- Email: [email protected]
Methemoglobin and cyanide kinetics in smoke inhalation
more years, nonpre~mnt, a toxic acetaminophen level, and NAC therapy begun at eight or more hours. In even months patients received only standard NAC therapy (NACI, while in odd months patients were also given 300 mg of C IVPB every six hours (C + NAC). In 16 months 80 patients met these criteria for SGOT evaluation. The time until NAC and number of patients with high levels was similar between the groups. Study Group
(C + NAC)
NAC
P
Analysis
1,230 + 807
0.45
t test
Mean peak
SGOT Medianpeak SGOT
1,193 -+ 966 61
Peak SGOTs < 100 Peak SGOTs 100-1,000 Peak SGOTs > 1,000
61
0.42 WilcoxonRS
23
(62%)
23
t53% }
8
(22%)
11
(26%)
6
116%)
9
(21%}
0.73
Xa
1
There were no statistical differences between the C + NAC or NAC groups. When administered later than eight hours after acetaminophen overdose C given IV 300 mg every six hours does not add to the hepatoprotection provided by NAC. Higher doses and earlier administration of C should be studied.
Efficacy of Early Hemoperfusion in the Management of Paraquat Poisoning SM Pond, ECGM Hampson / University of Queensland, Department of Medicine, Princess Alexandra Hospital, Brisbane, Australia Our prospective, controlled study in the dog of the efficacy of repeated hemoperfusion, begun 12 hours after the 1V administration of an LDloo dose of paraquat, showed that the procedure did not reduce mortality. One previously reported study in the dog showed that a single hemoperfusion, performed earlier after a lower, oral dose of paraquat, improved the survival figures. Therefore, we examined the efficacy of a single charcoal hemoperfusion, begun at the end of a two-hour infusion of paraquat dichloride (7.48 mg PQ ion&g) in four dogs (PQ/sHP-group) and compared the results with those from the group given PQ only {PQ group). All of the dogs in the PQ/sHP-group developed the clinical and laboratory manifestations of paraquat toxicity. Only two of the four died, at two and four days, in contrast to four of four in the PQ group. At 12 days the two survivors were clinically normal and on postmortem examination, 18 days after the paraquat dose, there were no significant abnormalities. At the end of the infusion, the plasma paraquat concentrations in the survivors were similar to those in the nonsurvivors and to those in the PQ group. The mean extraction and clearance of paraquat by the hemoperfusion cartridges were 0.6 _+ 0.2 (_+ SD) and 27.5 _+ 11.5 mL/min, respectively. The percentage of the total dose of paraquat adsorbed in the two survivors was 25% and 26%, whereas in the nonsurvivors, it was 6% and 13%. Most of the balance of the dose was excreted in the urine within the first 24 hours. Therefore, single hemoperfusion, begun at the end of a twohour infusion of an LDmo dose of paraquat, reduced mortality by 50%. If extrapolated to patients, the results imply that attempting hemoperfusion within two to four hours of an oral dose of paraquat may be worthwhile. At later time points, the procedure cannot be said to be efficacious.
0
Plumbism in the Children of Young Professionals: Yuppie Lead
JG Linakis, MW Shannon / Massachusetts Poison Control System; The Children's Hospital Lead Treatment Program, Boston We have identified 26 lead (Pb)-intoxicated (blood Pb [PbB] > 25 ~g/dL) children (14% of our clinic population) who were exposed to lead during renovation of older homes owned by the children's parents. In contrast to cases of plumbism that occur in inner-city chil-
19:6June 1990
dren who live in dilapidated housing, these children were all from upper-middle-class families. The mean age of these children was 25.3 months (range, 11 to 63), and their mean PbB at presentation was 39.2 Ixg/dL (range, 26 to 116) with a mean erythrocyte protopophyrin [EP) of 132.8 p~g/dL (range, 21 to 412). They did not display iron {Fe) deficiency (mean serum Fe, 87 ~g/dL; Fe binding capacity, 322 ~g/dL); only one had iron indices below the norms for age. Treatment included IM or IV EDTA (13), and/or d-penicillamine (21). To date, 20 have achieved PbB below 25 ixg/dL, after a mean of 4.2 months of therapy. One patient's pregnant mother also had a markedly elevated PbB. There are several implications of our findings: Renovation of older homes poses a hazard to young children and perhaps to their parents; children suffering from yuppie lead have a better Fe status than low socioeconomic status children; all c h i l d r e n in older h o u s i n g u n d e r g o i n g r e n o v a t i o n s should be screened for lead; and physicians should provide anticipatory guidance to families regarding potential lead sources.
