Repetitive Doses of Activated Charcoal in Dapsone Poisoning in a Child

Abstract

A case of Dapsone poisoning, treated by repetitive dosing with activated charcoal, is reported. This 18-month-old child showed remarkably rapid resolution of his symptoms with this mode of therapy, becoming symptom free in 64?h. This rapid improvement is attributed to interruption by activated charcoal of the entero-hepatic circulation of Dapsone. This mode of therapy may be indicated for other compounds having an enterohepatic circulation.

Activated charcoal is a generally well-accepted agent for gastrointestinal decontamination in the treatment of oral poisoning in childhood. It is considered a secondary method to induced emesis or gastric lavage for this purpose. Activated charcoal adsorbs a variety of compounds, thereby preventing their systemic adsorption until the charcoal and adsorbed material are excreted by fecal elimination. It is usually recommended that the charcoal be administered in a water slurry as a single dose approximately 10 times that of the ingested toxic material [1]. Several investigators have suggested that repetitive administration of activated charcoal may enhance the clearance of compounds that undergo enterogastric or enterohepatic recirculation or are very slowly adsorbed [2, 3].

Suggestive cases that support this concept have been reported in exposure of adult patients to nortriptyline and Dapsone [3]. To our knowledge there have been no reports of management of such cases in the pediatric literature.

Our case illustrates the use of this mode of therapy in a child.     

胃镜胃管合并使用在抢救急性有机磷农药中毒中的临床效果观察

目的探讨胃镜胃管合并使用在胃镜直视下抢救急性有机磷农药中毒的临床作用。方法选取有机磷农药中毒患者83例,分实验组41例,对照组42例,比较两组洗胃时间、不良反应及并发症、插管一次性成功率、阿托品化出现时间、住院时间和抢救成功率。结果实验组：洗胃时间为（25．46±6．34）min、不良反应及并发症发生率为9．76％、插管一次性成功率为95．12％、阿托品化时间为（3．27土1．62）h、住院时间为（7．21±3．34）d、抢救成功率为97．56％;对照组：洗胃时间为（35．31±8．50）min、不良反应及并发症发生率为73．81％、插管一次性成功率为73．81％、阿托品化时间为（6．58±4．25）h、住院时间为（13．24±4．38）d、抢救成功率为78．57％,两组比较有显著差异性（P〈0．01）。结论胃镜胃管合并使用在胃镜直视下抢救有机磷农药中毒能明显地提高疗效。     

Efficacy of Charcoal Hemoperfusion in Massive Carbamazepine Poisoning

Background: Carbamazepine poisoning can be life threatening. The role and efficacy of extracorporeal drug clearance is not clearly defined. Case Report: A 16-year-old male ingested 34 g of slow-release carbamazepine. His course was complicated by seizures, recurrent cardiac arrests, and renal failure. Intestinal ileus at the time of presentation prevented effective gastrointestinal decontamination. His carbamazepine concentration peaked at 93.8 mg/L (397 μmol/L) 106 hours after ingestion. There was evidence suggesting ongoing absorption for 120 hours. He underwent seven episodes of charcoal hemoperfusion for a total of 109.25 hours. He subsequently made a full recovery. Methods: The efficacy of charcoal hemoperfusion was evaluated by measuring the carbamazepine concentrations in the afferent and efferent loops of the hemoperfusion cartridge using 17 paired convenience samples. Extraction ratios were calculated and plotted against time for each individual episode of charcoal hemoperfusion. Conclusion: The extraction ratio was linearly related to time, and ranged 0.46–0.02. The peak clearance was 69 mL/min. Cartridge saturation was defined as a clearance that was equal to an estimate of the patient's intrinsic clearance. In our patient, this was equivalent to an extraction ratio of 0.2 at a flow rate of 150 mL/min. By this definition, cartridge saturation appeared to occur at 7 hours. Charcoal hemoperfusion was associated with a significant reduction in the apparent half-life, which is most easily explained by clearance from the central vascular compartment, during a prolonged absorptive phase. The patient made full recovery without evidence of neurological deficit.     

