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Bupropion inhibits the uptake of dopamine and norepinephrine. Clinical effects in overdose include seizure, status epilepticus, tachycardia, arrhythmias, and cardiogenic shock. We report two cases of severe bupropion toxicity resulting in refractory cardiogenic shock, cardiac arrest, and repeated seizures treated successfully. Patients with cardiovascular failure related to poisoning may particularly benefit from extracorporeal membrane oxygenation (ECMO). These are the first cases of bupropion toxicity treated with veno-arterial EMCO (VA-ECMO) in which bupropion toxicity is supported by confirmatory testing. Both cases demonstrate the effectiveness of VA-ECMO in poisoned patients with severe cardiogenic shock or cardiopulmonary failure., Competing Interests: Compliance with Ethical Standards Conflicts of Interest All authors have no conflicts of interest nor financial stake to disclose. Informed Consent Consent for publication of these cases was obtained and provided to the journal in accordance with JMT policy. Sources of Funding None

Introduction: A patient with chronic lithium toxicity developed a life-threatening ventricular arrhythmia that resolved during removal of lithium by hemodialysis. Chronic lithium toxicity commonly results from diminished elimination and can produce neurotoxicity. Cardiovascular complications have been reported and generally affect the sinoatrial node and produce bradyarrhythmias. The majority of these arrhythmias require no emergent intervention. Ventricular arrhythmias associated with lithium toxicity are occasionally mentioned in the literature, but actual cases are rarely reported., Case Report: A 74-year-old man was brought into the emergency department with a 3-day history of progressive encephalopathy, tremor, and weakness. The lithium level was elevated at 2.2 mmol/L, with a normal serum potassium. Electrocardiography revealed nonsustained monomorphic ventricular tachycardia (120-130 beats/min) lasting up to 1 min, alternating with sinus bradycardia and wandering atrial pacemaker. Episodes of monomorphic ventricular tachycardia recurred >100 times. The patient required a norepinephrine infusion for hypotension. Emergent hemodialysis was initiated to remove lithium and to treat the monomorphic ventricular tachycardia, which was felt to be secondary to lithium toxicity. Episodes of monomorphic ventricular tachycardia abated as hemodialysis progressed. The episodes resolved completely within 4 h of initiating hemodialysis. The patient was discharged home in sinus rhythm on day 5. Lithium was not reinstated., Conclusion: Monomorphic ventricular tachycardia associated with chronic lithium toxicity is exceptionally rare. Hemodialysis is a treatment option.

Introduction: North American rattlesnake envenomations typically result in local tissue injury and hematologic derangements. Neurotoxicity is uncommon but when present often manifests as fasciculations and paresthesias. Neurotoxicity following Sidewinder (Crotalus cerastes) envenomation has not been previously reported., Case Report: A 56-year-old man bitten on the right foot developed painful paresthesias, weakness and fasciculations of the right lower extremity, and involuntary muscle contractions of the anterior thigh. Local tissue effects and hemotoxicity never developed. The patient was discharged 5 days after the bite with resolution of fasciculations but continued to have right-sided weakness. The snake was identified as a Sidewinder, C. cerastes, by the patient and two independent herpetologists., Conclusion: This is the first reported case of a Sidewinder rattlesnake envenomation resulting in neurotoxicity.

Approximately 100 of the known species of mushrooms are poisonous to humans. New toxic mushroom species continue to be identified. Some species initially classified as edible are later reclassified as toxic. This results in a continually expanding list of toxic mushrooms. As new toxic species are identified, some classic teachings about mycetism no longer hold true. As more toxic mushrooms are identified and more toxic syndromes are reported, older classification systems fail to effectively accommodate mycetism. This review provides an update of myscetism and classifies mushroom poisonings by the primary organ system affected, permitting expansion, as new, toxic mushroom species are discovered.

Unlabelled: Africanized honeybees (Apis mellifera scutellata) are now found in the southern and southwestern United States. Swarmings can result in hundreds to thousands of stings delivering a venom load capable of producing multisystem organ failure and death. The literature on mass envenomations is scarce, being limited to case reports and case series. There are no prospective studies on mass envenomations in children., Methods: All patients were admitted to our toxicology service, and all stingers were counted. Laboratory data and clinical assessments were obtained at baseline, 8, and 16 hours after presentation., Results: Nineteen patients with a median age of 3.6 years and a median of 2.64 stings per kilogram (range, 1-4.5) were enrolled. Fifteen children had vomiting. Only a mild increase in creatine kinase was seen. None developed coagulopathy or renal insufficiency., Conclusion: Envenomations of up to 4.5 stings per kilogram resulted in only mild systemic illness. Vomiting does not portend involvement of other organ systems.

