The purpose of this research was to investigate the manner of deaths in Marion County, throughout the years of 2018 to 2021 to see if there were any correlative increases in homicide, suicide, natural, accidental, or ...The purpose of this research was to investigate the manner of deaths in Marion County, throughout the years of 2018 to 2021 to see if there were any correlative increases in homicide, suicide, natural, accidental, or drug overdose related deaths. We surveyed the incidence of all deaths that occurred from 2018 through 2021 which came through the Marion County Coroner’s Office, Indiana. The data was then divided into two halves. According to the data, the leading manner of death in the first half and second half was accidental. This study revealed a total of 8732 cases: 3817 of them were observed to be accidental, 3092 natural, 956 homicide, 689 suicide, and 178 were undetermined. There were initially 318 drug overdose related deaths in 2018 and they increased to 2163 by 2021. In 2018, the number of deaths due to fentanyl related overdoses increased from 195 to 799 in 2021. This research will contribute to the forensic science field by providing information about the manner of death and fentanyl trends in Marion County over the last four years.展开更多
Polysubstance Abuse (PSA) greatly complicates an attempt to implicate a single drug as sole cause of an overdose death. Since PSA now occurs in the majority of cases of drug overdoses, many or most overdose deaths are...Polysubstance Abuse (PSA) greatly complicates an attempt to implicate a single drug as sole cause of an overdose death. Since PSA now occurs in the majority of cases of drug overdoses, many or most overdose deaths are polysubstance overdose deaths. And since many of the substances involved in a polysubstance Overdose Death (POD) are Central Nervous System (CNS) depressants, many of which can cause overdose death themselves, or synergistically with opioids, it is somewhat puzzling that prescription opioids have been singled out as the cause of these deaths—without reference to PSA. This is particularly puzzling in light of the fact that the issues of PSA and POD have been recognized and discussed in the literature since at least the 1960’s and before. We therefore here consider the question: are we facing an “opioid” crisis or, instead, a “polysubstance crisis”? And we wonder if the issue has been over-simplified, to the detriment of the individuals affected, and to society more broadly. There is a need for an “agnostic” respiratory stimulant that can reverse polysubstance-induced respiratory depression.展开更多
Polysubstance (combinations of substances) abuse and overdose deaths now surpass mono-substance abuse and overdose deaths. Several international and governmental organizations such as the WHO (World Health Organizatio...Polysubstance (combinations of substances) abuse and overdose deaths now surpass mono-substance abuse and overdose deaths. Several international and governmental organizations such as the WHO (World Health Organization), CDC (Centers for Disease Control and Prevention), several of the Institutes of the NIH (National Institutes of Health), Regulators, and Enforcement Agencies, among others, track and provide a valuable source of statistical information about drug (prescription and illicit) (mis)use and overdose. The information is disseminated free to stakeholders and the general public for use. Although the numeric presentations of the data are helpful and adequate for professionals, the non-expert and the visual learner often find visual representation more clear and more compelling. With this in mind, the aim of this study was to present polysubstance use and overdose using visual maps of the available data. This article considers the opioids.展开更多
Rationale:Delayed post-hypoxic leukoencephalopathy(DPHL)is usually an overlooked condition,which arises as a result of a multitude of reversible and irreversible conditions.Patient’s Concern:A 50-year-old female with...Rationale:Delayed post-hypoxic leukoencephalopathy(DPHL)is usually an overlooked condition,which arises as a result of a multitude of reversible and irreversible conditions.Patient’s Concern:A 50-year-old female with a history of epilepsy,who developed DPHL 12 days after respiratory failure secondary to barbiturate toxicity.Diagnosis:DPHL on magnetic resonance imaging of the brain.Interventions:Mechanical ventilation was initiated for respiratory failure and hemodialysis for barbiturate toxicity.Outcomes:The patient developed akinetic mutism due to infirmity and had a residual disability,which led to permanent dependency.Lessons:The diagnosis of DPHL is often delayed or missed,given the rarity of this condition and its inconsistent clinical symptomatology.Diagnostic delay can be avoided by early recognition of the classical“delayed onset”symptoms.展开更多
Dear editor,We report a case of a 47-year-old female who presented with a toxic bupropion ingestion leading to cardiac arrest.She initially exhibited a loss of brainstem reflexes in conjunction with burst-suppression ...Dear editor,We report a case of a 47-year-old female who presented with a toxic bupropion ingestion leading to cardiac arrest.She initially exhibited a loss of brainstem reflexes in conjunction with burst-suppression pattern on EEG.Burst suppression is an EEG waveform pattern of alternating isoelectric suppressions and high voltage bursts.^([1])展开更多
A case is presented of a serious, potentially life-threatening intravenous acetaminophen overdose in a 3-month-old (40 weeks’ post menstrual age),2.3 kgbaby girl. The neonate was scheduled for urgent laser therapy fo...A case is presented of a serious, potentially life-threatening intravenous acetaminophen overdose in a 3-month-old (40 weeks’ post menstrual age),2.3 kgbaby girl. The neonate was scheduled for urgent laser therapy for retinopathy of prematurity. Instead of an intended intravenous Hartmann’s solution bolus of 10 ml·kgˉ1, the neonate received a 17 ml bolus of correctly labelled intravenous 1% acetaminophen. The National Poisons Bureau was immediately contacted for advice and in the absence of data suggested a treatment with N-acetylcysteine for a 24-hour period. Baseline blood samples for clotting, liver function, urea and electrolytes, full blood count and plasma acetaminophen concentration were taken 30 min, 8.25 h, 12.5 h, 18.5 h and 120 h after the overdose. Acetaminophen concentration was 78 mg·Lˉ1 at 30 min, but it was undetectable at any other time. Using a recent and complete PK-PD dataset we are able to show that the measured plasma acetaminophen concentration fits well on PK estimates for acetaminophen in this neonate. The non-detectable (low) plasma acetaminophen concentration at >8 h is also consistent with this model, especially if clearance is slightly increased in the premature nursery graduate. Medical errors are rarely the fault of an individual and they are often due to a combination of factors. Contributing factors, in this case, are described under the following headings: Catalyst event, system fault, loss of situational awareness, and human error.展开更多