Prediction of Serum TheophylUne Concentration After A c u t e Theophylline Intoxication
MW Shannon, FH Lovejoy Jr, A Woolf / Department of Medicine, Children's Hospital; Department of Pediatrics, Harvard Medical School; Massachusetts Poison Control System, Boston In a retrospective analysis of 52 patients with acute theophylline intoxication (ATHEI), we found that serum potassium (K) and glucose (gin) strongly correlated with admission serum theophylline concentration (theo} when these variables were placed in a multivariate linear regression equation with admission theo as the dependent variable (r = .76; P < .0041. Using the least squares regression equation theo - 141.9 + 0.3215 glu - 44.95 K, we tested our ability to predict theo. Eight patients with ATHEI who had simultaneous measurement of glu, K, and theo were prospectively evaluated. Mean/median admission theos were 43.1/66.5 ~g/mL (range, 38 to 211). K ranged from 2.4 to 3.4 mEq/L while glu was 125 to 325 mg/dL. Measured versus calculated theo had a strong correlation (r = .81; P = .027). The calculated theo correctly predicted the actual theo to be in the range of less than 60 txg/mL, 61 to 80 ~g/ mL, or more than 80 ~g/mL in seven of the eight cases (88%). Our data suggest that prediction of theo with significant accuracy is possible after ATHEI using the above equation. Such information may be beneficial in anticipating management of patients with ATHEI when the theo determination may be delayed.
2
Methemoglobin and Cyanide Kinetics in Smoke Inhalation
M Kirk, K Kulig, BH Rumack / Rocky Mountain Poison and Drug Center, Denver General Hospital, University of Colorado Health Sciences Center, Denver The role and timing of administration of the Lilly Cyanide Antidote Kit® (CAK) in the treatment of smoke inhalation victims remains unclear. We recently treated six smoke inhalation patients with elevated cyanide (CN] levels. Patients received hyperbaric oxygen (HBO) (four), CAK (four), or both t-IBO and CAK (two). We analyzed the results of serial CN and methemoglobin (METHB) levels. Ag~nit CO
Admit CN
H B
C A
TI/2 (h) 0
K
(min)
TIh (h)
(%)
(rain)
1 4.9
3.38
25
3.67
9.2* 7.9*
50 35
2.1 1.6
(%)
I~g/mL
Thne Thne Post Apparent Peak Peak Apparent Exposure CN METHB METHB METHB
+
2 38
3.16
60
2.14
13.4
54
3.7
+
+
3 22 4 29
0.96 1.5
85 120
3.86 2.69
12.4 .
70
3.5
+
+ +
5 32
2.0
72
2.66
+
-
+
-
6 35 2.0 43 *Treated with CAK twice.
Annals of Emergency Medicine
2.94
-
.
. -
. -
627/27
From these limited data it appears that sodium nitrite infusion resulted in lower than expected METHB levels, which occurred 35 to 70 minutes following the nitrite infusion. The slow fall in METHB levels did not appear to be affected by HBO. Concerns about CAKinduced METHB adding to the toxicity of COHB m a y be unfounded.
