California Poison Control System- San Francisco Division
Hot Topics in Toxicology - Nov 5, 2005
Case Session A
CASE 1. A 32 year old woman with a history of depression is found lethargic and
confused by paramedics. She had called her boyfriend and told him she planned to take
some pills, and he alerted 911. Her initial vital signs: BP 130/80, HR 110/min, RR
20/min. The monitor shows a sinus tachycardia with normal appearing complexes. She
receives activated charcoal en route to the ED.
In the ED she is somewhat more lethargic (GCS 8) and there is charcoal slurry at the
corners of her mouth. Bedside glucose test is 108 mg/dL. Pulse ox 92%
ECG:
Questions:
1. What is the preferred method of gut decontamination in this patient?
2. What is the mechanism of toxicity of the suspected ingestant?
3. What treatment do you recommend?
CASE 2. A 50 year old man ingests his entire bottle of Lithobid (lithium carbonate,
sustained-release). Her initial lithium level 1 hour after ingestion is 1.3 mEq/L. The
patient is asymptomatic.
Questions:
1. What is the preferred method of gut decontamination in this patient?
2. What if the ingested lithium was not in a sustained-release formulation?
Case, continued: 3 hours later the lithium level is 6.7 mEq/L. The patient remains
asymptomatic.
Questions:
3. How is lithium distributed in and removed from the body?
4. How should this patient be treated?
California Poison Control System- San Francisco Division
Hot Topics in Toxicology - Nov 5, 2005
CASE 3. A 62 year old woman accidentally takes six 80 mg propranolol tablets. She
feels dizzy and weak, and in the ED her BP is 70/50 mm Hg, and HR is 42/min. her other
medications include Lipitor and Lasix, but she did not take any extra of these.
Questions:
1. What is the mechanism of toxicity of propranolol?
2. What treatment do you recommend?
CASE 4. A patient in the ED has evidence of anticholinergic syndrome: dilated pupils;
tachycardia; dry oral mucosa; absent sweating; flushed skin; and agitated delirium. Your
colleague wants to try some physostigmine (Antilirium) to reverse the symptoms.
Questions:
1. What is physostigmine? How does it work?
2. What are the indications for use of physostigmine in anticholinergic syndrome?
3. What are the potential side effects and precautions with physostigmine use?
California Poison Control System- San Francisco Division
Hot Topics in Toxicology - Nov 5, 2005
Case Session B
CASE 5. An elderly woman with a history of congestive heart failure, COPD,
osteoarthritis, and atrial fibrillation is brought to the ED with weakness and nausea. BP
110/80, HR 90/min and regular, RR 20/min, T 37.2 C. Pulse ox 95% on room air.
Initial labs: Na 134, K 4.2, Cl 106, HCO3 20, BUN 58, Cr 1.4, glucose 92 mg/dL.
Digoxin 4.2 ng/mL.
ECG:
Questions:
1. How would you interpret the serum digoxin level in this patient? What additional
information do you need?
2. How do you interpret the ECG findings?
3. How should this patient be treated?
CASE 6. A 76 year old woman undergoes a transesophageal echocardiogram. After the
procedure her pulse oximetry reads 89% and she appears cyanotic, so supplemental
oxygen is given, but there is no change in her appearance or the oximetry reading. Blood
drawn for analysis appears a dark red-brown color.
Questions:
1. What is the likely diagnosis?
2. What are some potential causes?
3. How should this patient be treated?
California Poison Control System- San Francisco Division
Hot Topics in Toxicology - Nov 5, 2005
CASE 7. A 29 year old man is brought to the ED by his girlfriend because of vomiting
and abdominal pain. He admits to alcohol use on a regular basis. His girlfriend tells you
she is worried that he has been depressed and drinking more lately, and it’s possible that
he might have tried to hurt himself. She found an empty container of antifreeze in the
garage but he told her it was previously used up.
Initial findings include BP 140/80, HR 110/min, RR 32/min, T 37.6 C. He is unshaven,
somewhat lethargic, and disheveled. There is a sour odor of old alcohol on his breath.