A paucity of literature exists linking acute extremity compartment syndrome associated with cocaine or olanzapine overdose. LJ, a 38-year male, was initially seen at an outside hospital for acute encephalopathy and le...A paucity of literature exists linking acute extremity compartment syndrome associated with cocaine or olanzapine overdose. LJ, a 38-year male, was initially seen at an outside hospital for acute encephalopathy and left lower extremity swelling shortly after cocaine and suspected olanzapine overdose. On presentation, totalcreatinine kinase levels were >1000 units/liter but quickly rose to 23,000 units/liter after 12 hours. He was transferred to a tertiary care center for surgical evaluation. Upon the exam, it was quickly determined that he had compartment syndrome and he was urgently taken to the operating room for a four-compartment lower extremity fasciotomy. Acute compartment syndrome is a limb threatening condition generally diagnosed clinically. Cocaine, a potent vasoconstrictor, is widely reported to cause rhabdomyolysis from ischemia of skeletal muscle tissue and direct toxicity to myocytes resulting in leakage of creatinine kinase. Other complications including cardiovascular, respiratory, neurological, and gastrointestinal disturbances have also been well documented. Olanzapine, an atypical antipsychotic, has also been reported to cause rhabdomyolysis. However, myositis with lower extremity compartment syndrome is a rare occurrence and requires quick diagnosis and aggressive treatment in order to achieve limb salvage. The potential causality of compartment syndrome from either cocaine, olanzapine, or both will be examined in this case report.展开更多
A 22-year-old pregnant female was transferred to the emergency department having ingested a bottle of iron-containing prenatal vitamins, ondansetron (Zofran?) tablets and alcohol. The patient was hemodynamically stabl...A 22-year-old pregnant female was transferred to the emergency department having ingested a bottle of iron-containing prenatal vitamins, ondansetron (Zofran?) tablets and alcohol. The patient was hemodynamically stable but suffered from intense bouts of brown, sandy emesis for the first few hours. Investigation revealed the patient ingested 13.57 mg/kg of elemental iron. Due to the initial iron level, history and presentation time whole bowel irrigation was initiated with polyethylene glycol solution. Acute iron toxicity in pregnancy is a medical emergency that can result in multisystem organ failure leading to maternal death and potential fetal demise. High maternal serum iron loads do not affect the developing fetus and are not associated with fetal malformations;however advanced poisoning can lead to maternal death, spontaneous abortions or preterm emergency deliveries. Initial treatment strategies may include whole bowel irrigation using polyethylene glycol electrolyte lavage solution and deferoxamine treatment along with necessary supportive care management. Despite concerns of teratogenicity deferoxamine does not cross the placenta and is regarded as safe for use during pregnancy. Maternal resuscitation must always be the primary objective in acute iron overdoses and, therefore such concern should not delay clinically indicated maternal treatment.展开更多
Valproic acid is used in the treatment of multiple disorders. Adverse effects from valproic acid include hepatotoxicity, hypotension, metabolic acidosis, and decreased mental status. Valproic acid also causes hyperamm...Valproic acid is used in the treatment of multiple disorders. Adverse effects from valproic acid include hepatotoxicity, hypotension, metabolic acidosis, and decreased mental status. Valproic acid also causes hyperammonemia. Many physicians assume that this is due to a supratherapeutic valproic acid concentration;when in fact, it can occur with therapeutic valproic acid concentrations. This is because the hyperammonemia may be related to carnitine deficiency and disruption of the urea cycle, which can both occur with therapeutic valproic acid concentrations. We report a patient presented to the emergency department with alteration of mental status after ingesting valproic acid for recreational purposes, who developed hyperammonemia with a therapeutic valproic acid concentration.展开更多
The antidepressant venlafaxine in overdose can lead to serotonin syndrome, seizures, QTc interval prolongation and can increase the risk of cardiac arrhythmias. It has been reported to be more toxic in overdose than o...The antidepressant venlafaxine in overdose can lead to serotonin syndrome, seizures, QTc interval prolongation and can increase the risk of cardiac arrhythmias. It has been reported to be more toxic in overdose than other new antidepressants. We report a case of venlafaxine intoxication with a venlafaxine/O-desmethylvenlafaxine serum level of 2861/2670 ng/mL 22 h after ingestion. This is one of the so far highest survived venlafaxin serum levels. In contrast to other reported survived venlafaxin overdoses with high serum levels no clinical signs of intoxication were observed in our case. So venlafaxine overdose not necessarily leads to life-threatening signs of intoxication.展开更多
We report a near fatal case of paediatric amitriptyline overdose including a series of ECGs demonstrating the effects of sodium bicarbonate therapy on cardio-toxicity. We briefly discuss the role of sodium to countera...We report a near fatal case of paediatric amitriptyline overdose including a series of ECGs demonstrating the effects of sodium bicarbonate therapy on cardio-toxicity. We briefly discuss the role of sodium to counteract the sodium channel blockade of tricyclic antidepressants and discuss the possible utility of lipid emulsion therapy in such cases.展开更多
<span style="font-family:Verdana;">The </span><span style="font-family:Verdana;">“</span><span style="font-family:Verdana;">opioid crisis</span><sp...<span style="font-family:Verdana;">The </span><span style="font-family:Verdana;">“</span><span style="font-family:Verdana;">opioid crisis</span><span style="font-family:Verdana;">”</span><span style="font-family:""><span style="font-family:Verdana;"> has had a tremendous impact not only on its victims, but also on the practice of medicine, pain patients, and society in general. Unfortunately, efforts to “stem the tide” have not been successful at reducing overdose deaths. Counterbalancing the many ardent efforts to eliminate overdose deaths (such as the current widespread availability and use of opioid-receptor antagonists such as naloxone) is influx of the illicit fentanoids (</span><i><span style="font-family:Verdana;">i.e</span></i><span style="font-family:Verdana;">., fentanyl and analogs). In addition to their high-potency, the fentanoids differ in surprising ways from more “traditional” opioids such as morphine and heroin. This uniqueness contributes to a reduced effectiveness of opioid receptor antagonists in the treatment of opioid overdose. Further greatly complicating overdose treatment is polysubstance abuse (e.g., an opioid plus a benzodiaze</span><span style="font-family:Verdana;">pine). The non-opioid in the combination is not responsive to an opio</span><span style="font-family:Verdana;">id-recep</span></span><span style="font-family:Verdana;">- </span><span style="font-family:""><span style="font-family:Verdana;">tor antagonist, which imparts additional challenges. Thus, the new reality in</span><span style="font-family:Verdana;">troduces complications that negatively impact efforts to reverse </span></span><span style="font-family:Verdana;">“</span><span style="font-family:Verdana;">opioid</span><span style="font-family:Verdana;">”</span><span style="font-family:""><span style="font-family:Verdana;"> overdose. New approaches to improve outcomes in individuals who experience </span><span style="font-family:Verdana;">respiratory depression due to fentanoid-induced or polysubstance-induced</span><span style="font-family:Verdana;"> over</span></span><span style="font-family:Verdana;">- </span><span style="font-family:Verdana;">dose are needed. Approaches that harmonize with the new reality, perhaps something like a non-opioid </span><span style="font-family:Verdana;">“</span><span style="font-family:Verdana;">agnostic</span><span style="font-family:Verdana;">”</span><span style="font-family:Verdana;"> pharmacologic ventilatory stimulant, would provide a welcome addition to the current choices.</span>展开更多
