Unveiling the Rare Presentation of Acetylsalicylate Overdose: Grand Round

BACKGROUND

This case report highlights a rare occurrence of aspirin overdose presenting only as severe coagulopathy.

CASE PRESENTATION

An 85-year-old woman was admitted to the hospital with multiple lumbar vertebral compression fractures causing severe back pain. The patient had self-medicated with excessive consumption of Bufferin A containing 330 mg of aspirin. On arrival, she showed no typical symptoms of salicylate toxicity, such as nausea, vomiting, hyperventilation, tinnitus, or hearing loss. However, blood work revealed a significant decrease in vitamin K-dependent coagulation factors leading to coagulopathy. The administration of 20-mg menatetrenone (vitamin K) resulted in rapid improvement in coagulation abnormalities. The patient's blood salicylate level was later determined to be 42.7 mg/dL.

DISCUSSION

Acute salicylate poisoning is known to cause coagulopathy because of the inhibition of vitamin K-dependent coagulation factors. However, this case is unique because it demonstrates coagulopathy as the sole manifestation of aspirin toxicity without any other symptoms.

CONCLUSIONS

This case highlights the importance of considering the possibility of aspirin toxicity in patients with coagulopathy, especially those who are regularly consuming aspirin.

The efficacy of intermittent hemodialysis in severe bromovalerylurea poisoning

Bromvalerylurea (BVU) is a sedative-hypnotic drug with a high risk of acute poisoning. In the present case, hemodialysis (HD) was introduced in a patient with severe BVU poisoning who later demonstrated respiratory arrest, and then HD clearances (CLHD) were assessed in detail. A 20-year-old female was transported to the emergency department by ambulance, an estimated two to four hours after orally ingesting 144 tablets of Utto® (12,000 mg BVU) in a suicide attempt. The patient was comatose on arrival. After intratracheal intubation, 50 g of activated charcoal was administered through nasogastric tube. She was then transferred to the intensive care unit. Ten hours after arrival at the hospital, her light reflex, contralateral light reflex, corneal reflex, and spontaneous respiration disappeared, resulting in an introduction of HD 16 h after arrival. Eighteen hours after arrival, her light reflex, contralateral light reflex, and corneal reflexes had recovered. Twenty-one hours after arrival, her consciousness level improved and the patient was weaned from HD. During HD treatment, blood samples were collected pre-HD and post-HD every hour. Serum BVU concentrations were determined using liquid chromatography-tandem mass spectrometry (LC-MS/MS). The median CLHD was 133.61 mL/min, and the systemic clearance (CLSYS) was 117.77 mL/min. Higher CLHD of BVUs over CLSYS suggests that HD may play an important role in the treatment of severe BVU poisoning.

Sublingual administration of atropine eye drops for treating organophosphorus poisoning

An 89-year-old patient with fenitrothion toxicity received sublingual atropine eye drops, reducing the intravenous atropine requirement. This alternative method enabled rapid rehabilitation, and he walked unaided, leading to discharge.

Guanfacine poisoning resulting in transient ST-segment elevation: a case report

BACKGROUND

Guanfacine is an alpha-2 adrenergic agonist that decreases norepinephrine release and sympathetic outflow. With the increased use of guanfacine for attention-deficit hyperactivity disorder (ADHD), reports of guanfacine poisoning have also risen.

CASE PRESENTATION

A 15-year-old male (height: 170 cm, weight: 48 kg), who was taking 2 mg/day of guanfacine for ADHD, was brought to our emergency department after ingesting 40 tablets of guanfacine due to poor exam results. He presented with impaired consciousness and sinus bradycardia on an electrocardiogram (ECG), leading to diagnosis of guanfacine poisoning. Gastric lavage (5 L) was performed, and activated charcoal was administered. Although his consciousness gradually recovered, he developed ST-segment elevation on the ECG. Despite the absence of chest pain and elevated myocardial enzymes, coronary artery stenosis was not observed on coronary artery computed tomography. As his blood guanfacine level decreased, his ECG returned to normal.

CONCLUSIONS

This case highlights the need for careful monitoring of guanfacine poisoning patients due to the potential for various cardiovascular events.

Severe caffeine poisoning treated with intermittent hemodialysis under circulatory support

Caffeine poisoning can cause fatal ventricular arrhythmias. In this report, we describe a case of severe caffeine poisoning with extraordinarily high blood caffeine levels. Despite developing refractory ventricular fibrillation, the patient was successfully treated with intermittent hemodialysis (IHD) under circulatory support by venoarterial extracorporeal membrane oxygenation (VA-ECMO). A 22-year-old male was transported to our hospital approximately 2.5 h after ingesting 200 highly caffeinated tablets (200 mg/tablet) (40 g caffeine total) in a suicide attempt. On arrival, the patient vomited frequently with a Glasgow Coma Scale score E3V2M5, heart rate 185 beats/min, and a blood pressure of 97/62 mmHg. Shortly after arrival, the patient developed ventricular fibrillation which was refractory either to three electrical defibrillations or antiarrhythmic drugs, resulting in endotracheal intubation for mechanical ventilation and VA-ECMO. Starting from 2 h after arrival, intermittent hemodialysis (IHD) was performed for 11 h, which markedly improved clinical symptoms and circulatory parameters. Serum caffeine level was 454.9 mg/dL upon arrival at the hospital, but it decreased to 55.5 mg/dL by the end of IHD treatment. Renal replacement therapy (RRT) including intermittent hemodiafiltration, continuous hemodiafiltration, and IHD was continued because of rhabdomyolysis with myoglobinuria and secondary caused acute kidney injury. The patient was weaned off VA-ECMO on hospital day 7, extubated on hospital day 18, weaned from RRT on hospital day 46, and was transferred to another hospital for physical rehabilitation on hospital day 113. IHD under circulatory support by VA-ECMO should be considered in severe caffeine poisoning causing potentially fatal arrhythmias.