3
Hydrofluoric Acid in the Automotive Industry= Epidemiology
JM Heard, LK G a r r e r ~ C Siegel / Georgia Poison Control Center, Grady Memorial Hospital, Emory University; DeKalb Medical Center, Atlanta, Georgia In all 22 hydrofluoric acid exposures over an I 1-month period, circumstances of exposure and type of treatment were analyzed. Age distribution was even from 16 to 39 years. Ten of 22 occurred in June and July. Four of the 22 cases were women; one quarter were auto related. The site of exposure could not be determined in four. Fourteen of 18 (78%) occurred at work, with nine of 14 (64%) auto related, two air conditioner cleaners, two rust removers for fa~nc~, and-one jewelry cleaner. Four of 18 (22%) occurred at home, three of four with car products; two of four home exposures occurred with products brought from the workplace. Two of the exposures in unknown locations were with auto products. Thus, 14 of 22 (64%) were with auto products. All reported pain, erythema, or edema. The involved part of the body was: finger(s) only, nine of 22; hand and finger(s), eight; eye, two; abdomen, one; leg, one; arm, one. Eleven (65%) received intra-arterial calcium therapy. Three received subcutaneous and six received topical therapy only. Only one had symptoms suggestive of systemic hypocalcemia. The automotive cleaning products are a major source of hydrofluoric acid exposure. While concentrations are relatively low, exposure is often prolonged and injury may be severe.
4
Subacute Home Chlordane Poisoning: Fact or Fallacy
DA Spyker, RR Bond, M Jylkka, PG Bernad / Pharmaceutical Research Associates Inc, Charlottesville, Virginia; Neurology Services Inc, Fairfax, Virginia Chlordane and heptachlor (C/H), currently the subject of a "no US distribution" agreement between Velsicol and the EPA, has been the termiticide of choice in the US since the 1940s. Due to its chemical stability, C/H persists in approximately 70% of the homes in the US. Unquestionably a potent neurotoxin and animal carcinogen, the frequency and severity of injury from inhalation exposure in the home remains unresolved. We report on 68 of the patients living in 30 domiciles from nine states whom we have examined with a chief complaint of chlordane exposure in their home. Their ages ranged from 2 to 63, with a mean of 33 years. Symptom frequency was headache in 67%, gastrointestinal difficulties 63%, fatigue 62%, m e m o r y deficits 57%, personality changes 54%, decreased attention span 52%, n u m b n e s s or paresthesias 45%, disorientation 36%, loss of coordination 30%, dry eyes 25%, and seizures 8%. EMG was abnormal in five of 23 (22%), current perception threshold in two of 11 (18%), electronystagmogram in eight of 13 [62%), and neuropsychiatric testing in nine of 16 (56%). Adipose biopsy in 22 patients showed C/H metabolites in the 11 to 73 percentile of adult normals, but ratio of C/H to DDT + metabolites ranged from 0.5 to 35 with a mean of 4.1 [1 expected). Our patients thus exhibited an elevated C/H body burden relative to DDT, and our findings support the presence of a neurotoxic syndrome with home C/H exposure.
5
Field Trial of a Rapid Acetaminophen Meter
MW Shannon, R Saladino, DL McCarthy, KM Parker, LDL Scott, PA Vaughan / Department of Medicine, Children's Hospital, Boston, Massachusetts; Poison Control System, University of Oklahoma
28/628
Health Sciences Center, Oklahoma City; MediSense (UK) Inc, Great Britain We conducted field trials of a newly developed meter that measures serum acetaminophen concentration (AC) after a 30-second analysis of one drop of whole blood (WB). Sixty-one WB samples from patients with known or suspected drug overdose were evaluated for acetaminophen overdose. In all cases a comprehensive toxic screen was sent with serum AC measured by high-performance liquid chromatography or TDx. AC was simultaneously tested with the meter. Twenty-five samples had a laboratory-confirmed elevated AC. The meter identified the elevated AC in all cases; there were no false-negatives (sensitivity, 100%). The rapid AC measurements correlated strongly with laboratory determinations (r = .983; P < .0001 ). Repeated testing (including with control solutions) documented the precision and reproducibility of the meter's results. Drug coingestion had no significant effect on the accuracy of the meter. These preliminary data identify the possibility of rapid determinations of AC after acute drug overdose. This meter would find its greatest value in the management of patients with acetaminophen overdose in whom expeditious but appropriate administration of antidotal therapy is desired.