Abuse of drug substances and resultant overdose deaths are no longer very straightforward—viz., attributable to a single chemical entity of known purity. The reality is that most overdose deaths involve polysubstance...Abuse of drug substances and resultant overdose deaths are no longer very straightforward—viz., attributable to a single chemical entity of known purity. The reality is that most overdose deaths involve polysubstance use (i.e., the use of combinations of substances). Further, the combinations are often of unknown purity, and even of unknown composition. Overdose deaths are at all-time highs. The depressing statistics are monitored and reported by several international and governmental organizations such as the WHO (World Health Organization), CDC (Centers for Disease Control and Prevention), several Institutes of the NIH (National Institutes of Health), Regulators, and Enforcement Agencies (e.g., DEA). The information is disseminated for free for review and use. But it is our observation that although numeric presentation is helpful and adequate for professionals, the non-expert and the visual learner often find a visual representation clearer and compelling. With this in mind, we present the “gestalt” of polysubstance use and overdose using available maps of the data. The previous article in the series considered the opioids. This one considers amphetamines and cocaine, and places the rise in opioid-associated overdose deaths in the context of other abused drugs.展开更多
Paroxetine is a selective serotonin reuptake inhibitor(SSRI)used in the treatment of depression and anxiety disorders.In some epidemiological studies,slightly increased risks of major malformations and cardiac malform...Paroxetine is a selective serotonin reuptake inhibitor(SSRI)used in the treatment of depression and anxiety disorders.In some epidemiological studies,slightly increased risks of major malformations and cardiac malformations have been reported following paroxetine exposure in the first trimester of pregnancy.However,such findings have been inconsistent.There is only one report of any overdose of an SSRI during pregnancy,and that involved escitalopram.The aim of this case report was to describe the impact of a paroxetine overdose in the first trimester of pregnancy on the health of the foetus.A 21-year-old mother of one child who was pregnant with a second child was prescribed 20 mg/day paroxetine hydrochloride for the treatment of anxiety/depression.The patient ingested 15 or 1620-mg tablets of paroxetine hydrochloride(300-320 mg)during the 5th week of pregnancy as a suicide attempt.Within 15 min of ingestion,she was admitted to hospital and treated for intoxication.No evidence of maternal SSRI intoxication was observed after treatment.The patient consulted our teratology information service for further risk assessment regarding possible major congenital malformations following the paroxetine overdose.We were unable to find previous reports of paroxetine overdose during pregnancy in the literature.The timely administration of the overdose treatment and the lack of maternal intoxication symptoms were considered positive for the foetal well-being,and the patient was referred for perinatology and psychiatry follow-ups.A healthy,3500-g male infant was born at 38 weeks’gestation,and his development at the age of 2 years was normal.This is the first reported case of paroxetine overdose during pregnancy.Comprehensive studies are needed to evaluate pregnancy outcomes after SSRI overdose.展开更多
Background and Aims:Acetaminophen(APAP)is the leading cause of drug overdose and hepatotoxicity worldwide,including in Thailand.Patterns of overdose and hospital management are known to have significant impacts on the...Background and Aims:Acetaminophen(APAP)is the leading cause of drug overdose and hepatotoxicity worldwide,including in Thailand.Patterns of overdose and hospital management are known to have significant impacts on the outcomes of APAP overdose,and these factors vary from country to country.Therefore,this study aimed to analyze clinical characteristics of Thai patients with APAP overdose in terms of overdose patterns,clinical presentation,treatment and outcomes.Methods:In this retrospective analytical study,medical records of adult patients hospitalized with a diagnosis of APAP overdose at Rajavithi Hospital,Bangkok,between January 2013 and December 2017 were reviewed.Results:A total of 184 patients diagnosed with APAP overdose were included.The median age was 22(15–76)years and the majority were female(79.9%).Most overdoses were intended self-poisoning ingestion(90.8%)with a median dose of 10.5 g(4.5–50).A total of 121 patients were treated with N-acetylcysteine with a median visit-to-N-acetylcysteine time of 2(0.5–15)h.Overall,15.6%developed mild hepatotoxicity(aspartate aminotransferase or alanine aminotransferase>3 times the upper limit of normal),6.4%developed severe hepatotoxicity(aspartate aminotransferase or alanine aminotransferase>10 times the upper limit of normal and international normalized ratio>2.0)and 3 patients developed acute liver failure(1 patient resolved spontaneously and 2 patients,neither of whom had a liver transplant,died).Significant predictors for hepatotoxicity included older age,chronic alcohol drinking,repeated taking of medication for more than 8 h(staggered ingestion),long duration between ingestion and hospital visit,alcohol coingestion,abdominal pain symptoms,and acute kidney injury.Conclusions:Most cases of APAP overdose in Thailand appear to be young women with intentional ingestion.With prompt management,most patients(76.4%)did not develop significant hepatotoxicity;nevertheless,despite N-acetylcysteine therapy,hepatotoxicity including acute liver failure was observed in a small proportion of patients,particularly those with unintentional overdose and chronic alcohol drinking.展开更多