Severe aconite poisoning successfully treated with veno-arterial extracorporeal membrane oxygenation: A case report

BACKGROUND

Most species of aconite contain highly toxic aconitines, the oral ingestion of which can be fatal, primarily because they cause ventricular arrhythmias. We describe a case of severe aconite poisoning that was successfully treated through veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and in which detailed toxicological analyses of the aconite roots and biological samples were performed using liquid chromatography-tandem mass spectrometry (LC-MS/MS).

CASE SUMMARY

A 23-year-old male presented to the emergency room with circulatory collapse and ventricular arrhythmia after ingesting approximately half of a root labeled, "Aconitum japonicum Thunb". Two hours after arrival, VA-ECMO was initiated as circulatory collapse became refractory to antiarrhythmics and vasopressors. Nine hours after arrival, an electrocardiogram revealed a return to sinus rhythm. The patient was weaned off VA-ECMO and the ventilator on hospital days 3 and 5, respectively. On hospital day 15, he was transferred to a psychiatric hospital. The other half of the root and his biological samples were toxicologically analyzed using LC-MS/MS, revealing 244.3 mg/kg of aconitine and 24.7 mg/kg of mesaconitine in the root. Serum on admission contained 1.50 ng/mL of aconitine. Beyond hospital day 2, neither were detected. Urine on admission showed 149.09 ng/mL of aconitine and 3.59 ng/mL of mesaconitine, but these rapidly decreased after hospital day 3.

CONCLUSION

The key to saving the life of a patient with severe aconite poisoning is to introduce VA-ECMO as soon as possible.

Fatal poisoning due to ingestion of boiled oleander leaf extract

Nerium oleander is an ornamental evergreen shrub belonging to the family Apocynaceae. The Apocynaceae family includes the attractive evergreen shrub known as oleander. The cardiotoxic glycoside, oleandrin, is present in all portions of the common oleander plant. Oleander consumption can result in deadly situations accidentally or as a suicide attempt. After consuming kettle-boiled oleander leaf extract as part of a suicide attempt, an 80-year-old man was discovered comatose in his home and taken to our emergency room. The patient's heart rate was 30 beats per minute, and he had hypotension. Arterial blood gas analysis revealed remarkable metabolic acidosis and hyperkalemia (K: 7.7 mEq/L). An electrocardiogram showed a wide QRS wave, similar to a sine curve. The patient collapsed following cardiac arrest soon after hospital arrival. Veno-arterial extracorporeal membrane oxygenation was initiated; however, the patient eventually died. The serum level of oleandrin at hospital arrival, subsequently measured by LC-MS/MS, was found to be 33.4 ng/mL, far above the levels reported in previous fatal cases.

Poisoning by abnormally high blood phenobarbital concentration treated with extracorporeal therapy

Phenobarbital poisoning, which may cause circulatory collapse as well as respiratory arrest in severe cases, has one of the highest mortality rates among acute drug poisonings. A 58-year-old man arrived at the emergency room in a deep coma (Glasgow Coma Scale E1V1M1) after taking an unknown dose of phenobarbital which had been prescribed for his cat's seizures. Venous blood gas analysis revealed hypercapnia (PvCO2: 113.0 mmHg) and a blood phenobarbital concentration of 197.3 μg/mL. Shortly after his arrival, respiratory arrest and circulatory collapse occurred. Mechanical ventilation after intubation, intravenous noradrenaline infusion, and multiple-dose activated charcoal through a nasogastric tube was started. Six hours after arrival, blood phenobarbital concentration was abnormally elevated to 356.8 μg/mL with circulatory collapse requiring an increased dose of intravenous noradrenaline infusion (up to 0.13 μg/kg/min). Continuous renal replacement therapy including high flow continuous hemodialysis was performed until hospital day 5, during which blood phenobarbital concentration decreased to 96.2 μg/mL on hospital day 4, resulting in a sufficient resumption of spontaneous breathing and full improvement of circulatory collapse. A search of the literature revealed that the peak phenobarbital concentration in the present case exceeded those of fatal cases, as well as those of survivors of acute phenobarbital poisoning. However, the patient was successfully treated with continuous renal replacement therapy. Among modalities of extracorporeal treatment, continuous renal replacement therapy could be considered if a patient's circulation is unstable.

