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Simon G. Detection of Fatal Potassium Overdose: A Case Report and Review of the Literature. Diagnostics (Basel) 2023; 13:diagnostics13071339. [PMID: 37046560 PMCID: PMC10093193 DOI: 10.3390/diagnostics13071339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/01/2023] [Accepted: 04/03/2023] [Indexed: 04/14/2023] Open
Abstract
Potassium overdose usually occurs accidentally, but potassium is also used for judicial executions, assisted death, and, rarely, suicides. In addition to exogenous overdose, various drugs, and renal failure, diabetic ketoacidosis can cause hyperkalemia. Potassium tablets are used in most cases of suicidal potassium overdose. Suicide by intravenous administration of potassium is rare but usually fatal. The author reports a rare case of suicide with potassium infusion. Autopsy and histology findings, along with post-mortem biochemical analysis of different body fluids and fluid from the infusion set, are reported. Previously published reports of potassium overdose were reviewed, and the detection possibilities of potassium overdose are discussed. The detection possibilities of lethal hyperkalemia are very limited since hyperkalemia produces only nonspecific autopsy and histology findings. Post-mortem potassium concentrations are not indicative of ante-mortem potassium concentrations; therefore, post-mortem biochemical analysis has limited value in determining potassium overdose. The best way to prove potassium overdose is via the collection and analysis of circumstantial evidence.
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Affiliation(s)
- Gábor Simon
- Department of Forensic Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
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2
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Vitamin and mineral supplement exposures: cases reported to Australia's largest Poisons Information Centre, 2014-2015 to 2018-2019. Br J Nutr 2021; 126:1788-1793. [PMID: 33597065 DOI: 10.1017/s0007114521000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Vitamin and mineral supplements (VMS) are widely available and commonly used. Little is known about patterns of poisoning exposures to VMS in the Australian population. We performed a retrospective study of calls to the New South Wales Poisons Information Centre (NSWPIC), July 2014-June 2019. NSWPIC is Australia's largest PIC, taking approximately 100 000 calls/year (50 % of Australian poisoning calls) from healthcare professionals and members of the public. We conducted additional analyses on Fe exposures due to their high risk of acute toxicity. There were 10 944 VMS exposures reported to NSWPIC during the study period, increasing 9·6 % per annum over a 5-year period (95 % CI, 7·2, 12·1 %). Toddlers (1-4 years) accounted for 41·5 % (4546) of cases. Agents most commonly involved were multivitamins (n 3610), vitamin D (n 2080), Fe (n 1533) and Mg (n 804). In 17·7 % (1934) of cases, the call originated from hospital or the patient was referred to hospital by NSWPIC. Fe exposures increased by 14·0 % per year (95 % CI, 9·5, 18·5 %), and most were associated with high-strength products (> 45 mg elemental Fe per unit dose, n 1036). Fe exposures were hospitalised in 38 % of cases (n 583). We conclude that VMS exposures are increasing in Australia. Although most exposures can be managed at home, many required hospitalisation. Fe exposures are increasing and had higher rates of hospitalisation than other agents. VMS are often considered safe and without the potential for adverse effects, highlighting the importance of public education into the potential risks of misuse of these products.