Objective:To investigate the effects of coconut water intake on lipid profile and atherogenic predictor indices of albino rabbits overdosed with paracetamol using standard methods.Methods:Thirty-five albino rabbits we...Objective:To investigate the effects of coconut water intake on lipid profile and atherogenic predictor indices of albino rabbits overdosed with paracetamol using standard methods.Methods:Thirty-five albino rabbits weighing between 800-1200 g and aged between 2 and 3 months,were divided into 7 groups(I-VII)of 5 animals each.Groups I,II and III were orally administered distilled water(20 mL/kg body weight),coconut water(20 mL/kg body weight)and paracetamol(1000 mg/kg body weight)respectively,for 7 days.Groups IV and V were administered coconut water(20 mL/kg body weight)and silymarin(35 mg/kg body weight),respectively,for 6 days,then paracetamol(1000 mg/kg body weight)on the 7th day.Groups VI and VII were administered distilled water for 6 days,paracetamol on the 7th day,then coconut water and silymarin,respectively,after 3 h.Results:The results showed that paracetamol overdose significantly reduced(P<0.05)the mean body weight of the animals,increased the concentrations of serum total cholesterol,triacylglycerol,very low density lipoprotein cholesterol,low density lipoprotein cholesterol and the atherogenic predictor indices but reduced the serum high density lipoprotein cholesterol concentration of the animals relative to the control.The observed changes in the lipid profile and atherogenic predictor indices were countered more by post-than pre-treatment with coconut water and silymarin.Conclusions:The results indicated that coconut water acted as an effective antidote to paracetamol overdose-induced lipid abnormality in animals.展开更多
Carfentanil,an ultrapotent analog of fentanyl,has invaded the street drug market,unbeknownst to many heroin users.About 10,000 times more potent than morphine,it was initially suspected that 20μg of the substance was...Carfentanil,an ultrapotent analog of fentanyl,has invaded the street drug market,unbeknownst to many heroin users.About 10,000 times more potent than morphine,it was initially suspected that 20μg of the substance was lethal.In this case series,we present 17 confirmed carfentanil overdoses in Michigan,with a primary focus on the concentration levels.Through a retrospective review,each public death reported in Oakland County,Michigan,with a subsequent toxicology report was investigated for suspected carfentanil use.To characterize each fatality,the autopsy results were collected,including the postmortem findings at scene and the decedent’s medical and social history.Carfentanil levels were measured through liquid chromatography and tandem mass spectrometry(LC-MS-MS)by National Medical Services(NMS)Laboratories.Our case series found postmortem carfentanil concentrations as low as 10 ng/mL,with a mean concentration of 0.387 ng/mL.Ultimately,there are implications on law enforcement,first responders,and health care providers when dealing with this emerging illicit substance,and there is an alarmingly high mortality rate associated with the abuse of carfentanil.展开更多
Suicidal drug overdose is a major public health issue.In the United States,every year more than 33,000 people commit suicides.Our study focused on the characteristics of suicide victims in the state of Maryland.Materi...Suicidal drug overdose is a major public health issue.In the United States,every year more than 33,000 people commit suicides.Our study focused on the characteristics of suicide victims in the state of Maryland.Material and methods:This study was a retrospective review of autopsy cases of all suicide deaths caused by drug(s)or drug(s)with alcohol intoxication investigated by the OCME in Maryland over a 7-year period from January 2004 to December 2011.All deaths investigated by the OCME that require autopsy examination are subject to comprehensive toxicology testing for drugs and alcohol.The screen tests were performed using gas chromatography(GC)and radioimmunoassay techniques.All detected drugs and/or metabolites were confirmed using GC-mass spectrometry(GC-MS).Results:From 2004 to 2011,434 deaths were certified as suicide.Of the 434 suicidal overdose deaths,84%were white,11%were African-American,and about 5%were either Hispanic or Asian.The male and female ratio was almost equal.Their ages ranged 15-82 years.Of the 434 suicidal drug overdose deaths,277 victims(63.8%)consumed a single drug type and 157(36.2%)consumed more than one type of drug.Of the 277 single-drug overdose cases,71.1%suicides were due to prescription drugs,23.5%due to over-the-counter drugs,and 5.4%due to street/recreational drugs.Among single-type prescription drugs,analgesic(N=76),antidepressant(N=45),and neuroleptic(N=35)classes were the three leading type of drugs used in suicidal deaths.Oxycodone,morphine,quetiapine,and amitriptyline were the most common prescription drugs in suicidal overdose.Diphenhydramine was the leading over-the-counter drug.Of the 157 victims who consumed more than one drug,combined prescription drugs were present in 54.1%,mixed prescription and overthe-counter drugs in 29.3%,and prescription drugs/over-the-counter drugs and street drugs in 16.6%of cases.Of the multiple-drug overdose suicides,66.2%cases involved antidepressants.Discussion:Suicide is found in every age,racial,and ethnic group.In the USA,poisoning is thethird-leading method of suicide,following firearm injuries and hanging/strangulation.Our study indicates that prescription drugs,such as those in the opioid analgesic,neuroleptic,and antidepressant class(e.g.,oxycodone,morphine,quetiapine,amitriptyline,doxepin,and citalopram),are of special concern in the context of suicidal overdose deaths in the state of Maryland.Therefore,addressing the problems of intentional drug overdose in our society is worthy of public attention.展开更多
BACKGROUND Dextromethorphan is a prevalent antitussive agent that can be easily obtained as an over-the-counter medication.There has been a growing number of reported cases of toxicity in recent years.Generally,there ...BACKGROUND Dextromethorphan is a prevalent antitussive agent that can be easily obtained as an over-the-counter medication.There has been a growing number of reported cases of toxicity in recent years.Generally,there are numerous instances of mild symptoms,with only a limited number of reports of severe cases necessitating intensive care.We presented the case of a female who ingested 111 tablets of dextromethorphan,leading to shock and convulsions and requiring intensive care that ultimately saved her life.CASE SUMMARY A 19-year-old female was admitted to our hospital via ambulance,having overdosed on 111 tablets of dextromethorphan(15 mg)obtained through an online importer in a suicide attempt.The patient had a history of drug abuse and multiple self-inflicted injuries.At the time of admission,she exhibited symptoms of shock and altered consciousness.However,upon arrival at the hospital,the patient experienced recurrent generalized clonic convulsions and status epilepticus,necessitating tracheal intubation.The convulsions were determined to have been caused by decreased cerebral perfusion pressure secondary to shock,and noradrenaline was administered as a vasopressor.Gastric lavage and activated charcoal were also administered after intubation.Through systemic management in the intensive care unit,the patient’s condition stabilized,and the need for vasopressors ceased.The patient regained consciousness and was extubated.The patient was subsequently transferred to a psychiatric facility,as suicidal ideation persisted.CONCLUSION We report the first case of shock caused by an overdose of dextromethorphan.展开更多
