Biomedical subjects
B H Rumack
Publications and source records attributed to B H Rumack.
Cyanide and arsenic poisoning by intravenous injection.
A 29-year-old man was found unresponsive a few minutes after self-injecting undetermined amounts of potassium cyanide and sodium arsenite intravenously in a suicide attempt. Treatment with the Lilly Cyanide Antidote kit rapidly resolved the initial coma, despite a whole blood cyanide level of 4.4 micrograms/mL. A 12-hour urine arsenic collection begun on admission showed 10,065 micrograms arsenic/12 hr. The patient received intramuscular BAL initially, which was followed by two ten-day courses of oral D-penicillamine. Complications included upper gastrointestinal tract bleeding requiring transfusion, transient elevations of liver function tests, self-limited complaints of decreased vision with conjunctival hyperemia and photophobia, and an abscess at the injection site. Although specific antidote therapy completely resolved the cyanide toxicity, early and prolonged arsenic chelation did not prevent a mild sensory peripheral neuropathy from developing with onset about 17 days after self-injection.
Non-aspirin salicylates: conversion factors for estimating aspirin equivalency.
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Hydrofluoric acid dermal exposure.
A retrospective review of 237 consecutive cases of dermal exposure to dilute (6-11%) hydrofluoric acid (HF)- containing rust stain remover consumer products reported to the Rocky Mountain Poison and Drug Center during 1986 was done to evaluate the toxicity of these agents and the efficacy of topical treatment with calcium gluconate gel. In 148 cases (62%), failure to follow manufacturers' recommended safety procedures was the likely cause of exposure. 219 patients developed the following symptoms: dermal swelling, redness, or both (131, 55%); blistering (12, 5%); black discoloration under fingernails (12, 5%); or pain without reported dermal changes (64, 27%). Local complications were noted in 7 cases (3%) (infection, 4 cases; fingertip dermal necrosis, 3 cases). No systemic toxicity was noted. 116 patients (49%) received treatment with topical calcium gluconate gel; 53 were followed until complete resolution of symptoms. There appeared to be a relationship between earlier initial gel application and more rapid resolution of signs and symptoms. Some degree of dermal injury may be quite common following exposure to dilute (6-11%) HF-containing rust stain remover consumer products. Failure to follow manufacturers' recommended safety procedures may be responsible for many exposures. Treatment with topical calcium gluconate gel may be effective, and more rapid resolution of signs and symptoms may occur with earlier initiation of this therapy.
Acute acetaminophen overdose during pregnancy.
During a nationwide acetaminophen overdose study conducted at the Rocky Mountain Poison and Drug Center from 1976-1985, 113 patients entered into the study were reported to be pregnant at the time of the overdose. Follow-up, including appropriate laboratory and pregnancy outcome data, was available in 60 cases. Of these, 19 women overdosed during the first trimester, 22 during the second trimester, and 19 during the third trimester of pregnancy. Of the 24 patients with acetaminophen levels above the acetaminophen overdose nomogram line, ten were treated with N-acetylcysteine within 10 hours post-ingestion; eight delivered normal infants and two had elective abortions. Of ten patients treated with N-acetylcysteine 10-16 hours post-ingestion, five delivered viable infants, two had elective abortions, and three had spontaneous abortions. Of four women treated with N-acetylcysteine 16-24 hours post-ingestion, one mother died, and there was one spontaneous abortion, one stillbirth, one elective abortion, and one delivery. Multiple logistic regression demonstrated a statistically significant correlation between the time to loading dose of N-acetylcysteine and pregnancy outcome, with an increase in the incidence of spontaneous abortion or fetal death when treatment was begun late. We recommend that pregnant women who take an acetaminophen overdose and have a potentially toxic serum level be treated with N-acetylcysteine as early as possible.
Superwarfarin poisoning in children: a prospective study.
This prospective study was undertaken to determine the incidence, severity, time of onset, and duration of coagulopathy in children following accidental ingestion of long-acting anticoagulant rodenticides, often called "superwarfarins." Of 110 children, who ingested superwarfarins and in whom one or more prothrombin time values were obtained, 8 had a prothrombin time ratio (patient to control) of greater than or equal to 1.2, indicative of anticoagulation. Prothrombin time values obtained 48 hours after ingestion were more likely to be prolonged (6/34, 17.6%) than values obtained 24 hours after ingestion (2/104, 1.9%) (P less than .005). The occurrence of an abnormal prothrombin time could not be predicted based on the history of amount ingested or on the presence of the characteristic green-blue product dye in or around the child's mouth. Acute toxicity was evidenced by transient abdominal pain, vomiting, and heme positive stools in 2 patients. The duration of prothrombin time prolongation could not be determined because of the few values obtained after 48 hours. To detect all possible abnormal prothrombin time values, 24- and 48-hour determinations are recommended after a child has ingested a superwarfarin.