Detection of major psychoactive compounds (safrole, myristicin, and elemicin) of nutmeg in human serum via GC-MS/MS using MonoSpin® extraction: Application in a nutmeg poisoning case

Nutmeg is an inexpensive, readily available spice used in a variety of recipes. However, the use of nutmeg powder as a recreational drug for its hallucinogenic effects is resulting in an increase in overdose rates. We encountered a male patient being hospitalized after ingesting 75 g of commercially available nutmeg powder with the intent of committing suicide. There are no available reports documenting the toxic or comatose-fatal blood concentrations or time-course of drug action in cases of nutmeg poisoning. Therefore, to improve patient management, we endeavored to determine the blood serum levels and time-course of the major psychoactive compounds (safrole, myristicin, and elemicin) present in nutmeg. We designed a simple and reliable method using the MonoSpin® extraction kit and gas chromatography-tandem mass spectrometry to detect the presence of these psychoactive compounds in human serum. The method had detection and quantitation limits of 0.14-0.16 and 0.5 ng/mL (lowest calibration points), respectively. The calibration curves displayed excellent linearity (0.996-0.997) for all three compounds at 0.5-300 ng/mL blood concentrations. The intra- and inter-day precision values for quality assurance were in the ranges of 2.4-11 % and 2.5-11 %, respectively; bias ranged from - 2.6 % to 2.1 %. Blood serum levels of safrole, myristicin, and elemicin were measured at admission (approximately 8 h post-ingestion) and approximately 94 h after a post-admission fluid therapy to evaluate their biological half-lives. We developed this method to obtain information on the psychoactive constituents of nutmeg and, thereby, determine the toxicokinetic parameters of nutmeg in a case of nutmeg poisoning.

Acute acrylamide poisoning with severe symptoms in a short time: a case report

BACKGROUND

Acrylamide poisoning is often reported as chronic poisoning presenting with peripheral neuropathy or carcinogenic action due to long-term exposure to low concentrations. However, there have been few reports of acute poisoning due to oral ingestion of acrylamide, where the symptoms appear a few hours after ingestion. Here, we report a case of acute acrylamide poisoning where a high concentration was ingested in a short time, resulting in a fatal outcome due to the rapid course of events.

CASE PRESENTATION

The patient was an adolescent female who ingested 150 ml (148 g) of acrylamide with suicidal intent. A disorder of consciousness was observed when the emergency medical team arrived 36 min later. An hour later, tracheal intubation and intravenous access were performed at a hospital, and 2 h after that, she was transported to our hospital. After she arrived at the hospital, circulatory dynamics could not be maintained despite vasopressor and colloid osmotic infusion, and hemodialysis could not be introduced. Subsequently, cardiopulmonary arrest occurred, and the patient passed away 7 h after ingestion. In the present case, severe symptoms appeared shortly after acrylamide ingestion, unlike other reported cases. In previous report summarizing animal studies, there was a relationship among the symptoms of acute poisoning, the dose, and onset time. The data from this case were compared to those from previous reports, and we were able to predict the early appearance of severe symptoms based on this comparison.

CONCLUSION

The severity of acute acrylamide poisoning by oral ingestion was primarily dependent on the amount and rate of ingestion.

Amatoxin poisoning caused by Galerina sulciceps, a species with no prior record of identification in Japan: a case report

A 60-year-old man presented with acute gastroenteritis, hypovolemic shock, acute renal failure (BUN/Cr, 56.7/4.24 mg/dl), and aspiration pneumonia. The previous day, he ingested 30 caps of mushrooms of an unknown species. The patient was treated with a massive intravenous infusion, renal replacement therapy, and antimicrobial agents. Late-onset mild liver injury peaked on day 11 (AST/ALT, 62/67 IU/l). Acute renal failure improved once before worsening, with the worst symptoms on day 19 (BUN/Cr, 99/6.61 mg/dl). Thereafter, the patient showed gradual improvement, and renal replacement therapy was discontinued on day 23. His general condition improved fully and he was transferred to another hospital for rehabilitation on day 47. The mushrooms were later identified as Galerina sulciceps by the Basic Local Alignment Search Tool, and toxicologic analysis using liquid chromatography-tandem mass spectrometry revealed an average of 85 ppm α-amanitin and 330 ppm β-amanitin in the tissue of the mushrooms brought in by the patient's family. Galerina sulciceps is distributed mainly in tropical and subtropical regions of Southeast Asia and had never been identified before in Japan. The heat of fermentation generated by the thick layer of wood chips on the ground or global warming may have contributed to its growth in Japan. Interestingly, our patient did not have liver dysfunction, which is one main and typical amatoxin poisoning symptom. Variation in clinical presentation may be attributed to the different ratios of α-amanitin to β-amanitin in different mushroom species.

A suicide attempt by intramuscular injection of pentobarbital sodium into rectus abdominis suggested by computed tomography

Suicide attempts in humans due to injections of the veterinary drug pentobarbital sodium have been rarely reported. Herein, we present a case of a suicide attempt by intramuscular injection of pentobarbital sodium into the rectus abdominis muscle, which was suggested by computed tomography (CT). A 73-year-old man was brought to the emergency department with GCS 3 (E1V1M1) and an incised wound on the right side of the neck. A bottle of Somnopentyl^® (pentobarbital sodium, 64.8 mg/ml), a 20-ml empty syringe with an 18-mm needle, and no. 10 scalpel were present at the scene. At the emergency department, the patient was intubated and was admitted to the intensive care unit. A urine drug screen test by SIGNIFY^® ER was positive for benzodiazepines and barbiturates, and continuous veno-venous hemofiltration (CHF) was initiated. The route of drug administration was initially unknown; however, a CT scan revealed swelling of the left rectus abdominis muscle with a wound suggestive of a needle puncture, and the CT analysis suggested 38.16 ml as the maximum dose of pentobarbital sodium. On day 3, the patient's consciousness improved, and he was weaned off CHF and mechanical ventilation. There have been several reports of postmortem CT yielding information on the site of administration of intoxicants, but there have been none for surviving intoxicated patients. This is the first report of the usefulness of CT to identify the site of administration of the causative agent of intoxication while the patient is still alive.