BACKGROUND:Severe poisoning due to the overdosing of cardiac drugs can lead to cardiovascular failure.In order to decrease the mortality rate,the most severe patients should be transferred as quickly as possible to an...BACKGROUND:Severe poisoning due to the overdosing of cardiac drugs can lead to cardiovascular failure.In order to decrease the mortality rate,the most severe patients should be transferred as quickly as possible to an extracorporeal membrane oxygenation(ECMO)center.However,the predictive factors showing the need for venous-arterial ECMO(VA-ECMO)had never been evaluated.METHODS:A retrospective,descriptive,and single-center cohort study.All consecutive patients admitted in the largest ICU of Reunion Island(Indian Ocean)between January 2013 and September 2018 for beta-blockers(BB),calcium channel blockers(CCB),renin-angiotensin-aldosterone system blockers,digoxin or anti-arrythmic intentional poisonings were included.ECMO implementation was the primary outcome.RESULTS:A total of 49 consecutive admissions were included.Ten patients had ECMO,39 patients did not have ECMO.Three patients in ECMO group died,while no patients in the conventional group died.The most relevant ECMO-associated factors were pulse pressure and heart rate at first medical contact and pulse pressure,heart rate,arterial lactate concentration,liver enzymes and left ventricular ejection fraction(LVEF)at ICU-admission.Only pulse pressure at first medical contact and LVEF were significant after logistic regression.CONCLUSION:A transfer to an ECMO center should be considered for a pulse pressure<35 mmHg at first medical contact or LVEF<20%on admission to ICU.展开更多
文摘The purpose of this research was to investigate the manner of deaths in Marion County, throughout the years of 2018 to 2021 to see if there were any correlative increases in homicide, suicide, natural, accidental, or drug overdose related deaths. We surveyed the incidence of all deaths that occurred from 2018 through 2021 which came through the Marion County Coroner’s Office, Indiana. The data was then divided into two halves. According to the data, the leading manner of death in the first half and second half was accidental. This study revealed a total of 8732 cases: 3817 of them were observed to be accidental, 3092 natural, 956 homicide, 689 suicide, and 178 were undetermined. There were initially 318 drug overdose related deaths in 2018 and they increased to 2163 by 2021. In 2018, the number of deaths due to fentanyl related overdoses increased from 195 to 799 in 2021. This research will contribute to the forensic science field by providing information about the manner of death and fentanyl trends in Marion County over the last four years.
文摘Polysubstance Abuse (PSA) greatly complicates an attempt to implicate a single drug as sole cause of an overdose death. Since PSA now occurs in the majority of cases of drug overdoses, many or most overdose deaths are polysubstance overdose deaths. And since many of the substances involved in a polysubstance Overdose Death (POD) are Central Nervous System (CNS) depressants, many of which can cause overdose death themselves, or synergistically with opioids, it is somewhat puzzling that prescription opioids have been singled out as the cause of these deaths—without reference to PSA. This is particularly puzzling in light of the fact that the issues of PSA and POD have been recognized and discussed in the literature since at least the 1960’s and before. We therefore here consider the question: are we facing an “opioid” crisis or, instead, a “polysubstance crisis”? And we wonder if the issue has been over-simplified, to the detriment of the individuals affected, and to society more broadly. There is a need for an “agnostic” respiratory stimulant that can reverse polysubstance-induced respiratory depression.
文摘Polysubstance (combinations of substances) abuse and overdose deaths now surpass mono-substance abuse and overdose deaths. Several international and governmental organizations such as the WHO (World Health Organization), CDC (Centers for Disease Control and Prevention), several of the Institutes of the NIH (National Institutes of Health), Regulators, and Enforcement Agencies, among others, track and provide a valuable source of statistical information about drug (prescription and illicit) (mis)use and overdose. The information is disseminated free to stakeholders and the general public for use. Although the numeric presentations of the data are helpful and adequate for professionals, the non-expert and the visual learner often find visual representation more clear and more compelling. With this in mind, the aim of this study was to present polysubstance use and overdose using visual maps of the available data. This article considers the opioids.
文摘Rationale:Delayed post-hypoxic leukoencephalopathy(DPHL)is usually an overlooked condition,which arises as a result of a multitude of reversible and irreversible conditions.Patient’s Concern:A 50-year-old female with a history of epilepsy,who developed DPHL 12 days after respiratory failure secondary to barbiturate toxicity.Diagnosis:DPHL on magnetic resonance imaging of the brain.Interventions:Mechanical ventilation was initiated for respiratory failure and hemodialysis for barbiturate toxicity.Outcomes:The patient developed akinetic mutism due to infirmity and had a residual disability,which led to permanent dependency.Lessons:The diagnosis of DPHL is often delayed or missed,given the rarity of this condition and its inconsistent clinical symptomatology.Diagnostic delay can be avoided by early recognition of the classical“delayed onset”symptoms.
文摘Dear editor,We report a case of a 47-year-old female who presented with a toxic bupropion ingestion leading to cardiac arrest.She initially exhibited a loss of brainstem reflexes in conjunction with burst-suppression pattern on EEG.Burst suppression is an EEG waveform pattern of alternating isoelectric suppressions and high voltage bursts.^([1])
文摘A case is presented of a serious, potentially life-threatening intravenous acetaminophen overdose in a 3-month-old (40 weeks’ post menstrual age),2.3 kgbaby girl. The neonate was scheduled for urgent laser therapy for retinopathy of prematurity. Instead of an intended intravenous Hartmann’s solution bolus of 10 ml·kgˉ1, the neonate received a 17 ml bolus of correctly labelled intravenous 1% acetaminophen. The National Poisons Bureau was immediately contacted for advice and in the absence of data suggested a treatment with N-acetylcysteine for a 24-hour period. Baseline blood samples for clotting, liver function, urea and electrolytes, full blood count and plasma acetaminophen concentration were taken 30 min, 8.25 h, 12.5 h, 18.5 h and 120 h after the overdose. Acetaminophen concentration was 78 mg·Lˉ1 at 30 min, but it was undetectable at any other time. Using a recent and complete PK-PD dataset we are able to show that the measured plasma acetaminophen concentration fits well on PK estimates for acetaminophen in this neonate. The non-detectable (low) plasma acetaminophen concentration at >8 h is also consistent with this model, especially if clearance is slightly increased in the premature nursery graduate. Medical errors are rarely the fault of an individual and they are often due to a combination of factors. Contributing factors, in this case, are described under the following headings: Catalyst event, system fault, loss of situational awareness, and human error.