Laboratory findings include Na 140, K 3.2, Cl 105, HCO3 15, BUN 9, Cr 1.1, glucose 90
mg/dL, lipase 568 U/L, AST 42 IU/L, Total bili 1.2, ketones weakly positive. Lactate 2.4
mEq/L. Serum measured osmolality 315 mOsm/L.
Questions:
1. What is the anion gap?
2. What is the osmolar gap?
3. What are causes of elevated gaps?
4. What are some pitfalls in making the diagnosis of toxic alcohol ingestions?
5. How would you treat this patient?
CASE 8. A 32 year old political analyst comes to the ED at 9 am with difficulty
swallowing and double vision. She relates that she felt well last evening, although she
returned home very late after a Republican Party dinner in San Francisco. She feels weak,
and says her throat feels dry. On examination, she is awake but her eyelids are droopy.
There are no visible lesions in her oropharynx. Orthostatic vital signs are normal.
Laboratory exam shows normal glucose, electrolytes and hemoglobin level, and the rapid
screen for Strep on a throat swab is negative.
Two hours later, a 38 year old newspaper journalist comes to the ED with similar
complaints.
Questions:
1. What toxic syndrome is suggested by this presentation?
2. What is the significance of a journalist and a political analyst having the same
symptoms?
3. What additional tests might help confirm the diagnosis?
4. What actions should you take?
California Poison Control System- San Francisco Division
Hot Topics in Toxicology - Nov 5, 2005
Case Session C
CASE 9. A 37 year old man with a history of depression and anxiety reports taking more
than 60 tablets of alprazolam (Xanax). In the ambulance, he becomes increasingly
drowsy. On arrival at the ED, his vital signs are: BP 130/80 mm Hg, HR 110/min, RR
12/min, T 37.7 C. Pupils are 6 mm and sluggishly reactive. The bedside glucose is 102
mg/dL. He has an equivocal response to eyelash stimulation (equivalent to a gag reflex).
There is no response to naloxone (Narcan) or flumazenil (Romazicon). Shortly after, the
patient has a seizure, followed by two more seizures.
Questions:
1. What is your initial treatment?
2. What anticonvulsant should you give?
3. What is the role of flumazenil (Romazicon) in this patient?
CASE 10. A 21 y/o male was in a “drug house” when it was raided by police. After he
was apprehended, he admitted to smoking crank. Initially, he was alert oriented and
cooperative with police, but then stated that he was not feeling well. Then he admitted to
swallowing a bag of methamphetamine prior to his surrender. He became gradually
unresponsive and EMS was called. He had a seizure en route to the hospital.
In the ED: BP 110/80 mm Hg, HR 160/min, T >108 F. Diaphoretic with widely dilated
pupils. Shortly after arrival, his BP falls to 60/15 mm Hg.
Questions:
1. What are this patient’s problems?
2. What are your priorities in management?
California Poison Control System- San Francisco Division
Hot Topics in Toxicology - Nov 5, 2005
CASE 11. An 87 year old man swallowed what he thought was apple juice from a glass
container in his garage. Shortly after, he developed nausea and abdominal cramps. He
vomited several times before EMS arrived. They noted a chemical odor and found
moderate wheezing.
In the ED, BP 202/105, HR 90/min. He is diaphoretic. Bedside glucose is 108 mg/dL.
There are some muscle “tremors” and generalized weakness noted but his baseline
neuromuscular exam is not known.
Questions:
1. What toxic syndrome does this presentation suggest?
2. Discuss your approach to decontamination in the patient.
3. What laboratory tests would you send?
4. What is your treatment plan?
5. Does this case need to be reported to local authorities?
CASE 12. A 43 year old woman ingested Lysol Toilet Bowl Cleaner. She had immediate
pain in her throat and chest. In the ED, she was given intravenous analgesics and
antiemetics, and a plain CXR was negative for free air under the diaphragm or in the
mediastinum.
Labs: Na 144, Cl 121, HCO 18.6.
Serum CPK 26,812
Arterial blood gases: pH 7.19, pCO2 24
Questions:
1. What is this patient’s anion gap?
2. What is the likely cause of her acidosis?
3. What is the role of gastric decontamination in patients with intentional liquid
corrosive ingestion?