Delirantes Syndrom nach Olanzapin-Intoxikation

We describe a case of delirium due to olanzapine overdose. After ingestion of 280 mg of olanzapine, a 19-year-old schizophrenic patient developed a delirium (ICD-10: F 05.0) with consciousness disturbance, disorientation in time, space, and situation, acoustic and visual hallucinations, and agitation. The symptoms lasted for approximately 36 h. Blood pressure, temperature, and heart frequency showed no disturbance. There were no abnormalities in ECG, EEG, or routine blood tests. Approximately 36 h after the intoxication, the patient recovered fully. Until now, there have been no reports of delirium from this cause.

Death rates from ecstasy (MDMA, MDA) and polydrug use in England and Wales 1996-2002

The present study reports on all deaths related to taking ecstasy (alone, or in a polydrug combination) occurring in England and Wales in the time frame August 1996-April 2002. Data presented here are based on all information recorded in the National Programme on Substance Abuse Deaths (np-SAD) database. The np-SAD regularly receives all information on drug related deaths in addicts and non addicts from coroners. A total of 202 ecstasy-related fatalities occurred in the chosen time-frame, showing a steady increase in the number of deaths each year. The ratio male:female was 4:1 and 3 of 4 victims were younger than 29. In 17% of cases ecstasy was the sole drug implicated in death and in the remaining cases a number of other drugs (mostly alcohol, cocaine, amphetamines and opiates) have been found. According to toxicology results, MDMA accounted for 86% of cases and MDA for 13% of cases; single deaths were associated with MDEA and PMA. This is the largest sample of ecstasy related deaths so far; possible explanations are given for the observed steady increase in ecstasy-related deaths and a tentative 'rationale' for this polypharmacy combination is then proposed.

National multicentre study of acute intoxication in emergency departments of Spain

OBJECTIVE

No studies have been published on global acute intoxication in Spanish emergency departments. We therefore designed a multicentre study to identify the epidemiology and management of intoxicated patients in Spain.

METHODS

We prospectively recorded cases from 14 emergency departments during 14 randomized days between February and April 2000. We included all age groups and all kinds of acute intoxication patients (including alcohol), except food-related cases, inert foreign bodies and deaths before arrival at the emergency department. Phone calls to poison control centres and inpatients were not followed.

RESULTS

A total of 419 cases were recorded, 0.66% of emergency department visits. The incidence of intoxication was higher at weekends and on Mondays (P<0.001). The mean age was 33 years (STD+/-18.10); males represented 56%, and 34.2% of patients arrived at the emergency department within the first 2 h. A total of 80% of patients were treated as outpatients, 3.7% were admitted to the intensive care unit, 6.7% were hospitalized, and 0.2% died.

DISCUSSION

We recorded a slightly lower incidence than other European countries with the same epidemiological profile, except for a low incidence of acetaminophen cases. If we apply the European Association of Poisons Centres and Clinical Toxicologists gastric lavage criteria, there were an important number of unnecessary gut decontamination techniques in drug poisoning. Most patients were treated in emergency departments, without hospital admission.

Interaction of alcohol and drugs in fatal poisonings

In Finnish data from 1995-2000, 1006 fatal poisonings due to alcohol (ethanol), a single drug or both were statistically analysed in retrospect to evaluate the interaction between alcohol and drugs. In 53% of these cases, low concentrations of some common benzodiazepines were present. The median postmortem blood alcohol concentration (BAC) was 3.3 percent per thousand (w/w) in the 615 alcohol poisonings, but significantly lower, ranging from 1.3 to 1.7 percent per thousand, when promazine, doxepin, amitriptyline or propoxyphene were found together with alcohol. When levomepromazine, temazepam or zopiclone were present, the median BAC was also significantly lower, 2.5-2.7 percent per thousand. Citalopram and diltiazem did not exhibit a significant effect. The median BAC was significantly lower in cases with high concentrations than in those with low concentrations of a drug (excluding citalopram), suggesting a positive concentration-effect relationship. Fatal toxicity indices (FTIs) were calculated by relating the number of deaths caused by a drug to the corresponding sales figures. Promazine had an extremely high FTI, followed by levomepromazine, propoxyphene, doxepin and amitriptyline. The other drugs had relatively low FTIs. The results reflect not only the acute toxicity of a given drug-alcohol combination but also the manners of use and abuse of these drugs.

