Foxglove poisoning : diagnostic and therapeutic differences with medicinal digitalis glycosides overdose

We report a case of a 19-year-old woman who ingested Digitalis purpurea leaves as a suicide attempt. She developed gastro-intestinal symptoms, loss of colour vision, cardiac conduction disturbances as well as an elevated serum potassium. Treatment was initiated in analogy to medicinal digoxin poisoning by means of digoxin-specific Fab-fragments with a good effect. However during the further course we faced difficulties of prolonged intestinal absorption and inability to estimate the ingested dose or half-life of the vegetal cardiac glycoside compounds. To prevent further absorption and interrupt enterohepatic recycling, multi-dose activated charcoal was administered. Because of a relapse of cardiac conduction disturbances and hyperkalemia, two supplementary doses of Fab-fragments were given, up to a total dose of nineteen vials (one vial containing 40 mg). The important diagnostic and therapeutic differences of vegetal digitalis intoxication as compared to medicinal intoxication and the applicability of existing guidelines on medicinal digitalis intoxication in the light of these differences will be discussed here

First report on brorphine : the next opioid on the deadly new psychoactive substance horizon?

New psychoactive substances (NPS) continue to appear on the drug market. Until recently, new synthetic opioids, which are amongst the most dangerous NPS, primarily encompassed analogues of the potent analgesic fentanyl. Lately, also other new synthetic opioids have increasingly started to surface. This is the first report on the identification and full chemical characterization of brorphine, a novel potent synthetic opioid with a piperidine benzimidazolone structure. Brorphine was identified in a powder and in the serum of a patient seeking medical help for detoxification. Liquid chromatography–high resolution mass spectrometry (LC–HRMS) identified an exact mass of m/z 400.1020 and 402.1005 for the compound, corresponding to both bromine isotopes. Further chemical characterization was performed by gas chromatography–mass spectrometry (GC–MS), LC–diode array detection (DAD) and Fourier-transform infrared (FT-IR) spectroscopy analyses. Finally, the structure was confirmed by performing 1H- and 13C-NMR spectroscopy. In vitro biological activity of brorphine was determined by a cell-based µ-opioid receptor (MOR) activation assay, resulting in an EC50 of 30.9 nM (13.5 ng/mL) and an Emax of 209% relative to hydromorphone, confirming the high potency and efficacy of this compound. In a serum sample of the patient, brorphine and a hydroxy-metabolite were found using the LC–HRMS screening method. The presence of opioid activity in the serum was also confirmed via the activity-based opioid screening assay. The occurrence of brorphine is yet another example of how the illicit drug market is continuously evolving in an attempt to escape international legislation. Its high potency poses a serious and imminent health threat for any user

Adequacy of bystander actions in unconscious patients : an audit study in the Ghent region (Belgium)

Objective Early recognition and appropriate bystander response has proven effect on the outcome of many critically ill patients, including those in cardiac arrest. We wanted to audit prehospital bystander response in our region and identify areas for improvement. Patients and methods We prospectively collected data, including Emergency Medical Services dispatch center audio files, on all patients with a decreased level of consciousness presenting to the Ghent University Hospital prehospital emergency care unit (n = 151). Three trained emergency physicians reviewed the bystander responses, both before and after dispatcher advice was given. Suboptimal actions (SAs) were only withheld if there was 100% consensus. Results SAs were recognized in 54 (38%) of the 142 cases, and most often related to delayed (n = 35) or inaccurate (n = 12) alerting of the dispatch center. In seven cases, the aid given was considered suboptimal in itself. Importantly, in 21 (25.9%) of the 81 cases where a clear advice was given by the dispatcher, this advice was ignored. In 12 cases, a general practitioner was present at scene. We recognized SAs in 80% of these cases (8/10; insufficient information, n = 2). Cardiopulmonary resuscitation was started in only 29 (43.3%) of the 67 cases of cardiac arrest where dispatcher-assisted cardiopulmonary resuscitation was indicated at the moment of first Emergency Medical Services call. Conclusion We audited bystander response for unconscious patients in our region and found a high degree of suboptimal actions. These results should inform policy makers and healthcare professionals and force them to urgently reflect on how to improve the first parts of the chain of survival