非静脉曲张胃内出血的内镜治疗

目的：探讨急性非静脉曲张胃出血内镜治疗的价值。方法：对急性非静脉曲张胃出血患者行胃镜下局部止血合剂、微波、钛夹钳夹3种方法进行治疗。结果：37例胃出血患者中,ForrestIa喷射状活动性出血15例、ForrestIb活动性渗血22例,活动性出血为100%。所有病例均行急诊胃镜下止血,止血率为91.8%（34/37）,采用止血合剂、微波、钛夹3种方法治疗止血率分别为100%（13/13）、91.6%（11/12）和83.3%（10/12）。结论：胃镜下局部止血合剂、微波、钛夹钳夹是治疗急性非静脉曲张胃出血的安全、快速、有效治疗方法。     

Radiopacity of Clomipramine Conglomerations and Unsuccessful Endoscopy: Report of 4 Cases

Background: The radiopacity of ingested substances may serve as a clue to the presence of particular compounds, as this characteristic varies considerably among medications and household products. Tablet conglomerations are also variably radiopaque. We report 4 cases of clomipramine poisoning associated with formation of radiopaque masses, believed to be clomipramine, in the area of the stomach. Case Reports:Four patients were admitted to the Toxicological Intensive Care Unit after ingestions of, respectively, 8.5 g (180 tablets of mixed strength), 7.5 g (100 tablets), 10.5 g (140 tablets), and 4.5 g (60 tablets) of clomipramine, along with other sedatives and antipsychotics. In each case, a rounded density was observed in the gastric area on plain chest radiograph. The hospital courses of each patient were marked by tachycardia, hypotension, QRS and QT prolongation, seizures, and decreased mental status. Three of 4 patients underwent unsuccessful endoscopy to remove tablet fragments and subsequently suffered gastrointestinal hemorrhage requiring transfusion. All patients were discharged recovered from the hospital. Discussion: Clomipramine, a potent tricyclic antidepressant, has been previously reported to be nonradiopaque, and has not been reported to induce formation of concretions. These cases suggest that massive ingestions of clomipramine may form bezoars which are radiopaque and may be associated with serious toxicity. Careful consideration should be given prior to the use of gastric endoscopy for the retrieval of tablet fragments since significant hemorrhage, attributed to the procedure itself rather than to clomipramine toxicity, may ensue.     

The History of Poisoning in the Future: Lessons from Star Trek

Background: The Arts are replete with examples of presaged events of the future. Since a unique glimpse of the 23rd century is afforded by the television series Star Trek, a survey of the toxin-related events as chronicled by the crew of the USS Starship Enterprise may provide insight to prepare toxicologists for the future. Methods: An investigation of the logs of the Enterprise was undertaken for the years 2266 to 2269 which were part of its first 5-year mission. Internet sites, published databases, and selected recorded episodes from the original Star Trek television series were searched for poisonings or toxin-related incidents. Results: Out of the 79 Star Trek episodes, 28 (35%) involved toxin-related incidents. A total of 31 poisoning incidents were documented with 13 environmental, 9 intentional, 5 unintentional, and 4 homicidal circumstances. Biotoxins (10 incidents) were the most frequently involved toxin followed by neurotoxins (9), radiation (3), cytotoxins (3), temporal toxins (3), acids (2), and phytotoxins (1). Of these cases, 2 involved hazardous materials incidents, 1 was contamination of food, and 3 involved therapeutic misadventures. Conclusion: Many of the circumstances encountered in poisonings of the future will likely be similar to contemporary reasons, but the nature of the toxins will differ. Clinical toxicologists should prepare for the future by increasing their study of molecular biology, comparative medicine, physics, and history.     

渔舱内有害气体中毒护理抢救的临床研究

目的减轻中毒症状,提高治愈率,降低死亡率。方法应用2%~4%碳酸氢钠溶液清洗皮肤。结果能迅速中和鱼是鱼蛋白中的有害气体硫化氢和二氧化硫,减轻对神经系统、呼吸系统的影响。结论此法效果确切,对病人无不良刺激,为抢救鱼是中毒病人开辟了一条新的途径。     

胃癌的CT与内镜对照研究(附89例分析)

目的　探讨螺旋CT(SCT)及内镜在胃癌诊断及术前分期中的价值 ,并就二者的相关性进行对照研究。方法　89例胃癌患者在术前行SCT及内镜检查。CT扫描采取患者口服水及低张处理 ,增强扫描时相分别设置为动脉期、门静脉期及延迟期。结果　① 9例早期胃癌 (EGC)均为内镜所诊断 ,而仅 2例为CT检出。② 80例进展期胃癌 (AGC)内镜的检出率及诊断准确率分别为 95 %、90 % ;而CT的检出率及诊断率为 90 %、87.5 %。③SCT对于AGC的分期 :单相 (平扫 )扫描准确率为 70 % ,多相 (平扫 三期增强 )扫描为 91.8%。结论　内镜在EGC的诊断方面优于SCT ,而在AGC的定位及定性诊断方面与SCT相当 ,判断术前分期是CT的独到优势 ,故对于胃癌的术前检查应重视二者的结合     