Methadone substitution: medicolegal problems in Germany

In Germany, the substitution of methadone for heroin abusers has arisen recently and has resulted in various medicolegal problems. Normally, these concern methadone-associated deaths, or the prescription of methadone resulting in criminal prosecutions concerning physicians. Not to be forgotten is the problem of driving while taking methadone. In the years 1997-2001, we detected methadone in the blood of 398 cases that were analysed by the Institute of Legal Medicine, Bonn. Methadone was the only drug in only 18 cases. In most of the cases, up to five additional drugs were also being taken: benzodiazepines (61%), ethanol (40%), morphine (39%), cannabinoids (35%), cocaine (28%), anti-depressants (3%), and amphetamines (2%).

Methadone and its role in drug-related fatalities in Cologne 1989-2000

All drug-associated deaths from 1989 to 2000 were analysed at the Institute of Forensic Medicine in Cologne. Information concerning sex, gender, drug consumption, time, place and circumstances of death were analysed. A number of 605 cases were recorded; in 518 cases a toxicological analysis was possible and in 171 an autopsy was performed. When it was possible to determine the cause of death form the information available, acute drug intoxication was recorded in 65%. Heroin head the list of identified substances. Sixty-three percent of the specimens showed a combination of several substances, especially a combination of morphine, benzodiazepines, other medications and alcohol. In comparison with other studies the percentage of methadone-positive specimens is low, even though the proportion of specimens positive for methadone increased from 1989 to 2000. This analysis is discussed using background information concerning the management of substitution therapy and the available literature.

[Investigations of poisonings with benzodiazepine derivatives mixtures by thin-layer chromatography]

The thin-layer chromatography method was proposed for separation and identification of drugs in mixture alprazolam : brotizolam : clorazepate dipotassium. The mixture of these drugs excreted from body fluid (blood) was investigated by the thin-layer chromatography. Most acceptable is this mobile phase : benzene : dioxane : conc. ammonia : methanol : ethanol (60:25:5:10:10). Rf values for drugs: alprazolam 0.81-0.83, brotizolam 0.59-0.62, clorazepate dipotassium 0.67-0.69.

[Benzodiazepine poisonings among elderly patients of Acute Poisoning Department of the Marciniak Memorial Hospital in Wroclaw in the years 2000-2001]

Acute benzodiazepines poisonings in the group of 27 elderly patients is discussed. Majority of patients suffer from depression and cognitive impairment. Compared this special group of patients with younger the prognosis is worse what is expressed in greater number of deaths.

A review of methadone deaths in Jefferson County, Alabama

Interpretation of the concentration of a drug is more difficult when a combination of drugs is present in a decedent's blood. An increase in deaths resulting from co-intoxication with methadone and a benzodiazepine led the authors to perform a retrospective study of cases examined at the Jefferson County Coroner/Medical Examiner Office. They found 101 deaths wherein methadone was detected in the blood. Based on the drugs detected in the blood, these 101 cases were grouped into four categories: (1) pure methadone intoxication, (2) intoxication with methadone and benzodiazepine, (3) intoxication with methadone and other drugs excluding benzodiazepine, and (4) intoxication with methadone, benzodiazepines, and other drugs. Methadone was the sole intoxicant in 15 cases, with a mean concentration of 0.27 mg/L. Benzodiazepines were the most frequently detected co-intoxicant (60 of 101 cases). Benzodiazepine was the only co-intoxicant in 30 cases, and the mean methadone concentration in those 30 cases was 0.599 mg/L. Higher levels of methadone may occur in acute intoxication with methadone and benzodiazepine because benzodiazepines compete with methadone for methadone receptors. Higher levels of methadone may occur with chronic abuse of methadone and benzodiazepines because over time, benzodiazepines inhibit the hepatic enzymes that metabolize methadone.

