A 66-year-old male with chronic alcoholism presented with tremor, gait disturbance, memory impairment, insomnia, decreased appetite, and confusion. The patient had been taking lithium daily for treatment of bipolar disorder. Brain CT showed no specific abnormality, and serum lithium and ammonia levels were 3.63 mEq/L (therapeutic range, 0.6~1.2 mEq/L) and 85microg/dL (reference range: 19~54microg/dL), respectively. Therefore, the initial differential diagnosis included chronic lithium intoxication, hepatic encephalopathy, Wernicke encephalopathy, or alcohol withdrawal syndrome. Even with the provision of adequate hydration, the patient's neurologic status did not show improvement, so that lactulose enema, thiamine replacement, and continuous venovenous hemodiafiltration (CVVHDF) were started on the third admission day. By the fifth admission day he had made a rapid neurologic recovery, and was discharged on the 20th admission day. Therefore, CVVHDF might be a treatment for patients with chronic lithium intoxication, because, even if serum lithium concentration is normal, lithium concentration in the brain may be different from that of the serum.
Aged ; Alcoholism ; Ammonia ; Appetite ; Bipolar Disorder ; Brain ; Diagnosis, Differential ; Enema ; Gait ; Hemodiafiltration ; Hepatic Encephalopathy ; Humans ; Lactulose ; Lithium ; Male ; Memory ; Sleep Initiation and Maintenance Disorders ; Thiamine ; Tremor ; Wernicke Encephalopathy

Zoletil is a non-opioid, non-barbiturate animal anesthetic and proprietary combination of two drugs, a dissociative anesthetic drug, tiletamine, with the benzodiazepine anxiolytic drug, zolazepam. Zoletil has greater potency than ketamine. Zoletil is abused for recreational purposes, especially by people with easy access to medicine. However, in Korea, it is available over-the-counter. Here we report on a case of an 83-year-old woman who received injection of seven vials of "Zoletil 50" by her daughter and presented with an altered mental change. Her mental state was stupor and vital sign was hypotension, bradycardia. Her blood tests indicated metabolic and respiratory acidosis and hyperkalemia. She was treated with intravenous naloxone and flumazenil but was not responsive. She was admitted to the ICU and treated with supportive therapy. Her mental state showed transient recovery, however, her clinical manifestation worsened and she expired.
Acidosis, Respiratory ; Aged, 80 and over ; Animals ; Benzodiazepines ; Bradycardia ; Drug Combinations ; Female ; Flumazenil ; Hematologic Tests ; Humans ; Hyperkalemia ; Hypotension ; Ketamine ; Korea ; Naloxone ; Nuclear Family ; Stupor ; Tiletamine ; Vital Signs ; Zolazepam

Dextromethorphan and chlorpeniramine are common ingredients of over-the-counter (OTC) cough pills. They are known to be safe when used alone, however, combination with other serotonergic drugs or use of an overdose can cause serotonergic toxicity. We report on a 43-year-old male and a 57-year-old female who ingested an overdose of antitussive drugs containing dextromethorphan and chlorpeniramine. They commonly presented with altered mentality and hyperreflexia on both upper and lower extremities. After conservative therapies, they were discharged with alert mentality. These cases are meaningful in that there are few cases of serotonin syndrome with an overdose of a combination of dextromethorphan and chlorpeniramine. Careful use with medication counseling for OTC cough pills is needed in order to prevent overdose of these ingredients.
Adult ; Antitussive Agents ; Cough ; Counseling ; Dextromethorphan ; Female ; Humans ; Lower Extremity ; Male ; Middle Aged ; Reflex, Abnormal ; Serotonin ; Serotonin Agents ; Serotonin Syndrome

PURPOSE: Antidotes for toxicological emergencies can be life-saving. However, there is no nationwide stocking and delivery system for emergency antidotes in Korea. We report on a two-year experience of a nationwide stocking and delivery trial for emergency antidotes at emergency departments in Korea. METHODS: An expert panel of clinical toxicologists reviewed and made a list of 15 stocked antidote. These antidotes were purchased or imported from other countries and delivered from 14 antidote stocking hospitals nationwide 24 hours per day, seven days per week. RESULTS: From August 1, 2011 to April 30, 2013, 177 patients with acute poisoning, with a median age of 48.5 years, were administered emergency antidotes. The causes of poisoning were intentional in 52.0% and 88.0% were intentional as a suicide attempt. Regarding clinical severity, using the poisoning severity score, 40.7% of patients had severe to fatal poisoning and 39.0% had moderate poisoning according to clinical severity. The most frequent presenting symptom was neurologic deficit, such as altered mentality (62.7%). alerted mentality (62.7%). Emergency antidotes were administered as follows: methylene blue (49 cases), flumazenil (31), N-acetylcysteine (25), glucagon (17), 100% ethanol (15), cyanide antidote kit (12), anti-venin immunoglobulin (5), pyridoxine (4), hydroxocobalamine (2), and deferoxamine (1). The median time interval from antidote request to delivery at the patient's bedside was 95 minutes (interquartile range 58.8-125.8). CONCLUSION: Findings of this study demonstrated the possibility of successful operation of the nationwide system of emergency antidotes stocking and delivery in Korea.
Acetylcysteine ; Antidotes ; Deferoxamine ; Emergencies ; Ethanol ; Flumazenil ; Glucagon ; Humans ; Hydroxocobalamin ; Immunoglobulins ; Information Centers ; Korea ; Methylene Blue ; Neurologic Manifestations ; Pyridoxine ; Suicide