文摘A paucity of literature exists linking acute extremity compartment syndrome associated with cocaine or olanzapine overdose. LJ, a 38-year male, was initially seen at an outside hospital for acute encephalopathy and left lower extremity swelling shortly after cocaine and suspected olanzapine overdose. On presentation, totalcreatinine kinase levels were >1000 units/liter but quickly rose to 23,000 units/liter after 12 hours. He was transferred to a tertiary care center for surgical evaluation. Upon the exam, it was quickly determined that he had compartment syndrome and he was urgently taken to the operating room for a four-compartment lower extremity fasciotomy. Acute compartment syndrome is a limb threatening condition generally diagnosed clinically. Cocaine, a potent vasoconstrictor, is widely reported to cause rhabdomyolysis from ischemia of skeletal muscle tissue and direct toxicity to myocytes resulting in leakage of creatinine kinase. Other complications including cardiovascular, respiratory, neurological, and gastrointestinal disturbances have also been well documented. Olanzapine, an atypical antipsychotic, has also been reported to cause rhabdomyolysis. However, myositis with lower extremity compartment syndrome is a rare occurrence and requires quick diagnosis and aggressive treatment in order to achieve limb salvage. The potential causality of compartment syndrome from either cocaine, olanzapine, or both will be examined in this case report.
文摘A 22-year-old pregnant female was transferred to the emergency department having ingested a bottle of iron-containing prenatal vitamins, ondansetron (Zofran?) tablets and alcohol. The patient was hemodynamically stable but suffered from intense bouts of brown, sandy emesis for the first few hours. Investigation revealed the patient ingested 13.57 mg/kg of elemental iron. Due to the initial iron level, history and presentation time whole bowel irrigation was initiated with polyethylene glycol solution. Acute iron toxicity in pregnancy is a medical emergency that can result in multisystem organ failure leading to maternal death and potential fetal demise. High maternal serum iron loads do not affect the developing fetus and are not associated with fetal malformations;however advanced poisoning can lead to maternal death, spontaneous abortions or preterm emergency deliveries. Initial treatment strategies may include whole bowel irrigation using polyethylene glycol electrolyte lavage solution and deferoxamine treatment along with necessary supportive care management. Despite concerns of teratogenicity deferoxamine does not cross the placenta and is regarded as safe for use during pregnancy. Maternal resuscitation must always be the primary objective in acute iron overdoses and, therefore such concern should not delay clinically indicated maternal treatment.
文摘Valproic acid is used in the treatment of multiple disorders. Adverse effects from valproic acid include hepatotoxicity, hypotension, metabolic acidosis, and decreased mental status. Valproic acid also causes hyperammonemia. Many physicians assume that this is due to a supratherapeutic valproic acid concentration;when in fact, it can occur with therapeutic valproic acid concentrations. This is because the hyperammonemia may be related to carnitine deficiency and disruption of the urea cycle, which can both occur with therapeutic valproic acid concentrations. We report a patient presented to the emergency department with alteration of mental status after ingesting valproic acid for recreational purposes, who developed hyperammonemia with a therapeutic valproic acid concentration.
文摘The antidepressant venlafaxine in overdose can lead to serotonin syndrome, seizures, QTc interval prolongation and can increase the risk of cardiac arrhythmias. It has been reported to be more toxic in overdose than other new antidepressants. We report a case of venlafaxine intoxication with a venlafaxine/O-desmethylvenlafaxine serum level of 2861/2670 ng/mL 22 h after ingestion. This is one of the so far highest survived venlafaxin serum levels. In contrast to other reported survived venlafaxin overdoses with high serum levels no clinical signs of intoxication were observed in our case. So venlafaxine overdose not necessarily leads to life-threatening signs of intoxication.
文摘We report a near fatal case of paediatric amitriptyline overdose including a series of ECGs demonstrating the effects of sodium bicarbonate therapy on cardio-toxicity. We briefly discuss the role of sodium to counteract the sodium channel blockade of tricyclic antidepressants and discuss the possible utility of lipid emulsion therapy in such cases.
文摘<span style="font-family:Verdana;">The </span><span style="font-family:Verdana;">“</span><span style="font-family:Verdana;">opioid crisis</span><span style="font-family:Verdana;">”</span><span style="font-family:""><span style="font-family:Verdana;"> has had a tremendous impact not only on its victims, but also on the practice of medicine, pain patients, and society in general. Unfortunately, efforts to “stem the tide” have not been successful at reducing overdose deaths. Counterbalancing the many ardent efforts to eliminate overdose deaths (such as the current widespread availability and use of opioid-receptor antagonists such as naloxone) is influx of the illicit fentanoids (</span><i><span style="font-family:Verdana;">i.e</span></i><span style="font-family:Verdana;">., fentanyl and analogs). In addition to their high-potency, the fentanoids differ in surprising ways from more “traditional” opioids such as morphine and heroin. This uniqueness contributes to a reduced effectiveness of opioid receptor antagonists in the treatment of opioid overdose. Further greatly complicating overdose treatment is polysubstance abuse (e.g., an opioid plus a benzodiaze</span><span style="font-family:Verdana;">pine). The non-opioid in the combination is not responsive to an opio</span><span style="font-family:Verdana;">id-recep</span></span><span style="font-family:Verdana;">- </span><span style="font-family:""><span style="font-family:Verdana;">tor antagonist, which imparts additional challenges. Thus, the new reality in</span><span style="font-family:Verdana;">troduces complications that negatively impact efforts to reverse </span></span><span style="font-family:Verdana;">“</span><span style="font-family:Verdana;">opioid</span><span style="font-family:Verdana;">”</span><span style="font-family:""><span style="font-family:Verdana;"> overdose. New approaches to improve outcomes in individuals who experience </span><span style="font-family:Verdana;">respiratory depression due to fentanoid-induced or polysubstance-induced</span><span style="font-family:Verdana;"> over</span></span><span style="font-family:Verdana;">- </span><span style="font-family:Verdana;">dose are needed. Approaches that harmonize with the new reality, perhaps something like a non-opioid </span><span style="font-family:Verdana;">“</span><span style="font-family:Verdana;">agnostic</span><span style="font-family:Verdana;">”</span><span style="font-family:Verdana;"> pharmacologic ventilatory stimulant, would provide a welcome addition to the current choices.</span>
文摘Abuse of drug substances and resultant overdose deaths are no longer very straightforward—viz., attributable to a single chemical entity of known purity. The reality is that most overdose deaths involve polysubstance use (i.e., the use of combinations of substances). Further, the combinations are often of unknown purity, and even of unknown composition. Overdose deaths are at all-time highs. The depressing statistics are monitored and reported by several international and governmental organizations such as the WHO (World Health Organization), CDC (Centers for Disease Control and Prevention), several Institutes of the NIH (National Institutes of Health), Regulators, and Enforcement Agencies (e.g., DEA). The information is disseminated for free for review and use. But it is our observation that although numeric presentation is helpful and adequate for professionals, the non-expert and the visual learner often find a visual representation clearer and compelling. With this in mind, we present the “gestalt” of polysubstance use and overdose using available maps of the data. The previous article in the series considered the opioids. This one considers amphetamines and cocaine, and places the rise in opioid-associated overdose deaths in the context of other abused drugs.