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Janssens PMW, Pot MW, Wouters M, Leeuwen HJV, Borren MMGJV. What extreme laboratory values can be obtained that (some) patients can survive with? Scandinavian Journal of Clinical and Laboratory Investigation 2021; 82:50-57. [DOI: 10.1080/00365513.2021.2015800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Pim M. W. Janssens
- Department of Clinical Chemistry and Haematology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Michiel W. Pot
- Department of Clinical Chemistry and Haematology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Moniek Wouters
- Physician in Training for Specialist Physician Pulmonary Diseases, Department of Pulmonary Diseases, Rijnstate Hospital, Arnhem, The Netherlands
| | - Henk J. van Leeuwen
- Physician Internal Medicine, Registered Intensive Care Specialist, Department of Intensive Care, Rijnstate Hospital, Arnhem, The Netherlands
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Abstract
OBJECTIVE Severe toxicity from ingestions of oral sustained-release potassium is rare. While acute hyperkalaemia requires urgent intervention given the risk of cardiac toxicity, there is a lack of clinical consensus on optimal management. The aim of this study was to characterise the clinical manifestations of acute potassium overdose and its management approach. METHODS This is a retrospective case series of patients presenting following oral potassium overdose of ≥6000mg between January 2009 and December 2020 in Queensland, Australia as recorded in the state's Poisons Information Centre database and a tertiary Clinical Toxicology Unit database. Patients were identified from prospective databases maintained by both units and data were extracted from these in addition to medical records. RESULTS Thirteen presentations in eleven patients occurred in the twelve-year period. The median age was 35 years (range 14-55 years). The median dose ingested was 6.4 mmol/kg (range 0.9-30.8 mmol/kg). Severe hyperkalaemia >7mmol/L occurred in five patients, four with ingestions ≥60,000mg. All patients with hyperkalaemia received multiple modes of intracellular potassium shifting therapy. Four patients had endoscopic removal of pharmacobezoars. One also underwent whole bowel irrigation. Three presentations were managed with haemodialysis. All patients were discharged home with a median length of stay of 20 h. CONCLUSION Aggressive medical therapy to shift potassium into cells appears to be the mainstay of treatment in patients with normal renal function. Early decontamination may limit peak potassium concentrations. It is unclear if haemodialysis provides significant additional benefit in patients with normal renal function.
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Affiliation(s)
- Arushi Madan
- Department of Clinical Pharmacology, Princess Alexandra Hospital, Brisbane, Australia.,Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Christopher Morris
- Department of Clinical Pharmacology, Princess Alexandra Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Anna Goggin
- Queensland Poisons Information Centre, Queensland Children's Hospital, South Brisbane, Australia
| | - Katherine Z Isoardi
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Queensland Poisons Information Centre, Queensland Children's Hospital, South Brisbane, Australia
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Ibrahim M, Seto C, MacIntosh T. Hyperkalemic Emergency: When You Have Taken a Few Too Many KCl Tablets. Cureus 2020; 12:e10499. [PMID: 33094043 PMCID: PMC7571776 DOI: 10.7759/cureus.10499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Hyperkalemia is a common clinical problem that varies significantly in severity and indications for treatment. Hyperkalemic emergency exists when there are clinical signs or symptoms, including cardiac conduction abnormalities. The combination of nebulized albuterol and insulin with glucose is most effective for managing clinically significant hyperkalemia. Prompt recognition of hyperkalemic emergency, immediate interventions to lower extracellular potassium, and involvement of multiple disciplines (including critical care and nephrology) are essential to addressing this life-threatening presentation.
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Affiliation(s)
- Mahmoud Ibrahim
- Internal Medicine, University of Central Florida College of Medicine/Hospital Corporation of America Graduate Medical Education Consortium, Kissimmee, USA
| | - Christina Seto
- Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Tracy MacIntosh
- Emergency Medicine, Osceola Regional Medical Center, Kissimmee, USA
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Iijima S. Suicide attempt using potassium tablets for congenital chloride diarrhea: A case report. World J Clin Cases 2020; 8:1463-1470. [PMID: 32368538 PMCID: PMC7190950 DOI: 10.12998/wjcc.v8.i8.1463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/02/2020] [Accepted: 04/09/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Congenital chloride diarrhea (CCD) is a rare inherited disorder of intestinal electrolyte transport that results in a large wastage of electrolytes and water. Advances in substitution therapy using sodium chloride (NaCl) and potassium chloride (KCl) have dramatically improved survival for patients with CCD. Slow-release KCl is widely prescribed as a potassium supplement; however, it has also occasionally been used in suicide attempts, as potassium poisoning can generate life-threatening hyperkalemia.
CASE SUMMARY A 26-year-old female presented to the emergency department (ED) with self-poisoning, having taken 30 tablets of slow-release KCl (total: 240 mmol potassium) following an auditory hallucination. The patient had been undergoing substitution therapy with NaCl and KCl for CCD and been followed up in the pediatric department. One month prior, she developed insomnia and anxiety and had consulted a psychiatrist. At the ED, although her general condition was good, she appeared agitated. Her serum potassium level was 7.0 mmol/L, indicating hyperkalemia, and electrocardiographic changes showed tenting of the T-waves. She responded to the administration of calcium gluconate, sodium bicarbonate, and insulin with glucose, and the serum potassium level improved. Finally, she was diagnosed with schizophrenia.