Eucalyptus oil: 14 cases of exposure.
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Efficacy of oral N-acetylcysteine in the treatment of acetaminophen overdose. Analysis of the national multicenter study (1976 to 1985)
During the investigational use of oral N-acetylcysteine as an antidote for poisoning with acetaminophen, 11,195 cases of suspected acetaminophen overdose were reported. We describe the outcomes of 2540 patients with acetaminophen ingestions treated with a loading dose of 140 mg of oral N-acetylcysteine per kilogram of body weight, followed four hours later by 70 mg per kilogram given every four hours for an additional 17 doses. Patients were categorized for analysis on the basis of initial plasma acetaminophen concentrations and the interval between ingestion and treatment. Hepatotoxicity developed in 6.1 percent of patients at probable risk when N-acetylcysteine was started within 10 hours of acetaminophen ingestion and in 26.4 percent of such patients when therapy was begun 10 to 24 hours after ingestion. Among patients at high risk who were treated 16 to 24 hours after an acetaminophen overdose, hepatotoxicity developed in 41 percent--a rate lower than that among historical controls. When given within eight hours of acetaminophen ingestion, N-acetylcysteine was protective regardless of the initial plasma acetaminophen concentration. There was no difference in outcome whether N-acetylcysteine was started zero to four or four to eight hours after ingestion, but efficacy decreased with further delay. There were 11 deaths among the 2540 patients (0.43 percent); in the nine fatal cases in which aminotransferase was measured before treatment, values were elevated before N-acetylcysteine was started. No deaths were clearly caused by acetaminophen among patients in whom N-acetylcysteine therapy was begun within 16 hours. We conclude that N-acetylcysteine treatment should be started within eight hours of an acetaminophen overdose, but that treatment is still indicated at least as late as 24 hours after ingestion. On the basis of available data, the 72-hour regimen of oral N-acetylcysteine is as effective as the 20-hour intravenous regimen described previously, and it may be superior when treatment is delayed.
Captopril overdose resulting in hypotension.
We present a case in which a patient took an overdose of captopril (Capoten) and alprazolam (Xanax) in a suicide attempt. The patient presented with hypotension (systolic blood pressure of 80 mm Hg) and drowsiness. The hypotension initially responded to administration of intravenous fluids and dopamine; however, it recurred twice at 18.5 and 24.5 hours after ingestion. These episodes again responded to administration of fluids and dopamine. A plasma captopril level of 27,391.1 nmol/L (5982 ng/mL) was documented, as well as a depressed level of angiotensin converting enzyme. Captopril is an angiotensin converting enzyme inhibitor used in the management of hypertension and ventricular failure; to our knowledge, this is the first case of an acute captopril overdose reported in the English-language literature. The role of captopril in inducing hypotension is discussed herein.
Ethyl alcohol (ethanol)-containing cologne, perfume, and after-shave ingestions in children.
Colognes, perfumes, and after-shaves containing ethyl alcohol (ethanol) are frequently ingested by children. These products may contain from 50% to 99% ethanol. To determine if ingestion of colognes, perfumes, or after-shaves by children results in serious ethanol toxic reactions, this retrospective study was performed. One hundred twenty-three cases of children younger than 6 years old who ingested these products were reviewed. The cases were arbitrarily divided into three groups based on the amount ingested by history. Group 1 included children in whom less than 30 mL was ingested; group 2, 30 to 60 mL was ingested; and group 3, more than 60 to 105 mL was ingested. Of the 102 patients in group 1, no children experienced symptoms or signs. One of 17 children in group 2 was described by parents as sleepy but was asymptomatic one hour later. Two of four children in group 3 behaved as if intoxicated, yet blood ethanol levels were undetectable within 2 1/2 hours after ingestion. Based on our study, asymptomatic children who ingested by history less than 105 mL of a cologne, perfume, or after-shave and remain asymptomatic can be safely watched at home. All children with symptoms of intoxication need health care facility referral.
Five cases of Thermopsis poisoning.
Various Thermopsis species are found in the foothills and plains of the Rocky Mountains. There are no reported cases of human ingestion to Thermopsis reported in the literature. We report 5 cases of ingestion of seeds or flowers where the primary symptoms were nausea, vomiting and headache of several hours duration. As few as 6 seeds produced symptoms. The common names used by parents when calling the poison center could have easily lead to misidentification and a careful history and subsequent professional identification were required to ascertain the actual plant involved.
Cigarette and nicotine chewing gum toxicity in children.
A prospective review of 51 cases of tobacco ingestion and 5 cases of nicotine resin chewing gum exposure was conducted to evaluate the incidence and degree of toxicity caused by these products in children. A dose-response relationship was observed for cigarette exposures. Nine of 10 children ingesting more than one cigarette or three cigarette butts developed signs or symptoms, while 12 of 24 ingesting lesser amounts became symptomatic (P less than 0.01). Severe symptoms (e.g. limb jerking and unresponsiveness) were only seen with the larger amounts. Nicotine resin gum produced toxicity in 4 of 5 children who chewed 1/2 to 4 pieces. Agitation, lethargy, tachycardia, hypotension, abdominal pain, and vomiting were seen within 30 min of exposure to the gum.