Effectiveness of assertive case management for patients with suicidal intent

The aim of this study was to examine the effectiveness of assertive case management intervention in preventing suicidal behaviour in self-poisoning patients. We conducted a secondary analysis of data from the ACTION-J study. Participants were self-poisoning patients with clear suicide intent admitted to emergency departments and with a primary psychiatric diagnosis (as per DSM-IV-TR axis 1). Patients were randomly assigned either to assertive case management or enhanced usual care. The primary outcome measure was the incidence of a first recurrent suicide attempt within 6 months. This study is registered at ClinicalTrials.gov (NCT00736918) and UMIN-CTR (C000000444). There were 297 self-poisoning patients in the intervention group and 295 in the control group. The primary outcome was significantly lower in the intervention group than in the control group. The incidence of a first recurrent suicide attempt within 1 and 3 months was also significantly lower in the intervention group, as was the number of overall self-harm episodes over the entire study period. Furthermore, the number of non-suicidal self-harm episodes and suicide attempts was significantly lower in the intervention group. Assertive case management is effective when promptly introduced in a hospital setting as an intervention following a suicide attempt, particularly for self-poisoning patients.

Effectiveness of multiple-dose activated charcoal in lamotrigine poisoning: a case series

INTRODUCTION

Lamotrigine toxicity can cause coma, seizures, and intraventricular conduction disturbances, and treatment options include good supportive care. We report two cases of lamotrigine poisoning in which multiple-dose activated charcoal may have shortened the elimination half-life of lamotrigine.

CASE 1

A 21-year-old woman ingested 15.6 g lamotrigine, 14 g levetiracetam, and 15 mg clonazepam. She became comatose and developed generalized tonic seizure. One hour post-ingestion, 50 g activated charcoal was administered. Starting 11 h post-ingestion, 25 g activated charcoal was administered every 4 h for 4 doses. The peak concentration of serum lamotrigine was 49.5 µg/mL, and the elimination half-life after commencement of multiple-dose activated charcoal was 6.5 h.

CASE 2

A 46-year-old woman ingested 0.3 g lamotrigine and 0.1 g topiramate twice, 2 h apart. She became drowsy, complained of blurred vision, vertigo, nausea, and vomited. An initial dose of 50 g activated charcoal was administered at 4.5 h post-second ingestion, and subsequent doses of 25 g (total of 3 doses) were administered every 4 h, commencing at 8.5 h post-second ingestion. The peak concentration of serum lamotrigine was 19.9 µg/mL, and the elimination half-life after commencement of multiple-dose activated charcoal was 9.3 h.

DISCUSSION

The mean elimination half-life of lamotrigine in healthy volunteers and epileptic patients receiving lamotrigine monotherapy is 22.8-37.4 h. In our two cases, multiple-dose activated charcoal may have shortened the elimination half-life of lamotrigine, possibly by inhibiting enterohepatic circulation. Multiple-dose activated charcoal should be considered an option for treating lamotrigine poisoning.

LC-MS/MS method for rapid and accurate detection of caffeine in a suspected overdose case

Excessive intake of caffeine, otherwise known to be a safe and mild central nervous system stimulant, causes nausea, vomiting, convulsions, tachycardia, and eventually fatal arrhythmias and death. Caffeine intoxication, a global problem, has been increasing in Japan since 2013. Thus, there is a need for rapid and accurate diagnosis of caffeine poisoning in forensic and clinical toxicology investigations. Herein, we demonstrate rapid and accurate caffeine quantitation by liquid chromatography tandem mass spectrometry using the standard addition method in a fatal case. Biological samples were diluted 500-100,000-fold and subjected to a simple pretreatment (adding caffeine standard and internal standard and passing through a lipid removal cartridge). The multiple reaction monitoring transitions were 195 → 138 for quantitation, 195 → 110 for the qualifier ion, and 204 → 144 for the internal standard (caffeine-d9). The standard plots were linear over 0-900 ng/mL (r² = 0.9994-0.9999) for biological samples, and the reproducibility (%RSD) of the method was 1.53-6.97% (intraday) and 1.59-10.4% (interday). Fatal levels of caffeine (332 μg/mL) and toxic to fatal levels of olanzapine (625 ng/mL), along with other pharmaceuticals were detected in the external iliac venous blood. The cause of death was determined to be multi-drug poisoning, predominantly caused by caffeine. Our method is useful for not only forensic cases but also the rapid diagnosis of caffeine overdose in emergency clinical settings.