文摘Paroxetine is a selective serotonin reuptake inhibitor(SSRI)used in the treatment of depression and anxiety disorders.In some epidemiological studies,slightly increased risks of major malformations and cardiac malformations have been reported following paroxetine exposure in the first trimester of pregnancy.However,such findings have been inconsistent.There is only one report of any overdose of an SSRI during pregnancy,and that involved escitalopram.The aim of this case report was to describe the impact of a paroxetine overdose in the first trimester of pregnancy on the health of the foetus.A 21-year-old mother of one child who was pregnant with a second child was prescribed 20 mg/day paroxetine hydrochloride for the treatment of anxiety/depression.The patient ingested 15 or 1620-mg tablets of paroxetine hydrochloride(300-320 mg)during the 5th week of pregnancy as a suicide attempt.Within 15 min of ingestion,she was admitted to hospital and treated for intoxication.No evidence of maternal SSRI intoxication was observed after treatment.The patient consulted our teratology information service for further risk assessment regarding possible major congenital malformations following the paroxetine overdose.We were unable to find previous reports of paroxetine overdose during pregnancy in the literature.The timely administration of the overdose treatment and the lack of maternal intoxication symptoms were considered positive for the foetal well-being,and the patient was referred for perinatology and psychiatry follow-ups.A healthy,3500-g male infant was born at 38 weeks’gestation,and his development at the age of 2 years was normal.This is the first reported case of paroxetine overdose during pregnancy.Comprehensive studies are needed to evaluate pregnancy outcomes after SSRI overdose.
文摘Background and Aims:Acetaminophen(APAP)is the leading cause of drug overdose and hepatotoxicity worldwide,including in Thailand.Patterns of overdose and hospital management are known to have significant impacts on the outcomes of APAP overdose,and these factors vary from country to country.Therefore,this study aimed to analyze clinical characteristics of Thai patients with APAP overdose in terms of overdose patterns,clinical presentation,treatment and outcomes.Methods:In this retrospective analytical study,medical records of adult patients hospitalized with a diagnosis of APAP overdose at Rajavithi Hospital,Bangkok,between January 2013 and December 2017 were reviewed.Results:A total of 184 patients diagnosed with APAP overdose were included.The median age was 22(15–76)years and the majority were female(79.9%).Most overdoses were intended self-poisoning ingestion(90.8%)with a median dose of 10.5 g(4.5–50).A total of 121 patients were treated with N-acetylcysteine with a median visit-to-N-acetylcysteine time of 2(0.5–15)h.Overall,15.6%developed mild hepatotoxicity(aspartate aminotransferase or alanine aminotransferase>3 times the upper limit of normal),6.4%developed severe hepatotoxicity(aspartate aminotransferase or alanine aminotransferase>10 times the upper limit of normal and international normalized ratio>2.0)and 3 patients developed acute liver failure(1 patient resolved spontaneously and 2 patients,neither of whom had a liver transplant,died).Significant predictors for hepatotoxicity included older age,chronic alcohol drinking,repeated taking of medication for more than 8 h(staggered ingestion),long duration between ingestion and hospital visit,alcohol coingestion,abdominal pain symptoms,and acute kidney injury.Conclusions:Most cases of APAP overdose in Thailand appear to be young women with intentional ingestion.With prompt management,most patients(76.4%)did not develop significant hepatotoxicity;nevertheless,despite N-acetylcysteine therapy,hepatotoxicity including acute liver failure was observed in a small proportion of patients,particularly those with unintentional overdose and chronic alcohol drinking.
文摘Objective:To investigate the effects of coconut water intake on lipid profile and atherogenic predictor indices of albino rabbits overdosed with paracetamol using standard methods.Methods:Thirty-five albino rabbits weighing between 800-1200 g and aged between 2 and 3 months,were divided into 7 groups(I-VII)of 5 animals each.Groups I,II and III were orally administered distilled water(20 mL/kg body weight),coconut water(20 mL/kg body weight)and paracetamol(1000 mg/kg body weight)respectively,for 7 days.Groups IV and V were administered coconut water(20 mL/kg body weight)and silymarin(35 mg/kg body weight),respectively,for 6 days,then paracetamol(1000 mg/kg body weight)on the 7th day.Groups VI and VII were administered distilled water for 6 days,paracetamol on the 7th day,then coconut water and silymarin,respectively,after 3 h.Results:The results showed that paracetamol overdose significantly reduced(P<0.05)the mean body weight of the animals,increased the concentrations of serum total cholesterol,triacylglycerol,very low density lipoprotein cholesterol,low density lipoprotein cholesterol and the atherogenic predictor indices but reduced the serum high density lipoprotein cholesterol concentration of the animals relative to the control.The observed changes in the lipid profile and atherogenic predictor indices were countered more by post-than pre-treatment with coconut water and silymarin.Conclusions:The results indicated that coconut water acted as an effective antidote to paracetamol overdose-induced lipid abnormality in animals.
基金The authors wish to acknowledge the following individuals and organizations whose efforts contributed to the success of this project:Diana Schell,Oakland County Medical Examiner Forensic Pathologists,NMS Laboratories,and Michigan State University Department of Epidemiology’s T‑32 Lab.