Alcohol and benzodiazepines in fatal poisonings

BACKGROUND

Postmortem forensic toxicology frequently finds alcohol both alone and in combination with drugs. Although benzodiazepines are generally considered safe, they are considered dangerous with alcohol.

METHODS

A retrospective statistical analysis of alcohol and benzodiazepine concentrations in postmortem blood samples included 808 cases diagnosed as fatal alcohol or drug intoxication involving (1) ethanol alone; (2) ethanol with temazepam; or (3) ethanol with any combination of diazepam, chlordiazepoxide, and nordazepam.

RESULTS

The median concentration of ethanol was 3.3 per thousand in cases with ethanol alone and 3.5 per thousand when diazepam was present, but it was significantly lower, only 2.5 per thousand, when temazepam was present in the blood. Furthermore, the median concentration of ethanol was 2.2 per thousand in cases with high concentrations (>0.9 mg/liter) of temazepam and 2.7 per thousand in cases with therapeutic (< or =0.9 mg/liter) concentrations.

CONCLUSIONS

Diazepam and chlordiazepoxide pose a smaller risk of death by poisoning than does temazepam when given as a hypnotic to patients suffering from alcoholism.

[Use of intraocular fluid in the medico-legal practice in diagnosing fatal poisoning with various psychoactive substances]

In this paper results of the research on the usefulness of toxicological analysis relating to narcotics in intraocular fluid have been presented. The examined material comprised intraocular fluids and blood samples collected from 332 deceased suspected of being intoxicated or poisoned with psychoactive agents. The cases in which death resulted from injuries and those where an individual took drugs before his or her death were also considered. Drug analysis was carried out by fluorescence polarization immunoassay (FPIA). In both biological fluids the degree of hydratation was determined. Ethyl alcohol, opiates, barbiturates and benzodiazepines were found in all the examined cases. In few cases ethanol substitutes such as isopropyl alcohol, ethylene glycol and methyl alcohol were indicated. Results of the quantitative examinations were divided into sets according to the kind of xenobiotic and then on the basics of concentration of the substance found in the blood and vitreous body 2 different groups were separated in each set. Statistic analysis of the correlations among xenobiotic concentrations in both organic fluids was also performed. The obtained findings allow to assume that intraocular fluid can be used for toxicological diagnosis of poisonings with psycho-active agents. The analytical results for intraocular fluid not only confirms the result for blood but also makes it credible. In single cases it can be a sufficient basis to determine and recognize psychoactive agents in the deceased.

[Cases of acute poisoning admitted to a medical intensive care unit]

BACKGROUND AND OBJECTIVE

Because of the paucity of information on the epidemiology of acute poisoning requiring intensive medical care, all such patients treated on the medical intensive care unit of the university hospital in Frankfurt am Main, Germany, between January 1993 and December 1999, were retrospectively evaluated.

PATIENTS AND METHODS

Of the total of 6211 patients, 147 (80 women, 67 men, mean age 41 years, 2,3 %) were treated for acute intoxication in the intensive care unit.

RESULTS

Reasons for admission to the intensive care unit were the need for ventilator treatment or intensive monitoring of vital functions. 52 % of the patients (n = 76) had attempted suicide, most of them using anti-depressive drugs (n = 19), paracetamol (n = 16), or benzodiazepines (n = 9). Two patients (2,6 %) died. 48 % of the patients (n = 71) were admitted because of accidental poisoning. Leading toxic agents in this group were heroin (n = 19), alcohol (n = 18) and digitalis (n = 12). 11 patients had taken herbicides, animal poisons or chemicals used at work or for house cleaning. In this cohort, three i. v. drug abusers (4,2 %) had died. Depending on the agents used, a variety of treatments (charcoal, antidots, extracorporal therapy) were undertaken.