Effect of Suvorexant on Nocturnal Delirium in Elderly Patients with Alzheimer's Disease: A Case-series Study

Suvorexant, an orexin receptor antagonist used for insomnia, has been shown to have a preventive effect on delirium in a randomized placebo-controlled trial. However, its effectiveness in the management of nocturnal delirium has not yet been determined. Here we report four cases in which elderly patients with moderate to severe Alzheimer’s disease who developed nocturnal delirium were treated with suvorexant. In case 1, 15 mg suvorexant was initiated to manage nocturnal delirium refractory to antipsychotics, antidepressants, and a Japanese herbal medicine, resulting in immediate sleep improvement. However, treatment discontinuation led to recurrence of symptoms, which were reversed by recommencing suvorexant. In case 2, as antipsychotics used for the treatment of nocturnal delirium were ineffective, 15 mg suvorexant was administered. The patient achieved rapid improvement in sleep. In case 3, the use of atypical antipsychotics for the treatment of nocturnal delirium was contraindicated, as the patient had diabetes. Therefore, 15 mg suvorexant was administered following good outcomes in cases 1 and 2, resulting in immediate sleep improvement. Finally, in case 4, 15 mg suvorexant was used as an initial medication for nocturnal delirium, and the patient showed sleep improvement immediately. Elevated orexin levels in the cerebrospinal fluid are reportedly linked to sleep deterioration in patients with moderate to severe Alzheimer’s disease. The immediate and reproducible action and effectiveness of suvorexant observed in our patients suggest that enhanced cerebral orexin activity might be associated with sleep-wake cycle disturbances due to delirium in elderly patients with Alzheimer’s disease.

Application of probe electrospray ionization-tandem mass spectrometry to ultra-rapid determination of glufosinate and glyphosate in human serum

Glufosinate and glyphosate, which are non-selective herbicides that include an amino acid moiety in their structures, are frequently used worldwide to control unwanted vegetation. Unfortunately, these readily available herbicides are also used by people to commit suicide, and thus represent important chemicals of interest in the fields of clinical medicine and forensics. Because of the high water solubility of these herbicides, most analytical methods for their detection require a derivatization step, which results in longer analysis times. Therefore, derivatization-based methods do not currently contribute to judgements on treatment decisions in emergency medicine. In this study, we addressed this limiting factor by developing an ultra-rapid and simple analytical technique using a combination of probe electrospray ionization (PESI) and tandem mass spectrometry (MS/MS), which gives quantitative results within 0.3 min. Herbicide standards were added to human serum that was then subjected to analysis (N = 5 per concentration). The analysis was repeated daily over eight consecutive days. The limit of detection (LOD) was 0.59 μg/mL for glufosinate and 0.20 μg/mL for glyphosate. The limit of quantitation (LOQ), i.e., the lowest point on the calibration curves, was 1.56 μg/mL for both the herbicides. The matrix effects were observed at three different concentrations (between 95.7%-104% for glufosinate, and between 90.7%-95.7% for glyphosate). When applied to samples taken from actual poisoning cases (six samples for each herbicide), the present method gave almost the same quantitative values as those obtained by conventional high-performance liquid chromatography with fluorescence detection. Thus, we believe that PESI-MS/MS could emerge as a rapid diagnosis method in the clinical emergency field.

A pilot clinical evaluation of oral mucosal dryness in dehydrated patients using a moisture-checking device

This study included 30 patients (17 males and 13 females; mean age, 73.7 ± 13.1 years) who were diagnosed with dehydration based on vital signs, skin symptoms, and blood test findings by emergency medicine physicians. First, the attending physician of our department measured oral mucosal dryness. Subsequently, the emergency medicine physician blindly divided the severity of dehydration into three stages according to clinical findings and blood test results. In this study, the oral moisture-checking device (Mucus®; Life Co., Ltd., Saitama, Japan) was used to measure the oral mucosal dryness. We examined the oral moisture level for each dehydration severity level and the correlations of each severity level of dehydration with the measured values. Spearman's correlation coefficient (Medcalc version 11.3 for Windows) was used for statistical analysis. P < 0.05 indicated significant differences. Twenty-six patients were diagnosed with dry mouth, and a moderate negative correlation was found between the severity of dehydration and oral moisture degree (r = -0.686). The correlation coefficient for the relationship between oral moisture degree and severity of dehydration was -0.686, indicating a negative correlation (P < .05). These results suggest that the oral mucosal dryness may be a useful index of dehydration severity.

An ultra-rapid drug screening method for acetaminophen in blood serum based on probe electrospray ionization-tandem mass spectrometry

Poisoning incidents caused by drugs, accidental ingestion of poisons, attempted suicide, homicide, and exposure to toxic compounds occur frequently every year across the globe. This raises the need to rapidly identify toxic agents in poisoned patients in a clinical emergency setting. In addition, determining drug/poison concentration is undoubtedly necessary to arrive at a toxicological treatment plan. The purpose of this study was to develop an ultra-rapid drug screening method for the clinical treatment of poisoning. Probe electrospray ionization (PESI), one of the ambient ionization techniques, is able to detect compounds from various biological materials almost directly. We applied the PESI technique to the rapid detection of acetaminophen (APAP). Blood serum samples were diluted 100-fold with 10 mM ammonium formate/ethanol (1:1 v/v) solution including deuterium-labeled internal standards (IS; APAP-d4). Only 10 μL of the diluted sample was used for measurement. The tandem mass spectrometer (MS/MS) equipped with a PESI was used in selected reaction monitoring mode for the quantitation of APAP; the measurement time was only 18 s. Transitions were set at 152 > 110 for quantitation, 152 > 65 for qualifier, and 156 > 114 for IS (APAP-d4). All measurements were conducted in positive mode. The calibration curve (1/x²) was linear over the range of 1.56–200 μg/mL (r² = 0.998), and the limit of detection and quantitation were 0.37 μg/mL and 1.56 μg/mL, respectively. The accuracy (bias) and precision (RSD%) of the method were within an acceptable range (−0.15–2.8% and 2.3–6.1%, respectively) and matrix effect at 3 concentrations (95.1–104%) indicated that PESI-MS/MS is only slightly affected by matrices. In real forensic cases, quantitative values of APAP determined by the PESI-MS/MS were almost identical to those determined by the liquid chromatography-MS/MS method. Since PESI-MS/MS is a simple, reliable, and rapid determination method for toxic agents with virtually no need for blood serum pretreatment, it would be highly suitable for poisoning cases in clinical emergency settings. In the future, a method for simultaneous rapid determination of multiple toxic agents will be developed.