6
Cyanide Levels After Acetonitrile Exposure: An In.V'rtro Study
MK Kirk, SL Voorhees, K Kulig, BH Rumack / Rocky Mountain Poison and Drug Center, Denver General Hospital, University of Colorado Health Sciences Center; Analytitox Inc, Denver, Colorado Recent reports and one local case have demonstrated cyanide toxicity from ingestion of acetonitrile-containing products. Concern that cyanide quantitation performed locally was actually measuring acetonitrile or that cyanide was being generated in the blood specimen in vitro led us to assess the analytical method. Samples of whole blood from a normal volunteer and water samples were prepared by adding 5, 10, 25, 50, 100, and 150 ~g/mL of acetonitrile and analyzed immediately. An additional sample of blood was prepared with 500 ~g/mL, then analyzed five hours later. Cyanide levels were measured using the Conway microdiffusion technique. Detection limits for this method are 0.01 ~g/mL. A standard curve for cyanide was analyzed concurrently. Cyanide was not detectable in any of these specimens. These data suggest that the presence of acetonitrile in a whole blood sample does not generate cyanide in vitro within five hours when measured by this common analytical method. Detection of cyanide in whole blood after acetonitrile ingestion is therefore not likely to be a laboratory artifact when done by this technique.
7
Liver Transplantation in Amanita Phalloides Poisoning
MR Daya, RL Norton, RD Fields, R Kao, JR Lake, NL Ascher, CW Pinson, KG Benner, EB Keefe / Oregon Poison Center, Oregon Health Sciences University, Portland; University of California at San Francisco Orthoptic liver transplantation (OLT) offers definitive therapy for selected cases of Amanita phalloides (AP) poisoning associated with irreversible hepatic failure. Since liver procurement can be a lengthy process, early identification of potential candidates is desirable. The clinical course of five severely poisoned individuals, four of whom had OLT, is reviewed. All five developed nausea, vomiting, abdominal pain, and diarrhea 7.5 to 10.5 hours following a cooked mushroom meal. Patients presented to the emergency department 12 to 24 hours following ingestion, where AP poisoning was confirmed by identification of an intact remaining mushroom. Initial management consisted of aggressive fluid resuscitation with forced diuresis, high-dose IV penicillin, and oral silymarin. The subsequent course was characterized by diarrhea, coagulopathy, reduced protein synthesis, and bone marrow toxicity with cytopenia. Laboratory abnormalities (mean _+ SE) common to all included profound hypophosphatemia (1.0 _+ 0. l mg/dL), elevated transaminases
Annalsof EmergencyMedicine
19:6 June 1990
(C + NAC)
NAC
P
Analysis
1,230 + 807
0.45
t test
Mean peak
SGOT Medianpeak SGOT
1,193 -+ 966 61
Peak SGOTs < 100 Peak SGOTs 100-1,000 Peak SGOTs > 1,000
61
0.42 WilcoxonRS
23
(62%)
23
t53% }
8
(22%)
11
(26%)
6
116%)
9
(21%}
0.73
Xa
1
There were no statistical differences between the C + NAC or NAC groups. When administered later than eight hours after acetaminophen overdose C given IV 300 mg every six hours does not add to the hepatoprotection provided by NAC. Higher doses and earlier administration of C should be studied.
Efficacy of Early Hemoperfusion in the Management of Paraquat Poisoning SM Pond, ECGM Hampson / University of Queensland, Department of Medicine, Princess Alexandra Hospital, Brisbane, Australia Our prospective, controlled study in the dog of the efficacy of repeated hemoperfusion, begun 12 hours after the 1V administration of an LDloo dose of paraquat, showed that the procedure did not reduce mortality. One previously reported study in the dog showed that a single hemoperfusion, performed earlier after a lower, oral dose of paraquat, improved the survival figures. Therefore, we examined the efficacy of a single charcoal hemoperfusion, begun at the end of a two-hour infusion of paraquat dichloride (7.48 mg PQ ion&g) in four dogs (PQ/sHP-group) and compared the results with those from the group given PQ only {PQ group). All of the dogs in the PQ/sHP-group developed the clinical and laboratory manifestations of paraquat toxicity. Only two of the four died, at two and four days, in contrast to four of four in the PQ group. At 12 days the two survivors were clinically normal and on postmortem examination, 18 days after the paraquat dose, there were no significant abnormalities. At the end of the infusion, the plasma paraquat concentrations in the survivors were similar to those in the nonsurvivors and to those in the PQ group. The mean extraction and clearance of paraquat by the hemoperfusion cartridges were 0.6 _+ 0.2 (_+ SD) and 27.5 _+ 11.5 mL/min, respectively. The percentage of the total dose of paraquat adsorbed in the two survivors was 25% and 26%, whereas in the nonsurvivors, it was 6% and 13%. Most of the balance of the dose was excreted in the urine within the first 24 hours. Therefore, single hemoperfusion, begun at the end of a twohour infusion of an LDmo dose of paraquat, reduced mortality by 50%. If extrapolated to patients, the results imply that attempting hemoperfusion within two to four hours of an oral dose of paraquat may be worthwhile. At later time points, the procedure cannot be said to be efficacious.