Gastric lavage is one of gastrointestinal decontamination methods which have been controversial in the clinical toxicology field for a long time. Expert groups of American and European clinical toxicologists have published the position papers regarding gastric lavage three times since 1997. They recommended that gastric lavage should not be used as a routine procedure in the management of acute intoxication, because they thought that there is no certain evidence of improving clinical outcome by its use. However, the studies they reviewed were not well-controlled randomized trials, which cannot be conducted in the clinical toxicology field due to variability of patients and ethical problems. Therefore, the results from these studies should be interpreted with caution. They also insisted that gastric lavage can be undertaken within 60 minutes of ingestion. The limitation of one hour after ingestion is too arbitrary and may cause a lot of misunderstanding. Formation of pharmacobezoar or gastric hypomotility after ingestion may significantly delay the gastric emptying time so that gastric lavage can be useful even after several hours or more in case of highly toxic substances or severe intoxication. Furthermore, as there are a number of serious intoxication by toxic pesticides with large amount in suicidal attempts in Korea, it seems that gastric lavage may be used more frequently in Korea than in Western countries. When deciding whether or not to use gastric lavage, all the indications, contraindications, and possible adverse effects should be taken into account on the basis of risk-benefit analysis. If the procedure is decided to be done, it should only be performed by well-trained experts.
Decontamination ; Eating ; Gastric Emptying ; Gastric Lavage ; Humans ; Korea ; Pesticides ; Toxicology

Veratrum patulum has toxicological relevance because of the potential for misidentification of this plant as mountain garlic. Veratrum patulum has an ester-alkaloid that provokes cardiac arrhythmias by excessive vagal stimulation and depression of the sinoatrial and atrioventricular nodes of the heart and hypotension, cardiomegaly. We report on a retrospective case of successful outcome in patients with veratrum patulum poisoning through active treatment from the early phase after ingestion. We report on a case involving a patient who experienced dizziness, dyspnea, hypotension, and elevation of cardiac enzyme, cardiomegaly. These cases were kept under observation and generally recovered with supportive care. We report on cases of veratrum patulum poisoning with review of literature.
Arrhythmias, Cardiac ; Atrioventricular Node ; Cardiomegaly ; Depression ; Dizziness ; Dyspnea ; Eating* ; Garlic ; Heart ; Humans ; Hypotension ; Plants ; Poisoning ; Retrospective Studies ; Veratrum*

PURPOSE: The purpose of this study is to evaluate the effectiveness and the adverse events of high dose insulin/euglycemia therapy in acute calcium channel blocker (CCB) poisoning. METHODS: We developed a systematic search strategy and applied it to 4 electronic reference databases. We searched medical journals as well as the bibliographies of relevant articles. All forms of literature relevant to human use of high dose insulin for acute CCB poisoning were included. The literature search was conducted by two investigators in August, 2015 with publication language restricted to English and Korean. Case reports were divided between CCB overdose alone and multi-drug overdose including CCB. The effect and adverse event of high dose insulin and clinical outcome of each case were analyzed. RESULTS: Among 55 searched studies, 20 studies were included. A prospective study, a retrospective study, a systematic review study, and 17 case reports were identified. Case reports consisted of 11 CCB alone and 12 multidrug overdose cases including CCB. Although most cases described significant clinical improvements, one of them showed no beneficial effect. Several adverse events including hypoglycemia and hypokalemia were reported. No significant sequalae from adverse events was reported. CONCLUSION: Although there were many case reports demonstrating successful use of high dose insulin for CCB poisoning, the effect cannot be estimated due to a possibility of publication bias. Therefore, high dose insulin/euglycemia therapy might be considered adjunctive therapy in cases of CCB intoxication refractory for standard therapy.
Calcium Channel Blockers ; Calcium Channels* ; Calcium* ; Humans ; Hypoglycemia ; Hypokalemia ; Insulin ; Poisoning ; Prospective Studies ; Publication Bias ; Publications ; Research Personnel ; Retrospective Studies