The purpose of this report is to describe an unusual presentation of anaphylaxis after first-time rattlesnake envenomation. A patient on a medical toxicology inpatient service is presented who had signs of anaphylaxis, including airway compromise, after first-time rattlesnake envenomation. An epinephrine drip and oral intubation were initiated. This case is unusual in that dermal and gastrointestinal exposure may have been the primary sensitization process that preceded a severe anaphylactic reaction after envenomation. The patient's recovery was prolonged. In conclusion, rattlesnake envenomation may result in rapidly progressive airway compromise, possibly caused by anaphylaxis in patients with previous dermal or gastrointestinal exposure to snake proteins.

Respiratory compromise after rattlesnake envenomation (RSE) is an uncommon yet potentially lethal complication. We were interested in determining the frequency of respiratory compromise in patients treated for RSE. The incidence and indications for intubation were also determined. A retrospective chart review was conducted of all patients treated by medical toxicologists at a tertiary referral hospital between July, 1994 and November, 2000. Out of 294 total patients, 289 charts were reviewed. Of all 289 patients, 214 (74%) received Crotalidae Polyvalent Antivenin (Wyeth-Ayerst) and 23 (8%) had clinical evidence of respiratory compromise. Thirteen of 289 patients (4.4%) were intubated following RSE. No one was intubated for antivenin-induced complications. There were no deaths among studied patients during acute hospitalization. Respiratory compromise following RSE is rare, occurring in only 8% of studied patients. Only 2 patients (0.7%) required intubation as a direct consequence of RSE. No one required intubation for antivenin-induced hypersensitivity reactions.

Study Objective: We describe our postmarketing experience with patients receiving Crotalidae polyvalent immune Fab (CroFab; FabAV) antivenom for treatment of rattlesnake envenomation., Methods: The charts of 28 patients admitted between March 1 and September 9, 2001, with rattlesnake envenomation and treated with FabAV were reviewed for demographic information, time until antivenom treatment, laboratory findings, evidence of hypersensitivity reaction, length of hospital stay, and readmission to the hospital., Results: All patients had swelling, 20 patients had elevated prothrombin times (>14 seconds), 12 patients had low fibrinogen levels (<170 mg/dL), and 6 patients had thrombocytopenia (platelet count <120,000/mm(3)) on presentation. The total dose of FabAV ranged from 10 to 47 vials per patient. Hypofibrinogenemia was resistant to FabAV in some patients. On follow-up, recurrence of coagulopathy was detected in 3 patients, and recurrence of thrombocytopenia was detected in 1 patient. Two patients demonstrated delayed-onset severe thrombocytopenia. Recurrence or delayed-onset toxicity might have been underestimated because of incomplete follow-up in some patients. No acute hypersensitivity reactions occurred. Two patients reported mild symptoms of possible serum sickness on follow-up., Conclusion: FabAV effectively controlled the effects of envenomation; however, initial control of coagulopathy was difficult to achieve in some cases, and recurrence or delayed-onset hematotoxicity was common. When initially managing hematotoxicity, a trend toward normalization of laboratory values might be a more reasonable end point for FabAV treatment than attainment of normal reference values in nonbleeding patients.

Objective: To determine whether intravenous (IV) hypertonic sodium bicarbonate is effective in the reversal of QRS widening associated with severe Taxus intoxication., Methods: Seventeen anesthetized and instrumented swine were poisoned with an IV extract of Taxus media until doubling of the QRS interval on electrocardiography was achieved. After poisoning (time zero), the animals received either 4 mL/kg IV 8.4% sodium bicarbonate (experimental group; 6 animals), a similar volume of 0.7% NaCl in 10% mannitol (mannitol group; 6 animals), or nothing (control group; 5 animals). The main outcome parameter was QRS duration. Secondary outcome parameters were mean arterial pressure (MAP), heart rate (HR), and cardiac index (CI = cardiac output/kg). Additionally, arterial pH, partial pressure of carbon dioxide (pCO(2)), and plasma-ionized calcium, sodium, and potassium were monitored., Results: Taxus toxicity, defined as a 100% increase in QRS duration, was produced in all animals. The animals were similar in regard to baseline and time 0 physiologic parameters as well as amount of Taxus media extract administered. From times 5 through 30 minutes, following assigned treatment, significant increases in QRS duration were detected in the experimental and mannitol groups compared with the control group. A significant lowering of MAP was found in the experimental group compared with the control group. No significant difference between groups was noted in HR or CI. The swine treated with hypertonic sodium bicarbonate had a statistically significant increase in pH, plasma sodium concentration, and base excess compared with the other groups., Conclusions: Hypertonic sodium bicarbonate was ineffective in reversing the widening of QRS interval associated with Taxus poisoning in this swine model.

