Development of a life-threatening anaphylactoid reaction following administration of ioversol in a child

We report for the first time the case of a 3-year-old girl who developed a severe anaphylactoid reaction following the administration of the nonionic, low osmolar intravenous radiographic contrast agent ioversol. Severe reactions to ioversol have rarely been reported in adult patients and to our knowledge never in children. Health care providers managing children who may require radiologic imaging studies with ioversol should be aware of the potential complications of this radiographic contrast agent.

Rhabdomyolysis following oral ingestion of the hydrocarbon cyclohexanone in an adolescent

A 15-year-old boy with no prior medical problems ingested cyclohexanone in a suicide attempt. The patient developed altered mental status, shock, metabolic acidosis, chemical hepatitis, and renal insufficiency. In addition, he developed rhabdomyolysis as evidenced by muscle pain, increased serum creatine phosphokinase levels and myoglobinuria. He was treated successfully with intubation, fluid resuscitation, dopamine, and activated charcoal. The patient was discharged without clinical sequelae. Renal involvement, chemical hepatitis, shock, and metabolic acidosis following oral ingestion of hydrocarbon containing solutions have been well described in the literature. To our knowledge, the development of rhabdomyolysis following an oral ingestion of a hydrocarbon was reported only once in an adult patient and never in an adolescent. We reviewed literature pertaining to the occurrence, pathophysiology, and etiology of rhabdomyolysis in hydrocarbon intoxication.

Predictors of death and neurologic impairment in pediatric submersion injuries. The Pediatric Risk of Mortality Score

OBJECTIVE

To evaluate the Pediatric Risk of Morality Score (PRISM score) as a tool to distinguish which patients presenting to the emergency department (ED) or pediatric intensive care unit (PICU) would survive neurologically intact from those who would die or survive with severe neurologic impairment following a submersion incident.

DESIGN

Retrospective chart review.

SETTING

A regional tertiary care ED and PICU.

MATERIALS

Medical records of drowning and near-drowning patterns between the ages of 1 day and 18 years who were admitted to the ED or PICU from January 1986 through December 1995.

MAIN OUTCOME MEASURES

For each patient, a PRISM score was calculated based on data collected at the time of arrival to the ED or PICU. A "probability of outcome" was calculated using the PRISM score. Outcomes were defined as survival with intact neurologic function, survival with severe neurologic impairment, or death, and were assessed using the Pediatric Cerebral Performance Category Scale. Scores and probabilities of outcome were compared with the actual outcome for both the ED and PICU patients using the Fisher exact test (2 tailed).

RESULTS

All Ed patients with PRISM scores less than 25 or a probability of outcome less than 50% (n = 40) survived with intact neurologic function (P < .001). All ED patients with PRISM scores of 25 or greater or a probability of outcome of 50% or greater (n = 10) either died or survived with severe neurologic impairment (P < .001). All PICU patients with a PRISM score of 5 or less (n = 25) or a probability of outcome less than 4% (n = 30) survived with intact neurologic function (P < .05). All PICU patients with a PRISM score greater than 20 or a probability of outcome greater than 50% either died or survived with severe neurologic impairment (P < .05). Outcomes could not accurately be predicted in PICU patients when the PRISM scores were 6 or greater and < or = 20 or less (n = 10), or when the probability of outcomes was 4% or greater and 50% or less.

CONCLUSIONS

The PRISM scoring system accurately distinguished ED patients who would survive neurologically intact from those who would die or suffer neurologic impairment. There was not a specific PRISM score or probability of outcome that could distinguish PICU patients who would survive neurologically intact from those who would die or suffer severe neurologic impairment. The PRISM scoring system appeared to be more accurate in distinguishing intact survival from death or neurologic impairment in ED patients than in PICU patients.

Effects of dantrolene on cooling times and cardiovascular parameters in an immature porcine model of heatstroke

OBJECTIVE

To evaluate the effects of dantrolene on cooling times and cardiovascular parameters in an immature porcine model of heatstroke.

DESIGN

Prospective, randomized, controlled, multigroup study.

SETTING

Research animal laboratory.

SUBJECTS

Yorkshire piglets (n = 16), 4 to 5 wks of age, 3.5 to 4.5 kg of body weight.