0
Plumbism in the Children of Young Professionals: Yuppie Lead
JG Linakis, MW Shannon / Massachusetts Poison Control System; The Children's Hospital Lead Treatment Program, Boston We have identified 26 lead (Pb)-intoxicated (blood Pb [PbB] > 25 ~g/dL) children (14% of our clinic population) who were exposed to lead during renovation of older homes owned by the children's parents. In contrast to cases of plumbism that occur in inner-city chil-
19:6June 1990
dren who live in dilapidated housing, these children were all from upper-middle-class families. The mean age of these children was 25.3 months (range, 11 to 63), and their mean PbB at presentation was 39.2 Ixg/dL (range, 26 to 116) with a mean erythrocyte protopophyrin [EP) of 132.8 p~g/dL (range, 21 to 412). They did not display iron {Fe) deficiency (mean serum Fe, 87 ~g/dL; Fe binding capacity, 322 ~g/dL); only one had iron indices below the norms for age. Treatment included IM or IV EDTA (13), and/or d-penicillamine (21). To date, 20 have achieved PbB below 25 ixg/dL, after a mean of 4.2 months of therapy. One patient's pregnant mother also had a markedly elevated PbB. There are several implications of our findings: Renovation of older homes poses a hazard to young children and perhaps to their parents; children suffering from yuppie lead have a better Fe status than low socioeconomic status children; all c h i l d r e n in older h o u s i n g u n d e r g o i n g r e n o v a t i o n s should be screened for lead; and physicians should provide anticipatory guidance to families regarding potential lead sources.
Prediction of Serum TheophylUne Concentration After A c u t e Theophylline Intoxication
MW Shannon, FH Lovejoy Jr, A Woolf / Department of Medicine, Children's Hospital; Department of Pediatrics, Harvard Medical School; Massachusetts Poison Control System, Boston In a retrospective analysis of 52 patients with acute theophylline intoxication (ATHEI), we found that serum potassium (K) and glucose (gin) strongly correlated with admission serum theophylline concentration (theo} when these variables were placed in a multivariate linear regression equation with admission theo as the dependent variable (r = .76; P < .0041. Using the least squares regression equation theo - 141.9 + 0.3215 glu - 44.95 K, we tested our ability to predict theo. Eight patients with ATHEI who had simultaneous measurement of glu, K, and theo were prospectively evaluated. Mean/median admission theos were 43.1/66.5 ~g/mL (range, 38 to 211). K ranged from 2.4 to 3.4 mEq/L while glu was 125 to 325 mg/dL. Measured versus calculated theo had a strong correlation (r = .81; P = .027). The calculated theo correctly predicted the actual theo to be in the range of less than 60 txg/mL, 61 to 80 ~g/ mL, or more than 80 ~g/mL in seven of the eight cases (88%). Our data suggest that prediction of theo with significant accuracy is possible after ATHEI using the above equation. Such information may be beneficial in anticipating management of patients with ATHEI when the theo determination may be delayed.