Toxicokinetics of the Synthetic Cathinone α-Pyrrolidinohexanophenone

Synthetic cathinones inhibit monoamine transporters, such as serotonin, norepinephrine, and dopamine transporters, and act on the central nervous system via increasing synaptic concentrations of monoamines. These compounds, which are highly addictive and potentially poisonous, are new psychoactive substances. In this study, we investigated the toxicokinetics of the synthetic cathinone, α-pyrrolidinohexanophenone (α-PHP), and assessed the relationship between the toxicokinetics and the long-term clinical symptoms induced by α-PHP in a male patient. The patient (39 years old) suddenly started uttering inarticulate words and demonstrating incomprehensible behavior in his house, and was brought to the emergency department of Iwate Medical University hospital. He presented with psychotic symptoms, such as hallucinations and delusion; however, his vital signs were normal. The hallucinations and delusion improved by the third day of hospitalization. Toxicological analysis was performed using liquid chromatography-tandem mass spectrometry with QuEChERS extraction. α-PHP was detected in his serum at a concentration of 175 ng/mL on his arrival at the hospital. His serum concentrations of α-PHP were serially determined and their natural logarithms were plotted against time after arrival. Although serum concentrations at early time points were lacking, the obtained curve was consistent with a two-compartment model and indicated a serum elimination half-life of 37 h. The long-lasting psychotic symptoms induced by synthetic cathinones appear to be correlated with their toxicokinetic characteristics, such as their long half-lives. Finally, interpreting the toxicokinetics of synthetic cathinones may provide useful information for the toxicological assessment of new psychoactive substances for forensic and clinical purposes.

A Retrospective Study on the Epidemiological and Clinical Features of Emergency Patients with Large or Massive Consumption of Caffeinated Supplements or Energy Drinks in Japan

Objective We conducted a retrospective study on the epidemiological and clinical features of patients with acute caffeine poisoning in Japan. Methods Letters requesting participation were sent to 264 emergency departments of hospitals, and questionnaires were mailed to those that agreed to participate. Patients Participants were patients transported to emergency departments of hospitals between April 2011 and March 2016 after consuming large or massive amounts of caffeinated supplements and/or energy drinks (caffeine dose ≥1.0 g). Results We surveyed 101 patients from 38 emergency departments. Since April 2013, the number of patients has markedly increased. Of these young patients (median age, 25 years), 53 were men, and 97 had consumed caffeine in tablet form. Estimated caffeine doses (n=93) ranged from 1.2 to 82.6 g (median, 7.2 g). Serum caffeine levels on admission (n=17) ranged from 2.0 to 530.0 μg/mL (median level, 106.0 μg/mL). Common abnormal vital signs and laboratory data on admission included tachypnea, tachycardia, depressed consciousness, hypercreatinekinasemia, hyperglycemia, hypokalemia, hypophosphatemia, and hyperlactatemia. Common signs and symptoms in the clinical course included nausea, vomiting, excitement/agitation, and sinus tachycardia. Seven patients (6.9%) who had consumed ≥6.0 g of caffeine, or whose serum caffeine levels on admission were ≥200 μg/mL, developed cardiac arrest. Ninety-seven patients (96.0%) recovered completely, but 3 patients (3.0%) died. Conclusion The present analysis of data from more than 100 emergency patients revealed clinical features of moderate to fatal caffeine poisoning. We recommend highlighting the toxicity risks associated with ingesting highly caffeinated tablets.

Mild manifestation of methanol poisoning half a day after massive ingestion of a fuel alcohol product containing 70% ethanol and 30% methanol: a case report

Case

Is fomepizole necessary after massive ingestion of a mixture of methanol and ethanol? We report the case of a 37‐year‐old man who was transported to our Poison Center 12 h after ingesting 500 mL of fuel alcohol containing 70% methanol and 30% ethanol in a suicide attempt. On admission, he presented only with somnolence and mild metabolic acidosis. We hypothesized that most of the ethanol had been metabolized.

Outcome

As the estimated serum concentration of methanol was lethal (242.6 mg/dL), fomepizole was given i.v. and hemodialysis was carried out twice, resulting in complete recovery. Later, the serum concentrations of both methanol and ethanol on admission were found to be 224.1 and 0.51 mg/dL, respectively.

Conclusion

Therapeutic intervention was delayed by half a day after ingestion of a product containing methanol and ethanol in the present case. If the patient had arrived earlier, he may have only been treated with hemodialysis, but not fomepizole.