INTERVENTIONS

Animals were slowly heated with a radiant heat source to 43 degrees C and then maintained at this temperature for 30 mins. The animals were then removed from the heat source and randomized into one of four groups to receive either conventional cooling methods consisting of fluid resuscitation with 0.9% sodium chloride solution, sponging with room temperature water, mechanical fanning, and gastric lavage with iced 0.9% sodium chloride solution (group 1), conventional cooling methods and dantrolene (group 2), conventional cooling methods and dantrolene's vehicle mannitol (group 3), or no treatment (group 4). Cooling times, defined as the time required to reach a core body temperature of 38.5 degrees C, and cardiovascular parameters for each group were then compared.

MEASUREMENTS AND MAIN RESULTS

Animals in groups 1, 2, and 3 had significantly (p < .05) lower core body temperatures than animals that received no treatment at the conclusion of the experiment. Piglets in groups 2 and 3 had faster cooling times than piglets in group 1 (p < .05). However, there was no statistically significant difference in cooling times between the animals in groups 2 and 3. There were no statistically significant differences in heart rate, mean arterial pressure, central venous pressure, pulmonary artery occlusion pressure, or systemic vascular resistance index between animals in groups 1, 2, or 3. Group 3 piglets had higher cardiac indices and stroke indices than the piglets in the other groups (p < .05).

CONCLUSIONS

Therapeutic interventions with conventional cooling or conventional cooling and dantrolene provided significant improvement in cardiovascular function in an immature porcine heatstroke model. Dantrolene, given with conventional cooling methods, offered no significant improvement in cardiovascular parameters compared with conventional cooling methods alone. Dantrolene significantly shortened the cooling time compared with conventional cooling but did not significantly shorten the cooling time compared with its vehicle, mannitol. Although dantrolene significantly shortened the cooling time, it did not appear to be superior compared with conventional cooling methods in treating heatstroke in this immature porcine heatstroke model.

Neurologic complications following intranasal administration of heroin in an adolescent

OBJECTIVE

To describe an adolescent patient who developed a stroke following intranasal administration of heroin.

CASE SUMMARY

A 17-year-old adolescent with no prior medical problems "snorted" an unknown quantity of heroin. The patient developed respiratory failure, shock, and seizures. When he regained consciousness, the patient had evidence of hypoxic-toxic encephalopathy on neuropsychologic examination. Magnetic resonance imaging revealed an infarct in the globus pallidus region of the brain.

DISCUSSION

Serious neurologic complications following intranasal administration of heroin have been reported rarely in children. Correlations between findings on neuropsychologic examination and magnetic resonance imaging following drug overdoses have likewise been rarely described. We reviewed literature pertaining to the etiology, pharmacology, and pathophysiology of neurologic complications resulting from heroin intoxication.

CONCLUSIONS

As the use of intranasal heroin is increasing in the pediatric population, healthcare professionals should be aware of the various potentially serious complications that may occur.

Shock, metabolic acidosis, and coma following ibuprofen overdose in a child

OBJECTIVE

To report a child who developed shock, loss of consciousness, and metabolic acidosis following an ibuprofen overdose.

CASE SUMMARY

A 6-year-old boy with no prior medical problems ingested approximately thirty 200-mg tablets of ibuprofen. The patient developed shock, coma, and metabolic acidosis. He was treated successfully with intubation and mechanical ventilation, fluid resuscitation, and decontamination with activated charcoal. The patient was discharged without any clinical sequelae.

DISCUSSION

Serious adverse complications following ibuprofen overdose have been reported rarely in children. We reviewed literature pertaining to the etiology, pharmacology, pathophysiology, and management of complications following ibuprofen overdoses, as well as other case reports.

CONCLUSIONS

Coma, metabolic acidosis, and shock were noted in a child who ingested a large quantity of ibuprofen. These complications have been described rarely in children. We attribute his favorable clinical outcome to early and aggressive intervention consisting of tracheal intubation, fluid resuscitation, and decontamination with activated charcoal. Although ibuprofen overdoses are usually benign, healthcare professionals should be aware of the various potentially serious complications that may occur.