CONCLUSION

Due to excellent care in the prehospital phase and in the emergency room the number of patients requiring treatment on the intensive care unit was rather low. The mortality was in the range of other reports.

Limiting the use of gastrointestinal decontamination does not worsen the outcome from deliberate self-poisoning

AIM

To review the current epidemiology of patients with deliberate self-poisoning presenting to Christchurch Emergency Department, and to compare this with 1996, 1992, and 1989 data.

METHODS

A retrospective analysis of computer and case records over the twelve-month period of 1999 was conducted and compared with published data from 1996,1992 and 1989.

RESULTS

There were 561 presentations of deliberate self-poisoning to Christchurch Hospital, representing 0.87% of total presentations (compared with 1.1% in 1996, 1.2% in 1992, and 1.0% in 1989). The female to male ratio was 2.2:1.0 (compared with 1.9:1.0, 1.5:1.0, and 2.1:1.0). The principal drugs ingested were antidepressants 30.8% (compared with 20.1%, 24.4%,15.7%), paracetamol 23.5% (compared with 16.7%, 16.9%, 10.6%), benzodiazepines 23.0% (compared with 11.1%, 23.6% 22.8%) and antipsychotics 17.8% (compared with 10.7%, 16.1%, not reported). Gastrointestinal decontamination was performed in only 14.4% of patients (compared with 61%, 73%, 61%). Activated charcoal was given alone in 13.2% (compared with 54%, 46%, 0.4%), activated charcoal and gastric lavage in 0.7% (7%, 26%, 53%), a whole bowel irrigation in 0.5% (not recorded in previous papers). 70.4% were admitted (compared with 69%, 59%, 64%), 7% to intensive care (10.2%, 10.6%, 18%). There were two deaths (compared with 6, 2 and 2).

CONCLUSIONS

Over the time periods studied the drugs ingested and admission rates remain similar, although a large proportion are now being observed in the emergency short stay ward, reducing admission rates to the ward and intensive care. Trends in gastrointestinal decontamination have changed dramatically over the four time periods, but there has been no worsening in the outcome of patients with deliberate self-poisoning.

Trends in deaths from drug overdose and poisoning in England and Wales 1993-1998

BACKGROUND

The study examines time trends and sociodemographic aspects of drug poisoning deaths in England and Wales.

METHODS

Socio-demographic data from the four drug groups most commonly used in poisoning were extracted, and annual age- and sex-specific mortality rates calculated. Enumeration districts were ranked into five groups on the basis of their Carstairs scores, and the number of deaths in each of the five groups was calculated.

RESULTS

There were 15720 deaths from drug poisoning between 1993 and 1998. More deaths occurred in men than in women (10 223 versus 5497). Opiates were the most commonly used drugs in deaths from drug poisoning (32 per cent of deaths); mortality rates increased twofold for these drugs. Males had higher number of deaths from opiate poisoning than females (4523 versus 1221). Highest mortality rates from opiate poisoning (77.4 per million) occurred in men aged 24-35 years. Deaths from drug poisoning were strongly associated with deprivation.

CONCLUSION

There are substantial socio-demographic differences in mortality rates from drug poisoning.

[Guillain-Barre syndrome as a result of poisoning with a mixture of "kompot"(Polish heroin) and drugs]

Guillain-Barré Syndrome is the most common form of polineuropathy. It is suggested that some infectious, immune and allergic factors are involved in developing the syndrome. "Kompot" or "Polish heroine", a domestic product, is produced from poppy straw or juice of poppy head (Papaver somniferum) and it is administered intravenously. "Kompot" shows variable contents of heroine, 6-MAM, 3-MAM, morphine, acetylo-codeine and codeine as well as papaverine, thebaine and narcotine. The case history of a young man dependent on "Polish heroine" who developed the Guillain-Barré Syndrome due to severe intoxication induced by home made heroine, barbiturates and benzodiazepines is described.