Direct detection of the psychoactive substance MT-45 in human tissue samples by probe electrospray ionization-tandem mass spectrometry

Analyses of drugs and poisons in tissue samples are essential in forensic toxicology and pharmacology. However, current procedures for tissue analysis are laborious and time-consuming. Therefore, we assessed the utility of a newly devised probe electrospray ionization (PESI) technique with tandem mass spectrometry (MS/MS) for easy, ultra-rapid drug detection in human tissue samples. Using this system, typical pretreatment procedures, such as solid-phase extraction, liquid-liquid extraction, deproteinization, or homogenization, can be avoided. Briefly, a tissue sample of 1-2 mm³ was supplemented with a solution of ethanol and 10 mmol/L ammonium formate, and measurements were obtained. We demonstrated the successful application of this method in a forensic case by detecting an opioid analgesic, MT-45, in all tissue samples (liver, kidney, lung, brain, and heart). We also detected oxidized metabolites of MT-45 in the liver. Since the analysis required only 0.5 minutes per sample, PESI-MS/MS is an ultra-rapid detection method. Furthermore, for a quantitative approach, the total analysis time for the combination of PESI-MS/MS with the quick, easy, cheap, effective, rugged, and safe (QuEChERS) extraction method (from instrument start-up to extraction and PESI-analysis) was within 8 minutes. MT-45 concentrations obtained by QuEChERS-PESI-MS/MS and liquid chromatography (LC) -MS/MS were similar for all tissue samples. PESI-MS/MS cannot be used to separate isobars/isomers (ie, compounds with the same m/z value), similar to other direct introduction techniques. Further studies are needed to validate the quantitation method. However, our results indicate that PESI-MS/MS is a potentially easy and rapid technique for the analysis of drugs and poisons in human tissue samples.

Acute cholinergic syndrome in a patient with mild Alzheimer's type dementia who had applied a large number of rivastigmine transdermal patches on her body

CASE PRESENTATION

A 91-year-old woman was transferred to our Emergency Medical Center and Poison Center with somnolence, hypertension (186/61 mm Hg), and repeated vomiting. Three hours later, 10 transdermal patches, each containing 18 mg of rivastigmine (9.5 mg/24 h), were found on her lower back and both thighs, when miosis, facial and trunk sweating, enhanced bowel sound, hypertension, and sinus tachycardia were noted. She was diagnosed with acute cholinergic syndrome due to rivastigmine poisoning. Her hypertension and sinus tachycardia peaked 8 and 5 h after all the patches were removed, respectively. Her symptoms subsided spontaneously after 17 h.

DISCUSSION

In the present case, our patient was presented with acute cholinergic syndrome due to carbamate intoxication after massive transdermal exposure to rivastigmine. Toxicological analysis revealed a remarkably high estimated serum rivastigmine concentration (150.6 ng/ml) and notably low serum butyrylcholinesterase activity (35 IU/l) on admission, with a markedly prolonged calculated elimination half-life of 6.5 h.

CONCLUSIONS

Emergency physicians should consider acetylcholinesterase inhibitor exposure (e.g., rivastigmine) when patients are present with acute cholinergic syndrome.

A multicenter retrospective survey of poisoning after consumption of products containing novel psychoactive substances from 2013 to 2014 in Japan

BACKGROUND

In Japan, fatalities among patients who experienced an acute reaction following self-administration of novel psychoactive substances (NPS) have been more frequently reported since June 2014.

OBJECTIVE

This survey aimed to document and analyze trends in NPS consumption in emergency patients.

METHODS

We conducted a multicenter retrospective survey of patients who were transported to emergency facilities after consuming NPS-containing products between January 2013 and December 2014. Letters requesting participation were sent to 467 emergency facilities, and questionnaires were mailed to facilities that agreed to participate.

RESULTS

We surveyed 589 patients from 85 (18.2%) facilities. Most patients were male (89.6%) and young (median age, 30 years), and inhaled (88%) NPS contained in herbal products (80.5%). Harmful behavior was observed at the scene of acute reaction, including violence (6.9%), traffic accidents (4.9%), and self-injury or suicidal attempts (1.1%). Other than neuropsychiatric and physical symptoms, many patients also had physical complications such as rhabdomyolysis (17.5%), liver injury (12.4%), acute kidney injury (9%), and physical injury (1.9%). Of the 256 patients (43.5%) admitted to hospitals, 35 (5.9%) were hospitalized for seven or more days. Most patients (93.2%) completely recovered, although a few (1.4%) died. However, synthetic cannabinoids and synthetic cathinones were only detected in the blood of five patients.

CONCLUSION

Consumption of NPS-containing products have been associated with harmful behaviors such as violence and traffic accidents, physical complications (e.g., rhabdomyolysis, liver injury), death, or physical and neuropsychiatric symptoms. Compared to a previous survey (2006-2012), the present survey revealed more severe toxicity.

Risk factors for the delayed onset of neuropsychologic sequelae following carbon monoxide poisoning

Aim

Carbon monoxide (CO) poisoning often manifests delayed neuropsychological sequelae. The risks and preventive factors for the development of delayed neuropsychological sequelae are controversial at present. The purpose of this retrospective study was to assess the risk factors for this condition.

Method

We studied 81 patients with CO poisoning admitted to the Critical Care and Emergency Medicine Center at the Kansai Medical University from 2006 to 2012. All patients (64 males and 17 females; average age, 45.9 years) were divided into non‐ delayed neuropsychological sequelae and delayed neuropsychological sequelae groups and retrospectively studied. Patient data were analyzed by univariate and multivariate analyses.