Magnesium levels after magnesium-containing cathartics.
To determine the effect on serum Mg++ levels of oral Magnesium-containing cathartics (MgCC) used in the treatment of suspected drug overdose, a prospective, non-randomized study of 24 cases of suspected drug overdose was conducted. Ten cases admitted to the observation unit were assigned to the single dose MgCC group. Fourteen cases admitted to either the ICU or the observation unit were assigned to the multiple dose MgCC group. Single dose cases received 30 gm of magnesium sulfate (MgSO4) at 0 hours. Multiple dose cases received 3 30 gm doses of MgSO4 at 0, 4, and 8 hours. Mg++ levels were measured prior to each MgSO4 dose and 1 and 4 hours after the final dose in both groups. In the single dose group, there was no difference between baseline Mg++ levels and post MgSO4 levels, and only 2/10 developed slightly elevated levels (2.2, 2.3 mEq/L). In the multiple dose group, levels increased and remained significantly higher than baseline after the second MgSO4 dose, and 9/14 developed elevated levels (2.2 to 5.0 mEq/L). All patients who developed elevated Mg++ levels had normal BUN and creatinine values. When the single and multiple dose groups were compared, baseline Mg++ levels were no different (1.68 +/- 0.21 vs 1.69 +/- 0.24, p = 0.952), but peak Mg++ levels were significantly higher in the multiple dose group (1.80 +/- 0.31 vs 2.61 +/- 0.86, p = 0.004). Cases that developed hypermagnesemia had slightly higher baseline Mg++ levels (1.78 +/- 0.22 vs 1.60 +/- 0.19 mEq/L, p = 0.041). In the multiple dose group, higher peak Mg++ levels were noted in cases involving ingestions of anticholinergic or opioid drugs (2.83 vs 1.98, p = 0.025). Hypermagnesemia developed in some cases with normal renal function, blood pressure, and urine output. We conclude that significant hypermagnesemia can occur rapidly after use of multiple dose Mg++ cathartics in standard doses in patients with normal renal function.
Ibuprofen overdose--a prospective study.
Of 61 cases of ibuprofen overdosage reported consecutively to the Rocky Mountain Poison and Drug Center from September 1985 through April 1986, 16 were excluded because of incomplete follow-up or concurrent medication ingestion. A toxic reaction developed in 7 (16%) of the remaining 45 patients. Nausea, vomiting, abdominal cramps, mild central nervous system depression, coma, tachycardia, apnea, metabolic acidosis with or without respiratory alkalosis, hematemesis, and oliguric renal failure were noted. Two of six adults had a toxic reaction, and one died. Among pediatric patients, 5/39 (13%) had a toxic reaction. Of patients whose ibuprofen ingestion was less than 104 mg per kg, none became ill. All patients in whom the time of ingestion was known (six of seven) and who had a toxic reaction did so within four hours of ingestion. An ibuprofen overdose, although usually benign, can occasionally produce serious toxicity.
Severe hypermagnesemia due to multiple-dose cathartic therapy.
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Documenting the activity and effectiveness of a regional drug information center.
The methods of data collection, storage, and retrieval used by the Rocky Mountain Drug Consultation Center (RMDCC) are described. To substantiate that drug information services provided by RMDCC are clinically useful and have a beneficial effect on therapy, data on medication-related problems and case outcomes, as well as demographic data, are stored in an IBM PC-XT using a system that allows searching and linkage of any number of recorded categories. Data were compiled on 28,081 inquiries from health-care professionals and consumers during 1985 and 1986. Analysis revealed that (1) medication-related problems are common (involving 34% of consumer inquiries), especially among the elderly; (2) a positive effect on therapy was made in the majority (76%) of problem cases; and (3) consumers were given drug information by their physician or pharmacist in fewer than half of the cases in which medications were prescribed and dispensed. A computer-based system to assist in analyzing information can be an important asset in documenting the activity and effectiveness of a regional drug information center.
Berry identification using a modified botanic key.
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Clinical effects of accidental levothyroxine ingestion in children.
Forty-one children, aged 1 to 5 years, who accidentally ingested levothyroxine sodium were studied. Symptoms possibly associated with the ingestion occurred in 11 patients (27%). These symptoms (tachycardia, hyperactive behavior, fever, vomiting, diarrhea, diaphoresis, and flushing) were categorized as minor and all resolved without treatment. Because observed effects were generally mild and often unrelated to either estimated amounts of hormone consumed or serum thyroxine levels, a conservative approach to patient treatment is recommended in cases of levothyroxine ingestion in children.