Hemoperfusion with Amberlite resin in the treatment of self-poisoning

Ten patients with various intoxications were treated with resin hemoperfusion. Three of four patients with grade IV coma due to tricyclic antidepressant (TCA) poisoning could be extubated during or on termination of hemoperfusion. Clearance values of 135--185 and 190--200 ml/min were obtained for amitriptyline and nortriptyline, respectively. One patient with severe chloral hydrate poisoning could be extubated after less than one hour's hemoperfusion. A clearance of 140 ml/min was obtained in a uremic patient with AV block II due to digitoxin intoxication. Four patients with mushroom poisoning were treated with combined hemoperfusion-hemodialysis. A transient fall in platelet count was seen in all patients. Resin hemoperfusion is of definite value in selected, severe cases of self-poisoning with psychotropic drugs such as TCA and possibly in cases of mushroom poisoning where the prognosis with hemodialysis and supportive therapy is doubtful.

Pharmacokinetics of chloral hydrate poisoning treated with hemodialysis and hemoperfusion

In a severe case of chloral hydrate intoxication treated with combined hemodialysis and hemoperfusion the pharmacokinetics of the metabolites trichloroethanol (TCE), trichloroethanol glucuronide (TCE-Glu) and trichloroacetic acid (TCA) were studied. Indications of delayed absorption and some slowing of metabolism were found. At a blood flow rate of 200 ml/min clearances by hemodialysis and hemoperfusion, respectively, in ml/min were estimated to be 188 and 156 for TCE, 184 and 181 for TCE-Glu, 142 and 91 for TCA. Clearance by hemoperfusion declined with time. The half-lives of TCE and TCA were 3.2 and 4.3 hours during combined hemodialysis and hemoperfusion. After termination of treatment the half-life of TCE was 12.8 hours, whereas TCA was metabolized so slowly, that no reliable calculation could be performed. We conclude that hemodialysis and hemoperfusion are equally and highly efficient in the treatment of chloral hydrate poisoning, but hemoperfusion may increase the risk of gastric bleeding more than hemodialysis. Hemodialysis may therefore be preferable and should be tried in spite of low blood pressure.

Cardaic arrhythmias in chloral hydrate poisoning

In three patients admitted to hospital after ingestion of an overdose of chloral hydrate, the ECG showed supreventricular and ventricular tachyarrhythmias. The possible mechanism for the arrhythmias may be an enhanced automaticity of supraventricular and ventricular pacemaker cells caused by metabolites of chloral hydrate. The ventricular arrhythmia responded to i.v. treatment with lignocaine in one patient, and to phenytoin in another in whom lignocaine failed to restore a normal sinus rhythm.

[Mixed fatal poisoning caused by taking L-methadone and chloral hydrate]

A 42-year-old female drug user who was enrolled in a methadone maintenance program was found dead in her apartment. Cause of death was an intoxication with chloral hydrate and L-methadone. Trichloroethanol (TCE), the primary metabolite of chloral hydrate, was quantified by solid phase microextraction (SPME) and GC/MS in heartblood (27 micrograms/ml) and urine (338 micrograms/ml). D- and L-methadone were differentiated by chiral HPLC, which showed that only L-methadone had been taken. The quantitation of L-methadone and its metabolite EDDP was carried out by GC/MS from heartblood (1300 ng/ml and 86 ng/ml, respectively), urine (5239 ng/ml and 4960 ng/ml, respectively) and gastric contents (159 ng/ml and 122 ng/ml, respectively). The concentrations of both--trichloroethanol and methadone--were in toxic ranges.

Fatal intoxications with chloral hydrate

An alcoholic man, treated with chloral hydrate (CH) syrup to which he was dependent, was discovered comatose and in respiratory arrest. Death occurred on the ninth day of hospitalization following cerebral oedema. A woman, alcohol addicted, depressed, and epileptic was admitted in the Intensive Care Unit with heart and respiratory failure following CH absorption. She died three days later after a deep coma. In these two cases, CH intoxication was confirmed by toxicological analysis: CH and its major metabolite, trichloroethanol (TCE), were identified and determined in serum and urine using headspace-capillary gas chromatography-mass spectrometry. The concentrations measured were compared with those found in previously published fatalities. The analytical method used can be proposed for both clinical and forensic cases.

A case of Munchausen syndrome by proxy presenting as a medical negligence action

The parents of a child who was transported lifeless to a hospital initiated a medical negligence action. Only after discovery did it become clear that the mother, suffering from a disorder known as Munchausen syndrome by proxy, caused the death of the child. The case presented a number of complex evidentiary and litigation issues likely to be encountered by other medical-negligence defense attorneys.