急性砷化氢中毒的预后因素分析

目的 评估急性砷化氢中毒患者的临床预后,指导早期干预和治疗。 方法 回顾性分析2010年7月－2014年1月收治的20例急性砷化氢中毒患者的临床资料,通过单因素分析,比较死亡和存活患者中毒至首次救治的时间,尿砷浓度、血常规和肝肾功能检查、电解质、心肌酶及动脉血气分析等指标的差异性。并根据单因素分析结果,将上述有阳性意义的指标进行logistic回归分析,探寻可能影响患者生存的影响因素。 结果 死亡组患者中毒至救治的时间、尿砷浓度、血清总胆红素、肌酐、肌酸激酶明显高于存活组,而pH值、HCO3？、碱乘余值均低于存活组,差异有统计学意义（P＜0. 05）。logistic 回归分析显示,上述指标对生存有显著影响。 结论 急性砷化氢中毒后救治时间窗,心、肝、肾等脏器受损和酸碱失衡的程度与患者的生存预后密切相关,及早地掌控上述情况,并根据结果积极开展救治,有助于改善患者的预后。     

多层螺旋CT、内镜诊断胃脂肪瘤的效能分析

[目的]探讨多层螺旋CT(MSCT)及内镜检查诊断胃脂肪瘤的效能.[方法]本院收治的疑似为胃脂肪瘤的患者46例,经手术病理证实33例为胃脂肪瘤,13例为胃淋巴瘤.所有患者均于术前行内镜及MSCT检查.观察胃脂肪瘤MSCT及内镜检查及病理学检查表现;运用受试者工作特征曲线(ROC)分析内镜及MSCT诊断胃脂肪瘤的效能.[...     

A Case of Barbiturate Poisoning with a Readily-Accessible Laboratory Reagent

We report a patient with barbiturate intoxication due to surreptitious ingestion of barbital buffer from a clinical laboratory. Although detected in the urine toxicology screening test using an immunologic technique, this agent was not recognized in the more specific serum analysis done by gas-liquid chromatography. Barbital buffer is an effective long-acting sedative-hypnotic and is widely available from the laboratory shelf. It may not be reported by very specific analytical methods.     

有机磷农药中毒经鼻洗胃管插入深度的探讨

目的探讨洗胃管插入深度对有机磷农药中毒患者洗胃效果及愈后的影响。方法将62例中毒患者随机分为实验组和对照组,在其它条件相同的情况下,对照组按传统法胃管插入深度,实验组胃管插入深度为眉心一脐,观察两组洗胃效果。结果实验组洗胃总时间、洗胃的并发症、达到阿托品化的时间及治愈时间与对照组比较,经统计学分析有显著差异。结论延长洗胃管插入深度能够使洗胃畅通,缩短洗胃时间、减少并发症、尽快达到阿托品化、缩短治愈时间。     

Forearm Compartment Syndrome After Intravenous Mannitol Extravasation in a Carbosulfan Poisoning Patient

We report a case of forearm compartment syndrome caused by extravasation of mannitol in an intoxicated patient. The pathophysiology and management of a forearm compartment syndrome from extravasation of mannitol are discussed in this case.     

A Case of Strychnine Poisoning from a Southeast Asian Herbal Remedy

Background

Strychnine is a highly toxic alkaloid found in both naturally occurring compounds and commercial products. Extracts of fruits from the strychnine plant have been used in Southeast Asia as remedies for various illnesses. We describe strychnine poisoning from ingestion of a Southeast Asian herbal supplement quantitatively confirmed by serum and urine analysis.

松花粉对砷中毒小鼠肝脏及血清一些生化指标的影响

目的 通过检测松花粉对砷中毒小鼠肝脏及血清一些生化指标的影响研究松花粉对砷中毒小鼠的恢复情况.方法 54只小鼠被随机分为3组:即A组(正常对照组),B组(治疗组),C组(NaAsO2对照组).正常对照组饮用蒸馏水;治疗组、NaAsO2对照组均隔天注射NaAsO2(500 μg/100g)进行砷染毒.治疗组,在砷染毒进行的第15 d后开始用松花粉灌胃(1 g/kg),至第45 d,取肝组织做病理分析,测血清丙氨酸氨基转移酶(ALT)、直接胆红素(DBLL)、尿酸(SUA).结果 NaAsO2中毒对照组与治疗组相比,肝炎症程度高;NaAsO2对照组与治疗组相比,ALT,SUA含量差异有统计学极显著性意义(P<0.01),DBLL差异有统计学显著性意义(P<0.05).结论 松花粉能降低砷中毒后小鼠肝肾的损伤程度.     