2
Methemoglobin and Cyanide Kinetics in Smoke Inhalation
M Kirk, K Kulig, BH Rumack / Rocky Mountain Poison and Drug Center, Denver General Hospital, University of Colorado Health Sciences Center, Denver The role and timing of administration of the Lilly Cyanide Antidote Kit® (CAK) in the treatment of smoke inhalation victims remains unclear. We recently treated six smoke inhalation patients with elevated cyanide (CN] levels. Patients received hyperbaric oxygen (HBO) (four), CAK (four), or both t-IBO and CAK (two). We analyzed the results of serial CN and methemoglobin (METHB) levels. Ag~nit CO
Admit CN
H B
C A
TI/2 (h) 0
K
(min)
TIh (h)
(%)
(rain)
1 4.9
3.38
25
3.67
9.2* 7.9*
50 35
2.1 1.6
(%)
I~g/mL
Thne Thne Post Apparent Peak Peak Apparent Exposure CN METHB METHB METHB
+
2 38
3.16
60
2.14
13.4
54
3.7
+
+
3 22 4 29
0.96 1.5
85 120
3.86 2.69
12.4 .
70
3.5
+
+ +
5 32
2.0
72
2.66
+
-
+
-
6 35 2.0 43 *Treated with CAK twice.
Annals of Emergency Medicine
2.94
-
.
. -
. -
627/27
From these limited data it appears that sodium nitrite infusion resulted in lower than expected METHB levels, which occurred 35 to 70 minutes following the nitrite infusion. The slow fall in METHB levels did not appear to be affected by HBO. Concerns about CAKinduced METHB adding to the toxicity of COHB m a y be unfounded.
3
Hydrofluoric Acid in the Automotive Industry= Epidemiology
JM Heard, LK G a r r e r ~ C Siegel / Georgia Poison Control Center, Grady Memorial Hospital, Emory University; DeKalb Medical Center, Atlanta, Georgia In all 22 hydrofluoric acid exposures over an I 1-month period, circumstances of exposure and type of treatment were analyzed. Age distribution was even from 16 to 39 years. Ten of 22 occurred in June and July. Four of the 22 cases were women; one quarter were auto related. The site of exposure could not be determined in four. Fourteen of 18 (78%) occurred at work, with nine of 14 (64%) auto related, two air conditioner cleaners, two rust removers for fa~nc~, and-one jewelry cleaner. Four of 18 (22%) occurred at home, three of four with car products; two of four home exposures occurred with products brought from the workplace. Two of the exposures in unknown locations were with auto products. Thus, 14 of 22 (64%) were with auto products. All reported pain, erythema, or edema. The involved part of the body was: finger(s) only, nine of 22; hand and finger(s), eight; eye, two; abdomen, one; leg, one; arm, one. Eleven (65%) received intra-arterial calcium therapy. Three received subcutaneous and six received topical therapy only. Only one had symptoms suggestive of systemic hypocalcemia. The automotive cleaning products are a major source of hydrofluoric acid exposure. While concentrations are relatively low, exposure is often prolonged and injury may be severe.
4
Subacute Home Chlordane Poisoning: Fact or Fallacy
DA Spyker, RR Bond, M Jylkka, PG Bernad / Pharmaceutical Research Associates Inc, Charlottesville, Virginia; Neurology Services Inc, Fairfax, Virginia Chlordane and heptachlor (C/H), currently the subject of a "no US distribution" agreement between Velsicol and the EPA, has been the termiticide of choice in the US since the 1940s. Due to its chemical stability, C/H persists in approximately 70% of the homes in the US. Unquestionably a potent neurotoxin and animal carcinogen, the frequency and severity of injury from inhalation exposure in the home remains unresolved. We report on 68 of the patients living in 30 domiciles from nine states whom we have examined with a chief complaint of chlordane exposure in their home. Their ages ranged from 2 to 63, with a mean of 33 years. Symptom frequency was headache in 67%, gastrointestinal difficulties 63%, fatigue 62%, m e m o r y deficits 57%, personality changes 54%, decreased attention span 52%, n u m b n e s s or paresthesias 45%, disorientation 36%, loss of coordination 30%, dry eyes 25%, and seizures 8%. EMG was abnormal in five of 23 (22%), current perception threshold in two of 11 (18%), electronystagmogram in eight of 13 [62%), and neuropsychiatric testing in nine of 16 (56%). Adipose biopsy in 22 patients showed C/H metabolites in the 11 to 73 percentile of adult normals, but ratio of C/H to DDT + metabolites ranged from 0.5 to 35 with a mean of 4.1 [1 expected). Our patients thus exhibited an elevated C/H body burden relative to DDT, and our findings support the presence of a neurotoxic syndrome with home C/H exposure.