CONCLUSION In CCD management, physicians should pay careful attention to patients’ extraintestinal issues, including psychological disorders that may emerge in adulthood.
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Affiliation(s)
- Shigeo Iijima
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu 4313192, Japan
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Te Dorsthorst RPM, Hendrikse J, Vervoorn MT, van Weperen VYH, van der Heyden MAG. Review of case reports on hyperkalemia induced by dietary intake: not restricted to chronic kidney disease patients. Eur J Clin Nutr 2018; 73:38-45. [PMID: 29588531 DOI: 10.1038/s41430-018-0154-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 02/19/2018] [Accepted: 02/28/2018] [Indexed: 12/31/2022]
Abstract
Hyperkalemia is a metabolic disturbance of the potassium balance that can cause potentially fatal cardiac arrhythmias. Kidney dysfunction and renin-angiotensin-aldosterone system inhibiting drugs are notorious for their tendency to induce hyperkalemia by decreasing the excretion of potassium. The role of dietary potassium intake in inducing hyperkalemia is less clear. We review and analyze the common presentation, laboratory, and electrocardiogram (ECG) findings and therapeutic options associated with dietary-induced hyperkalemia, and find evidence for hyperkalemia development in non-renal impaired patients. Thirty-five case reports including 44 incidences of oral intake-induced hyperkalemia were assessed, 17 patients did not suffer from kidney dysfunction. Mean age was 49 ± 20 years. Mean potassium concentration was 8.2 ± 1.4 mEq/l, most frequently caused by abundant intake of fruit and vegetables (n = 17) or salt substitutes (n = 12). In patients with normal kidney function, intake of salt substitutes or supplements was the main cause of hyperkalemia. Main symptoms encompassed muscle weakness (29.5%), vomiting (20.4%), and dyspnea (15.9%). When ECGs were performed (n = 30), abnormalities were present in 86.7% of cases. Treatment involved administration of insulin (n = 22), sodium/calcium polystyrene sulfonate (n = 14), and/or calcium gluconate (n = 14). Forty patients fully recovered. Three, non-renal impaired, patients passed away. These results offer insight into the clinical aspects of dietary-induced hyperkalemia and suggest that the common assumption that dietary-induced hyperkalemia is a condition of renal impaired patients might be incorrect.
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Affiliation(s)
- Rogier P M Te Dorsthorst
- Participant in the Honours Program CRU2006 Bachelor, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jytte Hendrikse
- Participant in the Honours Program CRU2006 Bachelor, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Mats T Vervoorn
- Participant in the Honours Program CRU2006 Bachelor, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Valerie Y H van Weperen
- Participant in the Honours Program CRU2006 Bachelor, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marcel A G van der Heyden
- Department of Medical Physiology, Division of Heart & Lungs, University Medical Center Utrecht, Yalelaan 50, 3584 CM, Utrecht, The Netherlands.
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Palmiere C, Scarpelli MP, Varlet V, Baumann P, Michaud K, Augsburger M. Fatal intravenous injection of potassium: Is postmortem biochemistry useful for the diagnosis? Forensic Sci Int 2016; 274:27-32. [PMID: 27932048 DOI: 10.1016/j.forsciint.2016.11.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/15/2016] [Accepted: 11/22/2016] [Indexed: 02/06/2023]
Abstract
Fatal cases of potassium overdoses have traditionally been considered indemonstrable due postmortem biochemical investigation limits (mainly potassium determination in postmortem serum and vitreous humor). Nevertheless, some authors have expressed a divergent opinion over the years based on the results of their own investigations. In this study, we investigated left vitreous, right vitreous, postmortem serum from peripheral blood, postmortem serum from cardiac blood, urine, pericardial and cerebrospinal fluid potassium concentrations in 21 forensic autopsy cases. One of these was a case of accidental, fatal intravenous potassium injection in a hospitalized patient. The other twenty cases were subjects with various causes of death unrelated to potassium administration and comparable postmortem intervals. Our aim was to assess whether postmortem biochemical investigations performed in several biological samples may be useful in diagnosing exogenous potassium administration. No statistically significant differences were observed between the measured concentrations in the fatal case of potassium intravenous administration and the control cases in any of the tested samples. Potassium concentrations in the investigated case of exogenous potassium injection were within the range of those measured in the control cases, irrespective of the tested biological sample. Our findings corroborate the conclusions of former authors who highlighted that circumstantial evidence provides the greatest diagnostic contribution in situations of suspected potassium poisoning. This is due to the objective limitations demonstrated by postmortem biochemical investigations in such cases, even when potassium measurements are carried out in several biological samples of satisfying quality and within a relatively short postmortem interval.