A Curious Case of Ciguatera Fish Poisoning in the Midwest and a Review for Clinicians

BackgroundCiguatera poisoning is one of the most prevalent types of fish poisoning, but it is often underreported, leading many health practitioners to be unfamiliar in correctly identifying and treating this toxicity.Case ReportWe present a case of ciguatera toxicity encountered in an emergency department in a Midwest community hospital setting. A 56-year-old woman presented to the ED with symptoms of perioral numbness, generalized pruritis, and hot/cold temperature reversal. Through careful history taking it was determined that the patient had recently returned from vacationing in the Caribbean and had been consuming meals containing various types of fish. A clinical diagnosis of ciguatera toxicity was made, and the patient was treated supportively.Why Should an Emergency Physician be Aware of This?This topic is important in the realm of emergency medicine because it presents a known toxicologic pathogen in an unsuspecting geographic location. This case highlights the importance of maintaining broad differentials and considering a patient's travel and exposure history to make the clinical diagnosis of ciguatoxin as well as the importance of preventative management to avoid recurrence of symptoms. We review the etiology of this fascinating toxin as well as the clinical implications in the diagnosis and management of this toxicity.     

有机磷农药中毒并发中间综合征的早期防治

目的 :探讨有机磷农药中毒后并发中间综合征 (IMS)的早期防治措施。方法 :将中、重度有机磷农药中毒的 30 5例患者随机开放式分为治疗组 15 8例和对照组 14 7例 ,治疗组采用早期、突击剂量应用胆碱酯酶复活剂的治疗方法 (第 1个 2 4h氯磷啶平均用量 8.4± 1.1g) ,对照组采用传统的治疗方法 (第 1个 2 4h氯磷啶平均用量 3.2 5± 0 .5 g) ,观察两组胆碱酯酶恢复的时间 ,IMS的发生率及病死率 ,胆碱酯酶活力与IMS发生的关系。结果 :治疗组胆碱酯酶平均恢复的时间 (5 .8± 1.5d)较对照组(19.3± 3.5d)明显缩短 (P <0 .0 1) ;治疗组IMS的发生率 (5 .6 6 % )及病死率 (1.89% )较对照组 (2 5 .0 9%和 10 .2 7% )明显降低 (P <0 .0 1) ;并发IMS患者的胆碱酯酶活力均在 6 0 %以下。结论 :早期 (中毒 2h内 )足量 (第 1个 2 4h氯磷啶用量 8～ 10 g)应用胆碱酯酶复活剂是减少有机磷中毒后并发IMS及降低其病死率的有效措施。     

三氧化二砷诱导人胃癌细胞株MGC-803细胞凋亡的研究

【目的】为探讨三氧化二砷（Ａｓ２Ｏ３）对胃癌细胞的作用及可能的机制。【方法】用不同浓度的Ａｓ２Ｏ３作用于培养的胃癌细胞株ＭＧＣ－８０３细胞。【结果】噻唑蓝（ＭＴＴ）细胞活力测定显示Ａｓ２Ｏ３能明显抑制ＭＧＣ－８０３细胞生长;进一步用Ｈｏｅｇｈｅｓ３３３４２和碘化丙啶（ＰＩ）双荧光流式细胞仪（ＦＣＭ）检测和琼脂糖ＤＮＡ电泳,ＭＧＣ－８０３细胞表现为明显凋亡特征;扫描电镜显示凋亡的形态学特征。【结论】Ａｓ２Ｏ３能有效地抑制胃癌细胞的生长增殖,并具有时—效和量—效关系。     

Amatoxin Poisoning: Case Reports and Review of Current Therapies

Background

Diagnosis and management of Amanita mushroom poisoning is a challenging problem for physicians across the United States. With 5902 mushroom exposures and two resultant deaths directly linked to Amanita ingestion in 2009, it is difficult for physicians to determine which patients are at risk for lethal toxicity. Identification of amatoxin poisoning can prove to be difficult due to delay in onset of symptoms and difficulty with identification of mushrooms. Consequently, it is difficult for the Emergency Physician to determine proper disposition. Further, treatment options are controversial.

Objectives

To review current data to help health care providers effectively identify and treat potentially deadly Amanita mushroom ingestions.

Case Reports

We present two cases of Amanita mushroom ingestion in the northeastern United States treated with N-acetylcysteine, high-dose penicillin, cimetidine, and silibinin, a semi-purified fraction of milk thistle-derived silymarin, as part of their treatment regimen. The mushroom species was identified by a consultant as Amanita Ocreata.

Conclusions

We present the successful treatment of 2 patients who ingested what we believe to be an Amanita species never before identified in the northeastern United States.