Results

The results of our study indicated that prolonged CO exposure, elevated serum creatinine phosphokinase levels, head image abnormality in the basal ganglion or white matter region, low Glasgow Coma Scale score, bedsore occurrence, and CO poisoning attributable to burning charcoal were each predictive risk factors for the development of delayed neuropsychological sequelae. Bedsore occurrence and serum creatinine phosphokinase elevation were significant risk factors by multivariate analysis, whereas no significant differences were found for age, gender, mean blood pressure, heart rate, arterial carboxyhemoglobin and lactate concentrations, or base excess.

Conclusion

We identified several predictive risk factors of delayed neuropsychological sequelae. We believe that these factors will contribute to identifying optimum therapeutic methods and follow‐up terms for patients with acute CO poisoning at risk of developing delayed neuropsychological sequelae.

[Dangerous drugs: products containing synthetic chemicals]

When the patients poisoned with "dangerous drugs", that is, products containing synthetic chemicals such as synthetic cannabinoids and cathinones, are transferred to the emergency facilities, the chemicals really consumed cannot be determined there. So, supportive care may be the most important strategy for treating them. For example, those with serious consciousness disturbance should be supported with ventilator after intubation. Those with remarkable excitatory CNS or sympathetic symptoms, benzodiazepines such as diazepam and midazolam, should be administered. Those with hallucination or delusion, antipsychotics such as haloperidol or risperidone should be administered. Those with rhabdomyolysis, hypermyoglobinemia and acute kidney injury, intravenous fluids and hemodialysis should be introduced.

A multicenter retrospective survey of poisoning after ingestion of herbicides containing glyphosate potassium salt or other glyphosate salts in Japan

INTRODUCTION

A multicenter retrospective survey of patients poisoned by herbicides containing glyphosate salts in Japan was conducted to identify differences in symptoms and outcome of poisoning.

METHODS

Participants were patients who were transported to emergency facilities between October 2006 and March 2014 after consuming herbicides containing glyphosate potassium salt (GlyK(+)) (the K-group) or other glyphosate salts (the O-group). Questionnaires were mailed to 38 emergency facilities that agreed to participate in the study.

RESULTS

Serum potassium levels upon arrival were significantly higher (p < 0.01), and abnormal electrocardiogram findings were significantly more common (p < 0.01) in the K-group (n = 55) than in the O-group (n = 62). Conversely, acute lung injury (ALI) including acute respiratory distress syndrome (ARDS) (p = 0.05) and liver injury (LI) (p < 0.01) were significantly more common during hospitalization in the O-group, although no significant differences in the duration of hospital stay (p = 0.92) or outcomes (p = 0.95) were observed between the two groups.

DISCUSSION AND CONCLUSION

The ingestion of products containing glyphosate isopropylamine or ammonium salts, and polyoxyethyleneamine (POEA) as a surfactant, can cause severe organ injury. Physicians should note that the ingestion of products containing glyphosate potassium salt and surfactants other than POEA can cause hyperkalemia, potentially leading to fatal arrhythmias or cardiac arrest.

Rabbit syndrome after taking herbicide containing 2-(4-chloro2-methylphenoxypropionic) acid

Case

A 48-year-old woman attempted to commit suicide by ingesting a herbicide containing 4-chloro-2-methylphenoxypropionic acid. She was transferred to the emergency center. During this time, involuntary movements of her lips at approximately 5 Hz were observed, mimicking the chewing movements of a rabbit.

Outcome

The symptom resolved in concert with the decrease in her blood concentration of the herbicide.

Conclusion

It was suspected that the ingestion of 4-chloro-2-methylphenoxypropionic acid may have been associated with development of the rabbit syndrome.

[Demographics, clinical features, treatments, and outcomes of patients who were transferred to emergency facilities in Japan after consuming dangerous drugs]

We conducted a multicenter survey of patients who were transported to emergency facilities in Japan from January 2006 to December 2012 after consuming dangerous drugs. Participants were 518 patients. Harmful behavior was observed at the scene of poisoning for about 10% of patients, including violence to others, and traffic accidents. Some patients had physical complications such as rhabdomyolysis, renal dysfunction, and hepatic dysfunction. Of the 182 patients admitted to hospitals, 29 needed respirators and 21 were hospitalized for ≥ 7 days. Although most patients completely recovered, consuming dangerous drugs can result in physical complications including rhabdomyolysis, as well as physical or neuropsychiatric symptoms, which may require active interventions such as respirator use or prolonged hospitalization.

[Acute Drug Poisoning: Focus on Psychotropic Drugs]

In acute psychotropic drug poisoning, it is important to diagnose and treat complications, including aspiration pneumonitis, abnormal body temperature, and atraumatic crush syndrome/compartment syndrome (3As). For the gastrointestinal decontamination (GID) of psychotropic drugs, excluding lithium, the administration of activated charcoal through a nasogastric tube should be considered first. For the GID of sustained-release or enteric-coated psychotropic drugs, total bowel irrigation is an option. To eliminate phenobarbital and carbamazepine, multiple doses of activated charcoal or direct hemoperfusion should be considered. To eliminate lithium, hemodialysis is an option. As an antidote to tricyclic antidepressants, the intravenous administration of sodium bicarbonate may be effective.