Study Objective: Pyridoxine hydrochloride, the antidote for isonicotinic acid hydrazide (INH)--induced seizures, is available in solution at a concentration of 100 mg/mL at a pH of less than 3. Pyridoxine is often infused rapidly in large doses for INH-induced seizures. Effects of pyridoxine infusion on base deficit in amounts given for INH poisoning have not been studied in human subjects. We hypothesized that this infusion would result in transient worsening of acidosis., Methods: We conducted a randomized, controlled crossover trial in human volunteers. Five healthy volunteers (mean age, 35 years; range, 29 to 43 years) were randomized to receive intravenous placebo (50 mL of normal saline solution) or 5 g of pyridoxine (50 mL) over 5 minutes. A peripheral intravenous catheter was established in each arm, and a heparinized venous blood sample was obtained for base deficit at baseline and 3, 6, 10, 20, and 30 minutes after infusion. After at least a 1-week washout period, the volunteers were assigned to the alternate arms of the experiments, thus acting as their own control subjects. Data were analyzed by using the 2-tailed paired t test, controlling for multiple comparisons., Results: No difference was noted between groups at baseline. A statistically significant increased base deficit was noted after the pyridoxine infusion versus control at 3 to 20 minutes but not at 30 minutes (P =.1). Maximal mean increase in base deficit (2.74 mEq/L) was noted at 3 minutes., Conclusion: A transient increase in base deficit occurs after the infusion of 5 g of pyridoxine in normal volunteers.

Rattlesnake envenomations are common in some areas of the United States. Although fatal rattlesnake envenomations are rare and usually preventable, morbidity may be significant. Patients may present with localized edema, hypotension, coagulopathy, or thrombocytopenia. Patients with progressive swelling or severe coagulopathy are typically treated with Crotalidae polyvalent antivenin. We present a series of 4 patients with unusual complications of rattlesnake envenomation to illustrate the wide spectrum of disease that may be encountered. These case presentations include anaphylaxis to rattlesnake venom, an acute airway emergency, progressive and marked edema with a large pleural fluid collection, and death.

Study Objective: This study was conducted to determine whether hypertonic sodium bicarbonate would improve the hypotension associated with severe verapamil toxicity compared with volume expansion., Methods: The study design used a nonblinded acute animal preparation. Twenty-four anesthetized and instrumented swine were poisoned with verapamil delivered at a rate of 1 mg/kg per hour for 10 minutes followed by incremental increases of 1 mg/kg per hour every 10 minutes until the endpoint of a mean arterial blood pressure of 45% of baseline was achieved. Animals alternately received either 4 mEq/kg of hypertonic sodium bicarbonate intravenously over 4 minutes or similar volumes of 0.6% sodium chloride in 10% mannitol (control). The main outcome parameter followed was mean arterial pressure. In addition, physiologic parameters including cardiac output, heart rate, pH, PCO (2), PO (2), plasma ionized calcium, sodium, and potassium were monitored., Results: Verapamil toxicity, as defined by a mean arterial pressure of 45% of baseline, was produced in all animals following an average verapamil infusion dose of 0.6+/-0.12 mg/kg. This dose produced an average plasma verapamil concentration of 728.1+/-155.4 microgram/L, with no significant difference between groups. Swine treated with hypertonic sodium bicarbonate experienced a significant increase in mean arterial pressure (>50%) and cardiac output (>30%) over the first 20 minutes that slowly equilibrated with the control group over the remainder of the experiment. As expected, plasma sodium concentrations were elevated significantly in the sodium bicarbonate group while plasma potassium concentrations were decreased significantly. Finally, there was a significant decrease in plasma ionized calcium concentration in the sodium bicarbonate-treated group compared with controls., Conclusion: Hypertonic sodium bicarbonate reversed the hypotension and cardiac output depression of severe verapamil toxicity in a swine model.

Newer drugs of abuse, such as MDMA, GHB, GBL, 1,4-BD and ketamine, are frequently used in the settings of raves and are often promoted on the internet. The popularity of these agents is increasing; therefore, emergency physicians should become familiar with the clinical presentations and management of the toxicity induced by these agents.

Case Report: We report a 38-year-old man who experienced prolonged toxicity lasting over 16 hours from the time of ingestion of 1/4 ounce of crack cocaine. His illness included status epilepticus, wide and narrow complex bradyarrhythmias, ventricular arrhythmias, and delayed hyperthermia. His bradyarrhythmias were refractory to medicinal intervention and responsive to application of an external pacemaker. The patient recovered to his baseline state over the ensuing 48 hours.