文摘Carfentanil,an ultrapotent analog of fentanyl,has invaded the street drug market,unbeknownst to many heroin users.About 10,000 times more potent than morphine,it was initially suspected that 20μg of the substance was lethal.In this case series,we present 17 confirmed carfentanil overdoses in Michigan,with a primary focus on the concentration levels.Through a retrospective review,each public death reported in Oakland County,Michigan,with a subsequent toxicology report was investigated for suspected carfentanil use.To characterize each fatality,the autopsy results were collected,including the postmortem findings at scene and the decedent’s medical and social history.Carfentanil levels were measured through liquid chromatography and tandem mass spectrometry(LC-MS-MS)by National Medical Services(NMS)Laboratories.Our case series found postmortem carfentanil concentrations as low as 10 ng/mL,with a mean concentration of 0.387 ng/mL.Ultimately,there are implications on law enforcement,first responders,and health care providers when dealing with this emerging illicit substance,and there is an alarmingly high mortality rate associated with the abuse of carfentanil.
基金supported by the Scientific Research Foundation for the Returned Overseas Chinese Scholars,State Education Ministry[(2013)1792]Training Programmers Foundation for the Beijing Talents(2013D002023000002).
文摘Suicidal drug overdose is a major public health issue.In the United States,every year more than 33,000 people commit suicides.Our study focused on the characteristics of suicide victims in the state of Maryland.Material and methods:This study was a retrospective review of autopsy cases of all suicide deaths caused by drug(s)or drug(s)with alcohol intoxication investigated by the OCME in Maryland over a 7-year period from January 2004 to December 2011.All deaths investigated by the OCME that require autopsy examination are subject to comprehensive toxicology testing for drugs and alcohol.The screen tests were performed using gas chromatography(GC)and radioimmunoassay techniques.All detected drugs and/or metabolites were confirmed using GC-mass spectrometry(GC-MS).Results:From 2004 to 2011,434 deaths were certified as suicide.Of the 434 suicidal overdose deaths,84%were white,11%were African-American,and about 5%were either Hispanic or Asian.The male and female ratio was almost equal.Their ages ranged 15-82 years.Of the 434 suicidal drug overdose deaths,277 victims(63.8%)consumed a single drug type and 157(36.2%)consumed more than one type of drug.Of the 277 single-drug overdose cases,71.1%suicides were due to prescription drugs,23.5%due to over-the-counter drugs,and 5.4%due to street/recreational drugs.Among single-type prescription drugs,analgesic(N=76),antidepressant(N=45),and neuroleptic(N=35)classes were the three leading type of drugs used in suicidal deaths.Oxycodone,morphine,quetiapine,and amitriptyline were the most common prescription drugs in suicidal overdose.Diphenhydramine was the leading over-the-counter drug.Of the 157 victims who consumed more than one drug,combined prescription drugs were present in 54.1%,mixed prescription and overthe-counter drugs in 29.3%,and prescription drugs/over-the-counter drugs and street drugs in 16.6%of cases.Of the multiple-drug overdose suicides,66.2%cases involved antidepressants.Discussion:Suicide is found in every age,racial,and ethnic group.In the USA,poisoning is thethird-leading method of suicide,following firearm injuries and hanging/strangulation.Our study indicates that prescription drugs,such as those in the opioid analgesic,neuroleptic,and antidepressant class(e.g.,oxycodone,morphine,quetiapine,amitriptyline,doxepin,and citalopram),are of special concern in the context of suicidal overdose deaths in the state of Maryland.Therefore,addressing the problems of intentional drug overdose in our society is worthy of public attention.
文摘BACKGROUND Dextromethorphan is a prevalent antitussive agent that can be easily obtained as an over-the-counter medication.There has been a growing number of reported cases of toxicity in recent years.Generally,there are numerous instances of mild symptoms,with only a limited number of reports of severe cases necessitating intensive care.We presented the case of a female who ingested 111 tablets of dextromethorphan,leading to shock and convulsions and requiring intensive care that ultimately saved her life.CASE SUMMARY A 19-year-old female was admitted to our hospital via ambulance,having overdosed on 111 tablets of dextromethorphan(15 mg)obtained through an online importer in a suicide attempt.The patient had a history of drug abuse and multiple self-inflicted injuries.At the time of admission,she exhibited symptoms of shock and altered consciousness.However,upon arrival at the hospital,the patient experienced recurrent generalized clonic convulsions and status epilepticus,necessitating tracheal intubation.The convulsions were determined to have been caused by decreased cerebral perfusion pressure secondary to shock,and noradrenaline was administered as a vasopressor.Gastric lavage and activated charcoal were also administered after intubation.Through systemic management in the intensive care unit,the patient’s condition stabilized,and the need for vasopressors ceased.The patient regained consciousness and was extubated.The patient was subsequently transferred to a psychiatric facility,as suicidal ideation persisted.CONCLUSION We report the first case of shock caused by an overdose of dextromethorphan.
文摘BACKGROUND:Severe poisoning due to the overdosing of cardiac drugs can lead to cardiovascular failure.In order to decrease the mortality rate,the most severe patients should be transferred as quickly as possible to an extracorporeal membrane oxygenation(ECMO)center.However,the predictive factors showing the need for venous-arterial ECMO(VA-ECMO)had never been evaluated.METHODS:A retrospective,descriptive,and single-center cohort study.All consecutive patients admitted in the largest ICU of Reunion Island(Indian Ocean)between January 2013 and September 2018 for beta-blockers(BB),calcium channel blockers(CCB),renin-angiotensin-aldosterone system blockers,digoxin or anti-arrythmic intentional poisonings were included.ECMO implementation was the primary outcome.RESULTS:A total of 49 consecutive admissions were included.Ten patients had ECMO,39 patients did not have ECMO.Three patients in ECMO group died,while no patients in the conventional group died.The most relevant ECMO-associated factors were pulse pressure and heart rate at first medical contact and pulse pressure,heart rate,arterial lactate concentration,liver enzymes and left ventricular ejection fraction(LVEF)at ICU-admission.Only pulse pressure at first medical contact and LVEF were significant after logistic regression.CONCLUSION:A transfer to an ECMO center should be considered for a pulse pressure<35 mmHg at first medical contact or LVEF<20%on admission to ICU.