Successful treatment of chloral hydrate cardiac toxicity with propranolol

A case of chloral hydrate overdose causing resistant ventricular arrhythmias is presented. Our case and other case reports suggest that chloral hydrate-induced arrhythmias are resistant to standard antiarrhythmic agents and that intravenous beta blockers should be the firstline treatment for these arrhythmias.

Perimortem fixation of the gastric and duodenal mucosa: a diagnostic indication for oral poisoning

Two cases of fatal oral poisoning are presented. In the first case, a 40-year-old man died due to a lethal dose of mercury (blood concentration 113.8 microg/ml) and in the second, a 34-year-old man died of chloralhydrate overdose with a lethal blood concentration of trichloroethanol (52 microg/ml), the active metabolite of chloralhydrate. In both cases gross examination and histology showed an unusually well preserved gastrointestinal mucosa in addition to unspecific signs of intoxication. The two cases demonstrate that the phenomenon of perimortal fixation is a useful indication for the forensic pathologist and should direct the suspicion to oral poisoning. The detection of fixation facilitates toxicology screening by indicating that the relevant substance must have the capability to precipitate proteins.

Reversible segmental cerebral arterial vasospasm and cerebral infarction: possible association with excessive use of sumatriptan and Midrin

OBJECTIVE

To describe a patient who developed reversible segmental cerebral arterial vasospasm and cerebral infarction while taking excessive amounts of sumatriptan succinate and a combination drug (Midrin) consisting of isometheptene mucate, 65 mg, dichloralphenazone, 100 mg, and acetaminophen, 325 mg.

DESIGN

Case report.

SETTING

Tertiary care center.

PATIENT

A 43-year-old man who developed a left occipital infarct after taking a total of 23 sumatriptan succinate tablets (25 mg per tablet) and 32 Midrin tablets during a 7-day period and who on digital subtraction angiography was shown to have segmental cerebral arterial narrowing in multiple vessels. An extensive evaluation for other possible risk factors for cerebral infarction was unrevealing.

MAIN OUTCOME AND RESULTS

Discontinuation of sumatriptan and Midrin regimens and administration of nicardipine hydrochloride led to nearly total resolution of the angiographic findings, and the patient had no recurrent strokes.

CONCLUSIONS

One should consider the diagnosis of drug-induced vasospasm in patients with cerebral infarction and a history of excessive use of sumatriptan and Midrin. The initial angiographic abnormalities may resemble those found in patients with primary angiitis of the central nervous system.

Unusual death attributed to the combined effects of chloral hydrate, lidocaine, and nitrous oxide

A case in which the death of a 2-year-old male child was the result of an acute intoxication with chloral hydrate, lidocaine, and nitrous oxide is presented. Trichloroethanol (TCE), the primary metabolite of chloral hydrate, was qualitatively detected by the Fujiwara reaction. Quantitation of TCE was carried out by gas chromatography-mass spectrometry (GC-MS) with the following results: plasma, 79.0 mg/L; urine, 31.0 mg/L; gastric contents, 454.0 mg/L; bile, 111.0 mg/L; vitreous, 40.2 mg/L; cerebrospinal fluid (CSF), 68.3 mg/L; and liver, 164 mg/kg. Lidocaine was quantitated by GC analysis using nitrogen-phosphorus detection with the following results: plasma, 11.9 mg/L; urine, 3.7 mg/L; gastric contents, 15.3 mg/L; bile, 19.0 mg/L; vitreous, 17.8 mg/L; CSF, 9.4 mg/L; and liver, 19.0 mg/kg. Nitrous oxide was quantitated in the blood with a value of 4.4 mL/L.

Chloral hydrate toxicity from oral and intravenous administration

BACKGROUND

Overdose from enteric chloral hydrate results in cardiovascular and central nervous system symptoms.

CASE REPORTS

This case series compares and contrasts two cases of oral chloral hydrate overdose with two cases of accidental i.v. administration. Whereas ingestion of 219 mg/kg of chloral hydrate resulted in transient bigeminy, ingestion of up to 960 mg/kg caused torsades de pointes and ventricular fibrillation which were effectively treated with defibrillation and a beta blocker. I.V. administration in humans does not appear previously documented. Two cases of i.v. administration of a therapeutic chloral hydrate dose resulted in central nervous system depression and minimal local effects at the injection site.

CONCLUSIONS

Given the high bioavailability of oral chloral hydrate the major determinant of cardiotoxicity may be the dose rather than the route of administration. Cardiac arrhythmias due to chloral hydrate appear to be responsive to beta blocker therapy.