PURPOSE: Drug overdose is easily found in the emergency department (ED). Sedative-hypnotics overdose causes the aspiration pneumonia in patients with decreased mental status. The purpose of this study was to investigate the risk factors of aspiration pneumonia in patients poisoned with sedative-hypnotics. METHODS: One hundred seventy eight patients who were poisoned with sedative-hypnotics and who visited ED between 2009 and 2015 were included. This study was conducted retrospectively, with collection of data by review of medical records. We collected the data concerning the characteristics of patients and classified them into two groups based on the development of aspiration pneumonia. Logistic regression analysis was performed to investigate the factors for the development of aspiration pneumonia. RESULTS: Thirty five patients had an aspiration pneumonia during their hospital stay in 178 patients. The age, amount of ingestion, Glasgow Coma Scale (GCS) score at admission, a history of hypertension and diabetes mellitus, and the hypotension at admission were significantly different between two groups in univariate analysis. The age, amount of ingestion and GCS score at admission were associated with the development of aspiration pneumonia in the multivariate logistic regression analysis (OR 1.028 (95%CI, 1.002-1.056, p=0.037), 1.026 (95%CI, 1.004- 1.043, p=0.001), 0.737 (95%CI, 0.683-0.915, p=0.002)). All patients with aspiration pneumonia were discharged without a sequelae. CONCLUSION: The development of aspiration pneumonia in the patients of sedative-hypnotics overdose is associated with old age, amount of drug ingestion, and GCS score at admission.
Diabetes Mellitus ; Drug Overdose ; Eating ; Emergency Service, Hospital ; Glasgow Coma Scale ; Humans ; Hypertension ; Hypnotics and Sedatives ; Hypotension ; Length of Stay ; Logistic Models ; Medical Records ; Pneumonia, Aspiration* ; Retrospective Studies ; Risk Factors

PURPOSE: We investigated comparison of clinical characteristics and prognosis by initial endoscopic severity in caustic injury and then discussed predisposing factors which can be helpful in predicting the prognosis and determining the treatment. METHODS: This study was a retrospective review of medical records from patients over the age of 15, who underwent initial endoscopy for caustic injury from April 2007 through November 2014. Patients were classified according to two groups based on the initial endoscopic finding by Zargar's classification: patients with grade 0, I, IIa at esophagus (low risk group) and patients with grade IIb, IIIa, IIIb at esophagus (high risk group). The two groups were then compared. RESULTS: A total of 55 patients were included (low risk group [n=44] vs. high risk group [n=11]). Old age (p<0.001), large amount of ingestion (p<0.05), oropharyngeal symptoms (p<0.01), high SOFA score (p<0.001), high WBC count (p<0.05), low base excess (p<0.01), and HCO3 (p<0.05) were statistically significant factors in the high risk group. A poor prognosis was observed for hospital stay (p<0.001), ICU admission (p<0.001), mortality (p<0.01), and stricture (p<0.001) in the high risk group. CONCLUSION: Clinical characteristics including age, amount of ingestion, oropharyngeal symptoms, SOFA score, WBC count, base excess, and HCO3 can be helpful in the decision to undergo initial endoscopy and risk assessment by initial endoscopic severity can be helpful in predicting prognosis and determining the treatment plan.
Causality ; Caustics ; Classification ; Constriction, Pathologic ; Eating ; Endoscopy ; Esophagus ; Humans ; Length of Stay ; Medical Records ; Mortality ; Prognosis* ; Retrospective Studies ; Risk Assessment ; Toxicology

PURPOSE: The purpose of this study is to understand what kinds of chemical substances have been used annually and to investigate incidents that occurred due to chemical hazard release and to analyze statistically clinically chemical injury patients who visited one regional emergency medical center in Gumi city with documented references review. METHODS: Annual chemical waste emission quantity (Kg/Year) (Cwep) was reproduced using national web site data governed by the Ministry of Environment and 5 years (from 1 .Jan. 2010 to 31. Dec. 2014) of medical records of chemical injury patients who visited our emergency department were reviewed retrospectively. By applying exclusion criteria, 446 patients of 460 patients were selected. RESULTS: Dichloromethane, Toluene, Trichloroethylene, and Xylene were always included within Top 5 of Cweq. Six cases of chemical incidents were reported and in 3 of 6 cases involving Hydrogen fluoride were included during the study period. Male gender and twenties were the most prevalent group. Injury evoking chemicals were Hydrogen fluoride, unknown, complex chemicals (over 2 substances) in sequence. The most frequent site of wounds and injuries was the respiratory tract. Gas among status, intoxication among diagnosis, and discharge among disposition was most numerous in each group. CONCLUSION: There have been no uniform clinical protocols for chemical wounds and injuries due to various kinds of chemicophysical properties and ignorance of antidotes. Therefore conduct of a multicenter cohort study and experiments for ruling out chemicals according to chemicophysical priority as well as development of antidotes and clinical protocols for chemical injury patients is needed.
Antidotes ; Chemical Hazard Release* ; Clinical Protocols ; Cohort Studies ; Diagnosis ; Emergencies* ; Emergency Service, Hospital* ; Gyeongsangbuk-do ; Humans ; Hydrofluoric Acid ; Male ; Medical Records ; Methylene Chloride ; Respiratory System ; Retrospective Studies* ; Toluene ; Trichloroethylene ; Wounds and Injuries ; Xylenes