Unlabelled: A previous study reported that the co-infusion of IV sodium thiosulfate (STS) with sodium nitroprusside (SNP) to near-term gravid ewes prevented both maternal and fetal cyanide toxicity. We questioned whether maternally administered STS crossed the ovine placenta to enhance fetal transulfuration of cyanide, or whether the fetus was dependent on maternal detoxification of cyanide after diffusion of cyanide into the maternal circulation. Ten anesthetized, near-term gravid ewes underwent hysterotomies with delivery of fetal heads for venous catheterization. Five control ewes received IV isotonic sodium chloride solution, whereas five experimental ewes received IV STS (50 mg/kg over 15 min). Serial plasma thiosulfate concentrations in ewes and fetuses were measured over 135 min. Areas under the time-plasma thiosulfate concentration curves were calculated for experimental and control ewes at 2758+/-197 and 508+/-74 min x mg(-1) x L(-1), respectively (P < 0.008). Mean areas under the curve for experimental and control fetuses were 236+/-34 and 265+/-23 min x mg(-1) x L(-1), respectively (P > 0.5). Maternally administered STS may prevent fetal cyanide poisoning from SNP administration without relying on STS crossing the placenta into the fetal circulation. Fetal cyanide may cross down a concentration gradient from fetal to maternal circulation, to be transulfurated to thiocyanate in maternal tissues., Implications: We evaluated the mechanism of action of sodium thiosulfide (STS) in sodium nitroprusside-induced cyanide toxicity in the ewe. Fetal cyanide poisoning is alleviated by maternal administration of STS, although this cyanide antidote apparently does not cross the placenta.

This review is the second of a two-part review of heavy metal toxicity. This part will identify the salient features of the toxicopathophysiology, clinical presentation, and emergency department management of lead toxicity and metal fume fever.

This review is Part I of a two-part series focusing on heavy metal toxicity. Part I will cover arsenic and mercury toxicity. Acute and chronic arsenic toxicity, as well as arsine gas toxicity, will be reviewed. The clinical presentation, with focus on the nervous, cardiovascular, pulmonary, gastrointestinal, hepatic, renal, hematopoietic, and dermatologic systems, is delineated. Mercury exposure, including exposure to short chain alkyl mercury, elemental mercury, and acute inorganic salt, is reviewed. The discussion of clinical toxicity focuses on the nervous, cardiovascular, pulmonary, gastrointestinal, and renal systems, as well as on the teratogenic effects of mercury. Recommendations for diagnostic tests and management plans are discussed, including chelation regimens.

A variety of pearls, pitfalls, and updates related to the extremities and spine are discussed. Tricks of the trade regarding shoulder dislocations, easily missed fractures, radial head subluxation, and the approach to deep lacerations are discussed. In the pitfall section, potential difficulties in the evaluation of suspected nonaccidental trauma, compartment syndromes, partial cord syndromes, and hip pain in children are discussed. Finally, new information regarding cost-effective evaluation of knee and ankle injuries, as well as advances in ultrasound evaluation of shoulder and extremity injuries, is presented in the clinical updates section.

The aminoglycoside, macrolide, tetracycline, and sulfa classes of antibiotics provide antimicrobial coverage pertinent to many infectious diseases diagnosed in the emergency department (ED). The aminoglycosides are parenteral agents that are useful in Gram-negative infections and as synergistic drugs in the management of some Gram-positive infections. The macrolides, of which erythromycin is the prototype, are used for a number of Gram-positive and atypical bacterial infections, while the tetracyclines are appropriate for ED treatment of a diverse group of infections such as chlamydiae, spirochetes, and rickettsiae. The sulfa agents are appropriate for many urinary and respiratory tract infections, and also have particular utility in some infections encountered primarily in patients with AIDS. The urinary antiseptics are a group of antimicrobials that may be effective for cystitis but have no systemic efficacy. This article, which is the second in a four-part series on antibiotic use in the ED, reviews the pharmacology and clinical utility of these diverse agents for the emergency physician.

High specific activity estradiol labeled with iodine-125 was used to detect approximately 200 saturable, high-affinity (dissociation constant approximately equal to 1.0 nM) nuclear binding sites in rat (ROS 17/2.8) and human (HOS TE85) clonal osteoblast-like osteosarcoma cells. Of the steroids tested, only testosterone exhibited significant cross-reactivity with estrogen binding. RNA blot analysis with a complementary DNA probe to the human estrogen receptor revealed putative receptor transcripts of 6 to 6.2 kilobases in both rat and human osteosarcoma cells. Type I procollagen and transforming growth factor-beta messenger RNA levels were enhanced in cultured human osteoblast-like cells treated with 1 nM estradiol. Thus, estrogen can act directly on osteoblasts by a receptor-mediated mechanism and thereby modulate the extracellular matrix and other proteins involved in the maintenance of skeletal mineralization and remodeling.