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Affiliation(s)
- Cristian Palmiere
- University Center of Legal Medicine, Chemin de la Vulliette 4, 1000, Lausanne 25, Switzerland.
| | - Maria Pia Scarpelli
- University Center of Legal Medicine, Chemin de la Vulliette 4, 1000, Lausanne 25, Switzerland
| | - Vincent Varlet
- University Center of Legal Medicine, Chemin de la Vulliette 4, 1000, Lausanne 25, Switzerland
| | - Pia Baumann
- University Center of Legal Medicine, Chemin de la Vulliette 4, 1000, Lausanne 25, Switzerland
| | - Katarzyna Michaud
- University Center of Legal Medicine, Chemin de la Vulliette 4, 1000, Lausanne 25, Switzerland
| | - Marc Augsburger
- University Center of Legal Medicine, Chemin de la Vulliette 4, 1000, Lausanne 25, Switzerland
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Salfranc E, Candille C, Dumanoir P, Carpentier F. Une intoxication grave au chlorure de potassium. ANNALES FRANCAISES DE MEDECINE D URGENCE 2014. [DOI: 10.1007/s13341-014-0417-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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Self-inflicted hyperkalemia: a case report. Case Rep Emerg Med 2013; 2012:458049. [PMID: 23326714 PMCID: PMC3542891 DOI: 10.1155/2012/458049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Accepted: 04/03/2012] [Indexed: 11/25/2022] Open
Abstract
We present a case of a potentially lethal ingestion of potassium pills. After presentation, we briefly review the epidemiology and pathology of hyperkalemia.
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Rusyniak DE, Durant PJ, Mowry JB, Johnson JA, Sanftleben JA, Smith JM. Life-threatening hyperkalemia from cream of tartar ingestion. J Med Toxicol 2012; 9:79-81. [PMID: 22926733 DOI: 10.1007/s13181-012-0255-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Cream of tartar (potassium bitartrate) has a long history as a cooking aid and medicinal purgative. Despite containing large amounts of potassium, there are no well-documented cases of it causing toxicity. We report two cases in which intentional ingestions of cream of tartar resulted in life-threatening hyperkalemia. In addition, we briefly review the use of cream of tartar as a historical purgative. CASE REPORTS In both cases, individuals ingested a large quantity of cream of tartar in an effort to "clean themselves out". They manifested similar initial symptoms (vomiting), abnormal serum potassium (>8.0 mmol/L), and EKG's with peaked T waves. Both patients were treated for hyperkalemia and recovered without complication. A search for articles on an academic internet database failed to identify any cases specifically dealing with ill effects of potassium bitartrate and numerous websites continue to purport its beneficial health effects. CONCLUSION Ingestion of cream of tartar can potentially result in life-threatening hyperkalemia.
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Affiliation(s)
- Daniel E Rusyniak
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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Gunja N. Decontamination and enhanced elimination in sustained-release potassium chloride poisoning. Emerg Med Australas 2012; 23:769-72. [PMID: 22151677 DOI: 10.1111/j.1742-6723.2011.01469.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Potassium chloride poisoning can be potentially life-threatening, particularly in massive ingestions of sustained-release preparations. Profound hyperkalaemia, developing over several hours, can lead to cardiac arrhythmias and death. This case series reports three episodes of sustained-release potassium chloride poisoning in two individuals requiring whole bowel irrigation or haemodialysis. The first two episodes, in the same patient, illustrate the contrast between the successful use of decontamination versus the need for haemodialysis. The second case, in a child, illustrates the need for tertiary level paediatric expertise in managing this type of poisoning. Whole bowel irrigation with polyethylene glycol is a resource-intensive procedure most beneficial when large numbers of radio-opaque tablets are seen in the stomach. In cases where most of the tablet matter has already been absorbed, extracorporeal methods of rapidly reducing the total body burden of potassium, such as haemodialysis, might be life-saving.
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Affiliation(s)
- Naren Gunja
- New South Wales Poisons, The Children's Hospital at Westmead, New South Wales, Australia.
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