Deaths from drugs of abuse in Sheffield, 1998: the role of prescribed medication

Characteristics of recent drug abuse-related deaths in the city of Sheffield were examined from the coroner's records. Almost all of those who died of poisoning from a drug of abuse were known to be dependent on heroin yet less than half were receiving treatment. Benzodiazepines were frequently detected alongside opiates during toxicology, the source of which was likely to be the deceased's own prescription.

Pediatric benzodiazepine ingestion resulting in hospitalization

OBJECTIVE

To characterize the clinical findings in children hospitalized for benzodiazepine ingestion.

METHOD

Retrospective case series in two urban children's hospitals, with no intervention. Suicide attempts and polypharmacy ingestions were excluded.

RESULTS

Forty-six children (67% male) with a mean age of 36 months (range 14-127 months) were hospitalized from January 1987 through September 1994. Lorazepam was most frequently ingested (13/41 identified drugs, 32%). The most prevalent symptoms were ataxia (87%), lethargy (57%), coma (Glasgow coma score < 15, 35%; Reed coma score > 0, 22%), and respiratory depression (9%). Duration of symptoms was less than 24 hours in 88% of patients. Isolated ataxia occurred in eight patients; in five of these patients, benzodiazepine ingestion was unsuspected by the physicians. Three parents intentionally administered the benzodiazepine to their child. Only 50% of 32 toxicology screens were positive for benzodiazepines. One child required endotracheal intubation. Flumazenil administration preceded clinical improvement in two other children. The remaining patients received activated charcoal administration and supportive care.

CONCLUSION

Children hospitalized for benzodiazepine overdose occasionally had life-threatening symptoms. Ataxia was the most common clinical finding following benzodiazepine ingestion in this series. Flumazenil appeared beneficial for the treatment of severe benzodiazepine toxicity in only two patients. Most children recovered from their overdose uneventfully after receiving activated charcoal and supportive care.

D-lactic acidosis 23 years after jejuno-ileal bypass

Accumulation of D-lactate after gastrointestinal surgery, particularly jejuno-ileal bypass, is an uncommon and often misdiagnosed clinical disturbance. The syndrome may be complicated by dizziness, ataxia, confusion, headache, memory loss, and aggressive behavior. Serum chemistries are often deceptive because the anion gap is frequently normal in spite of severe metabolic acidosis. Moreover, the urine anion gap may be positive, incorrectly suggesting a defect in renal net acid excretion. Indeed, the combination of a normal anion gap metabolic acidosis and positive urine anion gap may erroneously suggest a diagnosis of renal tubular acidosis. Importantly, all reported cases of D-lactic acidosis secondary to bypass surgery have been encountered within 5 to 10 years following the surgery. Here we present an unusual case of D-lactic acidosis (complicated by encephalopathy) presenting 23 years after a jejuno-ileal bypass procedure. The patient was initially diagnosed with a drug intoxication secondary to benzodiazepines. Ultimately, the diagnosis of D-lactate encephalopathy was established after challenging the patient with a carbohydrate load. Thus, administration of 40 kcal/kg over 16 hours reproduced the clinical syndrome and was accompanied by a marked increment in serum and urine D-lactate concentration. The patient had sustained resolution of her symptoms after treatment with oral vancomycin.

Chronic liver injury related to use of bentazepam: an unusual instance of benzodiazepine hepatotoxicity

Liver injury induced by benzodiazepines is rare and is classified as an unpredictable or idiosyncratic hepatotoxic reaction. Early reports indicated that in most cases the pattern of liver injury was cholestatic. We describe three patients with persistent increases in liver transaminase levels after several weeks of treatment with bentazepam, a benzodiazepine marketed in Spain for anxiety disorders. In all cases withdrawal of the drug was followed by resolution of transaminase level abnormalities. A liver biopsy (done in one patient only) showed histological evidence of severe chronic active hepatitis. In conclusion, these findings, together with two previously published case reports, suggest that a benzodiazepine can cause chronic hepatitis and argue in favor of using liver function tests to monitor all patients taking bentazepam.