[Chloral hydrate--is it safe?]

Chloral hydrate is widely used as a sedative or hypnotic, especially in geriatric and pediatric patients. In therapeutic doses blood pressure and respiration are only minimally affected. We describe a 9-year-old boy in whom a life-threatening cardiac arrhythmia dominated the clinical presentation of chloral hydrate intoxication. In spite of its widespread use, the dangers of chloral hydrate overdosage, especially cardiac arrhythmias, are not sufficiently appreciated.

Suicidal chloral hydrate poisoning

BACKGROUND

The cumulative reports of chlorate hydrate toxicity suggest an unacceptable risk for this commonly used sleep aid.

CASE REPORT

A 29-year-old male was admitted after ingestion of 70 g of chloral hydrate. He was hypotensive and hypothermic. Spontaneous respiration was insufficient. Fluid resuscitation did not restore adequate blood pressure levels. Low dose catecholamine infusion resulted in ventricular arrhythmias. The patient was treated with combined hemoperfusion and hemodialysis during an eight hour period. During this time, serum concentrations of trichlorethanol fell. Blood pressure and heart rate increased and consciousness was regained without signs of neurological deficits.

CONCLUSIONS

Although outcome was favorable, this case report illustrates the potentially high acute toxicity of chloral hydrate and supports its removal from the market.

Determination of chloral hydrate and metabolites in a fatal intoxication

A young woman (32 years old) was found dead in her house. Screening of postmortem blood with enzyme multiplied immunoassay (EMIT) detected benzodiazepines, salicylic acid derivatives, and caffeine. These compounds were present in nontoxic concentrations as confirmed by thin-layer chromatography and high-performance liquid chromatography. The Fujiwara-Ross reaction on blood revealed the presence of chlorinated hydrocarbons in high concentrations. An optimized gas chromatographic method with electron capture detection allowed the identification and quantitation of chloral hydrate and both its metabolites, 2,2,2-trichloroethanol and trichloroacetic acid, in the available postmortem samples. The tissue concentrations indicated that chloral hydrate ingestion could be identified as the cause of this fatality.

[Chloral hydrate poisoning]

The intentional ingestion of 5 g of chloral hydrate by a 67-yr-old man resulted in cardiac arrhythmia including tachyarrhythmia and polymorphic ventricular extrasystoles. As the ingested agent was unknown at admission, the patient was treated among others with sodium lactate, a non validated therapy of arrhythmia caused by chloral hydrate overdose. The discontinuation of arrhythmia was in favour of a beneficial effect of this treatment which remains to be confirmed. This unusual therapy is the original point of this case report which allows to question the so-called innocuousness of chloral hydrate, to remind the conventional treatment of the arrhythmias caused by this agent, the place of beta-adrenergic blockers, as well as the therapeutic difficulties when the causative agent remains unknown.

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).

[Accidental chloral hydrate poisoning]

A 42-year-old woman had an accidental overdose of chloral hydrate due to repeated absorption of a therapeutic dose of chloral syrup for insomnia. The total ingestion was estimated at 8 g. Overnight slight loss of consciousness associated with severe cardiac arrhythmia (bigeminia ventricular extra-systole) needed admission to the intensive care unit and intravenous lignocaine for two days. The evolution was satisfactory.

Chloral hydrate toxicity in a term infant

Chlorate hydrate is commonly used for neonatal sedation, but blood levels are infrequently monitored, reflecting an underemphasis of acute toxic effects. This report describes a case of chloral hydrate toxicity in a term infant with cardiac, renal, neurologic, bladder and gastrointestinal dysfunction. The effects of exchange transfusion are described as well as pharmacokinetics.

Overdose with chloral hydrate: a pharmacological and therapeutic review

The purpose of this review is to highlight the toxicity of chloral hydrate and to review the management of overdoses with chloral hydrate. Three patients are presented in whom life-threatening cardiac arrhythmias dominated the clinical presentation. These arrhythmias were resistant to standard antiarrhythmic therapy. Also, we have reviewed selected features in eight patients who took overdoses of chloral hydrate who were admitted to an intensive care unit between 1981 and 1988. The pharmacology and toxicology of chloral hydrate are discussed with particular reference to the cardiac arrhythmias that are seen with overdosage. A proposed management scheme is detailed, including intravenously-administered propranolol as the preferred first-line antiarrhythmic agent. A case may be made for the discontinuation of the usage of chloral hydrate.

