Case report: Survival after deliberate strychnine self-poisoning, with toxicokinetic data

INTRODUCTION: Strychnine poisoning is uncommon, and in most severe cases, the patient dies before reaching hospital. The management of strychnine poisoning is well documented, although there are few data on the kinetics of elimination of strychnine after overdose. CASE REPORT: A 42-year-old man presented shortly after ingestion of an unknown quantity of strychnine powder. After a respiratory arrest, with intensive supportive management requiring admission to an intensive care unit, he survived. Eight serum samples were taken over the first 5 days and analysed subsequently for strychnine concentrations. RESULTS: The initial concentration at 1.5 hours after ingestion was 4.73 mg/l, falling to 0.38 mg/l at 74 hours postingestion. Serum concentrations followed a monoexponential elimination curve with a calculated elimination half-life of 12 hours. DISCUSSION AND CONCLUSION: Strychnine poisoning presents with classical features, and with early diagnosis and supportive management, the patient can survive. The initial serum concentration of 4.73 mg/l is the highest reported concentration in a patient who has survived. Previous reports of the elimination half-life have suggested it is between 10 and 16 hours, which conforms to the elimination data in our case

Fatality after deliberate ingestion of the pesticide rotenone: a case report

Rotenone is a pesticide derived from the roots of plants from the Leguminosae family. Poisoning following deliberate ingestion of these plant roots has commonly been reported in Papua New Guinea. However, poisoning with commercially available rotenone in humans has been reported only once previously following accidental ingestion in a 3.5-year-old child. Therefore, the optimal management of rotenone poisoning is not known. After deliberate ingestion of up to 200 ml of a commercially available 0.8% rotenone solution, a 47-year-old female on regular metformin presented with a reduced level of consciousness, metabolic acidosis and respiratory compromise. Metformin was not detected in premortem blood samples obtained. Despite intensive supportive management, admission to an intensive care unit, and empirical use of N-acetylcysteine and antioxidant therapy, she did not survive. Poisoning with rotenone is uncommon but is potentially fatal because this agent inhibits the mitochondrial respiratory chain. In vitro cell studies have shown that rotenone-induced toxicity is reduced by the use of N-acetylcysteine, antioxidants and potassium channel openers. However, no animal studies have been reported that confirm these findings, and there are no previous reports of attempted use of these agents in patients with acute rotenone-induced toxicity

Fatality after deliberate ingestion of sustained-release ibuprofen: a case report

INTRODUCTION: Ibuprofen is a nonsteroidal anti-inflammatory drug available over the counter and on prescription for the management of pain and inflammation. Severe toxicity is rare following deliberate self-poisoning with ibuprofen, and patients are usually either asymptomatic or develop only mild gastrointestinal toxicity. Although there have been nine other reported fatalities, co-existent factors have probably contributed to all of these deaths. We report here a fatality from isolated toxicity following self-poisoning with sustained-release ibuprofen. CASE REPORT: A 26-year-old female presented after deliberate ingestion of up to 105 g sustained-release ibuprofen, with a reduced level of consciousness, severe metabolic acidosis and haemodynamic compromise. Despite intensive supportive management, gut decontamination with multidose activated charcoal and correction of the metabolic acidosis with sodium bicarbonate and haemofiltration, the patient did not survive. The ibuprofen concentration ante mortem on presentation in peripheral blood was 760 mg/l and the concentrations post mortem were 518 mg/l in peripheral blood, 74 mg/kg in liver extract and 116 mg/l in the gastric contents. DISCUSSION: Most patients with ibuprofen poisoning are either asymptomatic or have mild gastrointestinal symptoms; severe poisoning with ibuprofen is rare. We report the first death related to isolated sustained-release ibuprofen poisoning

Poisoned patients as potential organ donors: Postal survey of transplant centres and intensive care units

Background The number of patients awaiting allograft transplantation in the UK exceeds the number of organs offered for transplantation each year. Most organ donors tend to be young, fit and healthy individuals who die because of trauma or sudden cardiac arrest. Patients who die from drug and poison intoxication tend to have similar characteristics but are less frequently offered as potential organ donors. Methods A postal questionnaire survey of all transplantation centres and an equal number of intensive care units in the UK was undertaken. The use of kidney, heart, lung, liver and pancreas transplants from poisoned patients following deliberate methanol ingestion, cardiac arrest presumed secondary to cocaine overdose, accidental domestic carbon monoxide inhalation and industrial cyanide exposure were used as case scenarios. Results Response rates were 70% for transplantation centres and 50% for intensive care unit directors. Over 80% of organs would be offered or discussed with transplant coordinators by intensive care unit directors. Transplantation physicians/surgeons would consider transplanting organs in up to 100% of case scenarios, depending on the organ and poisoning or intoxication involved. Discussion The postal survey presented here shows that most transplantation physicians and surgeons and intensive care unit directors would consider those who die following acute drug intoxication and poisoning as potential organ donors. The previously reported literature shows in general that transplanted organs from poisoned patients have good long-term survival, although the number of reports is small. Poisoned patients are another pool of organ donors who at present are probably underused by transplantation services

Gut decontamination of acutely poisoned patients: what do doctors really know about it?

There are consensus guidelines on the appropriate use of gut decontamination in the management of poisoned patients. This study demonstrates that few doctors have read these guidelines and that they have poor knowledge of the use of gut decontamination, which can be improved with specific clinical toxicology teaching. Future guidelines should be published in journals more widely read by those doctors treating poisoned patients