5
Field Trial of a Rapid Acetaminophen Meter
MW Shannon, R Saladino, DL McCarthy, KM Parker, LDL Scott, PA Vaughan / Department of Medicine, Children's Hospital, Boston, Massachusetts; Poison Control System, University of Oklahoma
28/628
Health Sciences Center, Oklahoma City; MediSense (UK) Inc, Great Britain We conducted field trials of a newly developed meter that measures serum acetaminophen concentration (AC) after a 30-second analysis of one drop of whole blood (WB). Sixty-one WB samples from patients with known or suspected drug overdose were evaluated for acetaminophen overdose. In all cases a comprehensive toxic screen was sent with serum AC measured by high-performance liquid chromatography or TDx. AC was simultaneously tested with the meter. Twenty-five samples had a laboratory-confirmed elevated AC. The meter identified the elevated AC in all cases; there were no false-negatives (sensitivity, 100%). The rapid AC measurements correlated strongly with laboratory determinations (r = .983; P < .0001 ). Repeated testing (including with control solutions) documented the precision and reproducibility of the meter's results. Drug coingestion had no significant effect on the accuracy of the meter. These preliminary data identify the possibility of rapid determinations of AC after acute drug overdose. This meter would find its greatest value in the management of patients with acetaminophen overdose in whom expeditious but appropriate administration of antidotal therapy is desired.
6
Cyanide Levels After Acetonitrile Exposure: An In.V'rtro Study
MK Kirk, SL Voorhees, K Kulig, BH Rumack / Rocky Mountain Poison and Drug Center, Denver General Hospital, University of Colorado Health Sciences Center; Analytitox Inc, Denver, Colorado Recent reports and one local case have demonstrated cyanide toxicity from ingestion of acetonitrile-containing products. Concern that cyanide quantitation performed locally was actually measuring acetonitrile or that cyanide was being generated in the blood specimen in vitro led us to assess the analytical method. Samples of whole blood from a normal volunteer and water samples were prepared by adding 5, 10, 25, 50, 100, and 150 ~g/mL of acetonitrile and analyzed immediately. An additional sample of blood was prepared with 500 ~g/mL, then analyzed five hours later. Cyanide levels were measured using the Conway microdiffusion technique. Detection limits for this method are 0.01 ~g/mL. A standard curve for cyanide was analyzed concurrently. Cyanide was not detectable in any of these specimens. These data suggest that the presence of acetonitrile in a whole blood sample does not generate cyanide in vitro within five hours when measured by this common analytical method. Detection of cyanide in whole blood after acetonitrile ingestion is therefore not likely to be a laboratory artifact when done by this technique.
7
Liver Transplantation in Amanita Phalloides Poisoning
MR Daya, RL Norton, RD Fields, R Kao, JR Lake, NL Ascher, CW Pinson, KG Benner, EB Keefe / Oregon Poison Center, Oregon Health Sciences University, Portland; University of California at San Francisco Orthoptic liver transplantation (OLT) offers definitive therapy for selected cases of Amanita phalloides (AP) poisoning associated with irreversible hepatic failure. Since liver procurement can be a lengthy process, early identification of potential candidates is desirable. The clinical course of five severely poisoned individuals, four of whom had OLT, is reviewed. All five developed nausea, vomiting, abdominal pain, and diarrhea 7.5 to 10.5 hours following a cooked mushroom meal. Patients presented to the emergency department 12 to 24 hours following ingestion, where AP poisoning was confirmed by identification of an intact remaining mushroom. Initial management consisted of aggressive fluid resuscitation with forced diuresis, high-dose IV penicillin, and oral silymarin. The subsequent course was characterized by diarrhea, coagulopathy, reduced protein synthesis, and bone marrow toxicity with cytopenia. Laboratory abnormalities (mean _+ SE) common to all included profound hypophosphatemia (1.0 _+ 0. l mg/dL), elevated transaminases
Annalsof EmergencyMedicine
19:6 June 1990