Ventricular arrhythmia precipitated by flumazenil

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Death after chloral hydrate sedation: report of case

A young healthy female died after taking chloral hydrate syrup before surgery to extract third molars. Various aspects of the use of chloral hydrate are discussed, including the metabolism, active moiety, reported side effects, and effects on the heart. Recommendations are made concerning patient supervision, dosage limitations, and degree of sedation.

Chloral hydrate: unusually high concentrations in a fatal overdose

A case in which chloral hydrate as a pure chemical rather than the prescribed drug caused the death of a 27-year-old white male is presented. Trichloroethanol was quantified in blood and tissues by electron capture gas chromatography. The blood trichloroethanol concentration found in this case (1700 mg/L) was higher than had been previously reported in the literature.

[Induction of sister chromatide exchange by trichloroethylene and its metabolites (author's transl)]

The mutagenecity of trichloroethylene and its metabolites (trichloroethanol and chloral hydrate) have been tested by using the method of sister chromatide exchanges (SCE). We have found the increasing SCE in workers chronically exposed to trichloroethylene. The increasing of SCE was also observed when the human lymphocytes were exposed to trichloroethanol and chloral hydrate in vitro in certain concentrations. The all results of tests groups are compared with those of the control groups and the difference is statistically significant.

Spectrophotometric determination of trichloroethanol in chloral hydrate poisoning

A spectrophotometric method for the analysis of blood and urine has been used to quantify trichloroethanol in fatal chloral hydrate poisonings. Trichloroacetic acid and chloral hydrate do not interfere. A 4 mL blood sample is extracted at the pH of the blood with ether. A reaction product is formed during heating of the ether phase with pyridine and sodium hydroxide. A spectrum of the reaction product has maxima at 368 and 530 nm. Results obtained in fatalities are given.

Chloral hydrate overdose and cardiac arrhythmias

Two cases of chloral hydrate overdosage were associated with multiform ventricular tachycardia. Both were refractory to a number of antiarrhythmics, but responded to propranolol administration. Two of nine other cases reported in the literature also responded to beta-blocking agents. Mechanisms for the arrhythmia and its apparent response to beta blockade are discussed.

Cardiac arrhythmais after chloral hydrate overdose

A case of chloral hydrate overdose associated with ventricular arrhythmias which were refractory to treatment with lignocaine, but responsive to treatment with beta adrenergic blockade is reported. The probable mechanism of production of the arrhythmias is discussed together with its implications for management.

Hemodialysis and pregnancy

When severe renal failure requiring hemodialysis complicates pregnancy, there is hesitation to continue the pregnancy. However, successful hemodialysis in pregnancy is being reported with growing frequency. Fetal survival and even conception is possible in patients undergoing dialysis.

[Histochemical and cytologic changes in the liver in experimental poisoning and subsequent pregnancy]

In 275 white rats chronic intoxication was produced by injection of amidopyrine acetaldehyde and chloraldehyde derivatives for 4 months. Histochemical and electron microscopic investigations of the liver under the experimental conditions and subsequent pregnancy revealed certain changes in nucleic metabolism, glycogenolisis, in the content of sulfhydryl, disulfide, carboxylic groups of protein molecules. Decrease in activity of enzymes of Krebs cycle and pentosophosphate cycle proved the deep changes in hepatocytes at the level of oxidation-reduction processes and protein synthesis. Ultramicroscopic changes in the nucleus, in cytoplasmic network, mitochondria and local degenerative alterations determined the level of morphologic reconstructions in connection with the intoxication. As the liver performs a number of vital functions and is closely connected with regulatory systems of the organism, morphofunctional shifts in the organ affect unfavourably the system mother--fetus.

Acute massive chloral hydrate intoxication treated with hemodialysis: a clinical pharmacokinetic analysis

A 38-year-old female became comatose and exhibited signs of cardiac toxicity 2 hours after ingestion of approximately 38 Gm chloral hydrate. Hemodialysis was initiated 21 hours after ingestion, using twin coils in series, and was continued for 4.5 hours. Trichloroethanol, the active metabolite of chloral hydrate, was measured in plasma and dialysate. Two hours after ingestion, the plasma level was 330 micrograms/ml (average therapeutic level is 12 micrograms/ml or less). The predialysis level was 216 micrograms/ml and after dialysis declined to 141 micrograms/ml. The pre- and post-plasma half-life values were 35 hours, while on dialysis the half-life was only 6 hours. The average dialysis clearance was 120 ml/minute, and the amount of chloral hydrate removed by dialysis was 5.79 Gm. By the end of dialysis, the patient could respond to verbal commands and was ambulatory 36 hours later. In conclusion, hemodialysis can be a clinically important method of treating chloral hydrate overdose.

Cardiac arrhythmias caused by chloral hydrate

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