarbazepine (OXC) is considered to be a promising new antiepileptic drug with similar efficacy and better tolerability compared to carbamazepine (CBZ). However, hyponatremia is supposed to occur even more often than with CBZ. We report on a patient who developed hyponatremic coma under OXC with a serum sodium level of 115 mmol/l, the second published case of OXC-induced hyponatremia with serious clinical adverse effects.

Neuropsychiatric manifestations of defect in mitochondrial beta oxidation response to riboflavin

A 29 year old woman is described with severe hyperemesis gravidarum, atypical migraine, numerous admissions to hospital for psychiatric illness, non-epileptic seizures, and valproate-induced coma. Metabolic studies and measurement of [9,10(n)-3H]palmitate oxidation by cultured fibroblasts suggested a multiple acyl-CoA dehydrogenation disorder. Treatment with riboflavin abolished headaches and abnormal behaviour and normalised the plasma free carnitine level. Subtle defects in mitochondrial beta oxidation may be a treatable cause of disordered behaviour in adults.

Cyclosporine-associated central neurotoxicity after heart transplantation

Cyclosporine central neurotoxicity has been described after bone marrow, kidney, and liver transplantation but has not been well documented after heart transplantation. This case illustrates severe reversible neurotoxicity after heart transplantation with characteristic radiographic changes in magnetic resonance imaging.

A report of acute ethanol poisoning in a child: mouthwash versus cologne, perfume and after-shave

The ingestion of ethanol-containing products, such as cologne, perfume and after-shave, in children under six years of age is common, but serious poisoning is rarely reported. Thus, it has been recently suggested that children ingesting up to 3.5 ounces of these products may be safely observed at home as long as they remain asymptomatic. While it may be assumed that products with a significantly lower alcohol content represent a much smaller poisoning hazard, mouthwashes are a relatively frequent cause of serious poisoning in children. In the following case report, 75 milliliters of mouthwash caused hypoglycemia, coma and manifestations of tonic seizure activity. Because of the palatable nature of mouthwash, wine and liquor, it appears that children are more apt to drink large quantities, consuming dangerous amounts of ethanol. The apparent safety of cologne, perfume, and after-shave may be due to a lack of palatability as well as the irritant nature of high concentrations of ethanol. This case suggests that consumer items such as mouthwash should be packaged in child-resistant containers.

Severe amitriptyline overdose: relationship between toxicokinetics and toxicodynamics

The clinical features and toxicokinetics of amitriptyline were studied in nine patients with severe amitriptyline poisoning. Amitriptyline and amitriptyline metabolites were studied in plasma, red blood cells, and cerebral spinal fluid. Eight patients were intubated and six required assisted ventilation. Two patients had ventricular arrhythmias, three patients convulsions and two were hypotensive. All complications developed within four hours of admission. Early in the course of the intoxication the QRS duration correlated with plasma, unbound and red blood cell nortriptyline concentration. The QRS duration also correlated with unbound but not the plasma amitriptyline concentration. The level of consciousness correlated with the plasma and unbound amitriptyline both in alpha and beta phase and with red blood cell amitriptyline in alpha phase. There was no correlation between nortriptyline concentration and level of consciousness. No correlation between coma grade or QRS duration and cerebral spinal fluid concentration of amitriptyline was found. There was no correlation between any hydroxymetabolite in blood or cerebral spinal fluid and QRS duration or coma grade. The beta half-life for amitriptyline was shorter for two patients with high concentrations of hydroxymetabolites. Although intubated, neither patient required assisted ventilation or developed complications. Because of the wide range of concentrations of amitriptyline and amitriptyline metabolites observed between individuals, it is not possible to predict outcome based on a single tricyclic antidepressant concentration.

Oxaflozane overdose in a child

A case of severe poisoning in a 2 year-old child who ingested 150 mg of oxaflozane, a non-tricyclic antidepressant, is reported. After loss of consciousness, opisthotonos and coma, recovery was obtained with conservative treatment. Atropine-like symptoms were noted. The maximal plasma concentration of oxaflozane was 63 ng/mL. The elimination half-life for N-dealkyloxaflozane was 4.8 h.

Reversal of benzodiazepine intoxication by flumazenil

In order to firstly evaluate the efficacy of flumazenil in reversing benzodiazepine-induced sedation because of drug overdose and secondly to register adverse events, 13 patients admitted to the intensive care unit because of drug intoxication, were given flumazenil intravenously to a maximum of 1.0 mg. Sedation state was scored on a modified Glasgow Coma Scale and arterial blood pressure, heart rate and arterial blood gases were recorded before and after flumazenil was given, and every 30 min for 2 h. Results showed that flumazenil reversed the sedation due to benzodiazepines effectively increasing the coma score significantly (P less than 0.005). We found no change in arterial blood pressure (apart from one patient), heart rate or arterial blood gases. Two patients gave further information about drug intake after flumazenil was given. Six patients became resedated, only one needed additional flumazenil. One patient developed a hypertensive crisis after flumazenil was given as a result of the unmasking of an untreated hypertension. Another patient aspirated gastric content to the trachea during resedation and needed respiratory support.

Ethanol sensitivity

Ethanol sensitivity is a syndrome of flushing, tachycardia, weakness, fatigue, and other dysphoric symptoms in response to relatively small doses of ethanol. We describe a case of extreme ethanol sensitivity presenting with coma and review the pathophysiology of the syndrome.

Severe lactic acidosis following theophylline overdose

The patient with theophylline overdose commonly presents with gastrointestinal, cardiovascular, neurologic, and electrolyte abnormalities. Respiratory alkalosis is the most common acid-base alteration, but mild metabolic acidosis has been reported. Two cases of severe lactic acidosis (pH 6.67 and 6.63) in patients without hypoxemia, shock, or prolonged seizure activity are reported. Possible causative mechanisms and aspects of therapy are discussed. Theophylline toxicity should be considered when an unconscious patient with concurrent severe metabolic acidosis presents to the emergency department.

Prolonged survival following the inadvertent intrathecal administration of vincristine: clinical and electrophysiologic analyses

A 23-year-old man with a lymphoblastic lymphoma accidentally received 2.0 mg of vincristine intrathecally instead of intravenously. Although he underwent immediate CSF drainage, symptoms of an ascending myeloencephalopathy developed at 48 h. This progressed to coma, initially with a diffusely slow EEG, which evolved into alpha coma. He also developed a left frontal focus of epileptiform activity. He was transferred to our institution 1 month later. His court-appointed guardian refused to allow discontinuation of supportive treatment; therefore, the evolution of the disorder can be followed for 12 months. Although alpha coma remained the predominant pattern, some EEG evolution did occur, with a progressive decrease in amplitude being most prominent. An increase in amplitude in the 10th month was accompanied by the return of some nystagmoid eye movements. The patient's lymphoma then recurred, and further treatment was not attempted. This tragic case, in which transient exposure to a microtubular poison produced severe CNS toxicity, allows some insights into the mechanisms of alpha coma.