Neurotoxins, Metals, and Medications

Missed Diagnoses and Misleading Drugs

1. A 59-year-old male undergoes mitral valve surgery. After arrival to the cardiac surgical ICU, he develops shock, rigidity, and an elevated temperature. 2. A 61-year-old woman who lives in a trailer park presents to the ED with abdominal pain and bleeding. There is no clear etiology for either. 3. A 30-year-old man presents to the ED intubated following a seizure. Prior to the seizure, he walked into a police station with a plastic bottle and reported having ingested half of the contents.

1. A 63-year-old man presents with loss of vision and 'fixed dilated pupils.' He is noted to have profound acidemia with elevated lactate, AKI, and hyperammonemia. He is given fomepizole and is hemodialyzed. 2. A 62-year-old man presents to the ED after ingesting diltiazem, acetaminophen, aspirin, bupropion, and amitriptyline in a suicide attempt. While in the ICU he becomes hyperthermic to 107F. 3. A 25-year-old man presents to the ED after he was found seizing in his car. On arrival he is agitated, has a seizure, and is intubated.

1. A 52-year-old woman with a complex past medical history presents to the ED for altered mental status and seizure-like activity. During her hospitalization, she has several cardiac arrests. 2. A 64-year-old man presents with multiple self-inflicted stab wounds, shock, and a possible history of ingestion. He is taken emergently to the operating room, where he develops persistent metabolic acidosis and has a brief cardiac arrest. 3. A 40-year-old male bodybuilder with a history of palpitations presents to the ED in respiratory distress with tachycardia, hypertension, tachypnea, and hypoxia.

1. A 70-year-old man with schizoaffective disorder and a recent viral illness presents to the ED from an assisted living facility with garbled speech, hypotension, and hypothermia. 2. An 80-year-old man with a history of alcoholic cirrhosis admitted for ascites has been on a flumazenil infusion for two weeks. He becomes sedated whenever the infusion is turned off. 3. A 49-year-old woman with a past medical history of schizophrenia presents to the ED with foot pain and altered mental status after recently being discharged from the hospital. Over the next 24 hours she becomes progressively more altered and nonverbal.

ACMT members Gillian Beauchamp, MD, and Elizabeth (Elissa) Moore, DO deliver evidence-based medical toxicology core content and trending topics in easily digestible bites. Visit toxinten.com and follow on Twitter @toxinten.

Kratom Questions

ACMT members Gillian Beauchamp, MD, and Elizabeth (Elissa) Moore, DO deliver evidence-based medical toxicology core content and trending topics in easily digestible bites. Visit toxinten.com and follow on Twitter @toxinten.

This month's topic is On Shaky Ground: Predicting Seizures in Bupropion Toxicity. The articles will be reviewed by the Harvard Medical Toxicology Fellowship Program, led by Dr. Michele Burns.

1. A 65-year-old woman with cerebral palsy presents to the ED with severe facial swelling and scalp irritation after having her hair dyed at a salon two days prior. 2. A 3-year-old boy is found by EMS to have an altered mental status. His finger stick is 43 mg/dL for which glucagon is administered. In the ED his repeat glucose is 65. 3. A 5-year-old boy swallows a cluster of small magnetic balls. Initial endoscopic removal fails, he remains asymptomatic, and he is discharged after passing 1.

Delirium from a Toxicological Perspective