Pulmonary complications following tricyclic antidepressant overdose in an adolescent

OBJECTIVE

To report a case of pulmonary edema following a tricyclic antidepressant (TCA) overdose in an adolescent.

CASE SUMMARY

A 14-year-old girl with a history of prior suicide attempts ingested 54 50-mg desipramine hydrochloride tablets (45 mg/kg ingestion). The patient developed a cardiac dysrhythmia and hypotension, which were successfully treated. She subsequently developed pulmonary edema and a clinical picture suggestive of adult respiratory distress syndrome (ARDS). She was successfully managed with fluid restriction, tracheal intubation, application of positive end-expiratory pressure (PEEP), and vasopressors. The patient was discharged without any clinical sequelae.

DISCUSSION

Pulmonary complications secondary to TCA overdose have rarely been reported in children. We reviewed literature pertaining to the etiology, epidemiology, pathophysiology, and management of TCA-induced lung injury, as well as other case reports. We discuss the potential relationship between sequelae resulting from TCA ingestion (e.g., cardiac disturbances, hypotension, acidosis, gastric aspiration, pneumonia) and the development of ARDS and pulmonary edema, and relate this association to our patient.

CONCLUSIONS

Pulmonary edema and a clinical picture suggestive of ARDS was noted in an adolescent girl who ingested a large quantity of desipramine. Her lung injury may have been the result of a variety of factors including hypotension, metabolic acidosis, possible aspiration, or a direct action on the lung parenchyma by desipramine. We attribute her favorable clinical outcome to early intervention consisting of tracheal intubation, PEEP, fluid restriction, and vasopressor therapy.

The effect of methylcellulose on extrarenal erythropoietin production

The macromolecular polymer, methyl cellulose (MC), is a known hepatosplenomegalic agent which promotes a state of experimental hypersplenism in rats. This is characterized by massive splenomegaly, pancytopenia of the blood elements, medullary hypoplasia, and marked gross and histologic alteration of the liver, kidney, adrenals, and lungs. Massive splenomegaly results from storage of this inert material by splenic macrophages. In the present study, chronic MC administration in rats augmented the hepatic Ep response to hypoxia but did not appreciably affect renal production of Ep. Splenectomy resulted in a decrease in the extrarenal Ep response to hypoxia indicating a possible role of the massively enlarged spleen of these MC-treated rats in extrarenal Ep production. The augmentation of extrarenal Ep elaboration may be attributed to a stimulatory effect of MC on the hepatic and splenic macrophages.

The influence of pancreatic hormones and diabetogenic procedures on erythropoietin production

The influence of the pancreas on renal and extrarenal erythropoietin (Ep) production and on the elaboration of the hepatic erythropoietic factor (HEF) was studied in these experiments. Insulin was found to elevate Ep levels in the anephric hypoxic rat when compared to controls, whereas glucagon treatment augmented the hepatic Ep response to hypoxia in the subtotally hepatectomized (hepx) animal while lowering it in the renal intact rat. Production of experimental diabetes either through chemical induction by alloxan or following pancreatectomy diminished the Ep response in all groups tested. Treatment with antiglucagon caused an elevation in the Ep response to hypoxia in the intact rat but lowered Ep levels in the hepx animal. In addition, glucagon and a synthetic hepatotrophic agent (L-histidyl L-lysine acetate) stimulated HEF production in the hepx rat, although none of the agents tested were capable of enhancing HEF levels in the intact rat.

Haemolytic anaemia in rhesus monkeys induced by methylcellulose

The rhesus monkey was evaluated in its haemopoietic and histological response to intraperitoneal injections of methylcellulose. The haematologic alterations included a mild haemolytic anaemia, lymphopaenia, monocytosis, a shortened survival of Cr51 -labelled autologous erythrocytes (17 . 1 vs 13 . 3 days, P less than 0.025) and normoblastic hyperplasia of the bone marrow. There was a diffuse sequestration of the polymer in the phagocytic cells of the spleen, liver, bone marrow, lymph nodes and adrenal glands. The renal glomerular endothelium also consistently stored this material. Overt splenomegaly was not induced. The monkey appears to present, along with other animals, a rather species-specific response to methylcellulose that is accompanied by fundamental responses observable in all subjects.