Inoxicated / Poisoning-Related Coma Blister

 

Inoxicated / Poisoning-Related Coma Blister
Year	Country	Age	Gender	Substance	References
2022	US	82	F	lorazepam for insomnia	1
2012	Brazil	45	F	clonazepam, promethazine, oxcarbazepine and quetiapine	2
2009	UK			barbiturate	3
2007	UK	53	F	Acetaminophen 500mg, codeine 30mg	4
2002	Germany			theophylline toxicity	5
2002	Canada			amitriptyline overdose	6
1991	Australia	25	M	carbon monoxide	7
1990	Ichilov	75		200 mg oxazepam	8
1972				BARBITURATE	9

1.      https://pubmed.ncbi.nlm.nih.gov/35180064/

2.      https://pubmed.ncbi.nlm.nih.gov/22892778/

3.      https://pubmed.ncbi.nlm.nih.gov/19359256/

4.      https://pubmed.ncbi.nlm.nih.gov/17952753/

5.      https://pubmed.ncbi.nlm.nih.gov/12198361/

6.      https://pubmed.ncbi.nlm.nih.gov/12447625/

7.      https://pubmed.ncbi.nlm.nih.gov/1743385/

8.      https://pubmed.ncbi.nlm.nih.gov/2231838/

9.      https://pubmed.ncbi.nlm.nih.gov/4116178/

 edited by Yu-Jang Su  April 12, 2023. 

Theophylline Intoxication

 Substance

 -  theophylline intoxication.   

 -  (45.5%) had acute, (40.4%) had chronic, and (14.0%) had acute-on-therapeutic poisoning. [1]

Common name or Trade name

 -  definition: Therapeutic ranges are usually achieved between 10–20 μg/mL. Toxic effects are often seen above 20 μg/mL plasma concentrations. [2]

 

Involving system

-       Effect: diuretic, smooth muscle relaxant, cardiac, nervous system, and ventilator stimulant [2]

-       GI system: nausea, vomiting, gastrointestinal reflux [2]

-       Neuro: restlessness, and headache, convulsions (8.2%) [2, 3]

-       CV: severe cardiac arrhythmias (20.8%), hypotension (may result fromβ2-stimulated peripheral vasodilation) and even death occur at higher theophylline concentrations (usually 80–100 μg/mL). [1, 2]

 

Presentation 

-       severe cardiac arrhythmias, refractory hypotension, and convulsions [2]

-       Hypokalemia, hypercalcemia, hyperglycemia, and acidosis are metabolic disturbances that commonly occur after an acute overdose [2]

-       May complicate with Coma Blister. [4]

 

Antidote and Treatment

-       Gastrointestinal decontamination with activated charcoal. [2]

-       The use of beta-blockers is an acceptable approach to control tachydysrhythmias [2]

-       aggressive fluid administration + conventional vasopressors in cases of refractory hypotension.

-        

-       standard hemodialysis is a suitable alternative when severe theophylline toxicity [2].

Disposition 

-       Carefully DDx with a thyroid storm.  

-       4.2% fatality [D].  

REFERENCES

 [1]. Shannon M. Life-threatening events after theophylline overdose: a 10-year prospective analysis. Arch Intern Med. 1999 May 10;159(9):989-94. doi: 10.1001/archinte.159.9.989. PMID: 10326941.

 [2]. Aggelopoulou E, Tzortzis S, Tsiourantani F, Agrios I, Lazaridis K. Atrial Fibrillation and Shock: Unmasking Theophylline Toxicity. Med Princ Pract. 2018;27(4):387-391. doi: 10.1159/000490145. Epub 2018 Jun 22. PMID: 29936503; PMCID: PMC6170900.

[3]. Kopacz P, Kula K. Lethal poisoning with theophylline in the form of rectally administered tablets. Arch Med Sadowej Kryminol. 2014;64(3):158-64. doi: 10.5114/amsik.2014.48879. PMID: 25693173.

[4]. Tsokos M, Sperhake JP. Coma blisters in a case of fatal theophylline intoxication. Am J Forensic Med Pathol. 2002 Sep;23(3):292-4. doi: 10.1097/00000433-200209000-00019. PMID: 12198361.

 

edited by Yu-Jang Su            Dec 7, 2021

血液灌注 charcoal hemoperfusion

可由活性炭血液灌注(charcoal hemoperfusion)排除之毒物:

Barbiturates [1]

 
Carbamazepine[2] 

Glutethimide[3]

 

Paraquat[4] 

Star Fruit [5]

 

Theophylline用hemoperfusion效果比hemodialysis好 [6]
 

Valproic acid.[7]

REFERENCES

 
1.      急性中毒救命術 急診醫學會 三版, p.378

2.      Peces R, Azorín S, Peces C, Selgas R. Tratamiento con hemoperfusión prolongada en la intoxicación aguda por carbamazepina [Extended hemoperfusion in the treatment of acute carbamazepine intoxication]. Nefrologia. 2010;30(1):127–130. doi:10.3265/Nefrologia.pre2010.Jan.10217

3. Peces R, Azorín S, Peces C, Selgas R. Tratamiento con hemoperfusión prolongada en la intoxicación aguda por carbamazepina [Extended hemoperfusion in the treatment of acute carbamazepine intoxication]. Nefrologia. 2010;30(1):127–130. doi:10.3265/Nefrologia.pre2010.Jan.10217

4 .Nasr Isfahani S, Farajzadegan Z, Sabzghabaee AM, Rahimi A, Samasamshariat S, Eizadi-Mood N. Does hemoperfusion in combination with other treatments reduce the mortality of patients with paraquat poisoning more than hemoperfusion alone: A systematic review with meta-analysis. J Res Med Sci. 2019;24:2. Published 2019 Jan 31. doi:10.4103/jrms.JRMS_478_18

5. Chan CK, Li R, Shum HP, et al. Star fruit intoxication successfully treated by charcoal haemoperfusion and intensive haemofiltration. Hong Kong Med J. 2009;15(2):149–152.

6. Shannon MW. Comparative efficacy of hemodialysis and hemoperfusion in severe theophylline intoxication. Acad Emerg Med. 1997;4(7):674–678. doi:10.1111/j.1553-2712.1997.tb03758.x

7. Peces R, Fernández EJ, Sánchez RJ, Peces C, Montero A, Selgas R. Tratamiento con hemoperfusión de la intoxicación aguda por ácido valproico [Hemoperfusion in the treatment of acute valproic acid intoxication]. Nefrologia. 2007;27(3):370–373.

-- edited 24th Dec, 2019 Yu-Jang Su.

 

Poison, Hemodialysis is helpful

可血液透析(hemodialysis):急性中毒 consult Nephrologist  
Acetaminophen (paracetamol level >900 mg/L) [1, 2]

Barbiturates (>100 mg/dL) [1, 3]

Carbamazepine (serum levels >40 mg/L or hemodynamic instability). [1, 4]

Lithium (3--4.0 mEq/L with serious symptoms) [5].

Metformin (lactate >15 mmol/L and ABG pH < 7.0 with shock or organ failure) [1, 6]

Methanol (50 mg/dL) and Ethylene glycol (50 mg/dL) [7].

Mushroom, Amanita [8]

Salicylates (>100 mg/dL, AKI, lung edema, AMS, hepatic failure, coagulopathy.) [9]

Theophylline (level >100 mg/L) with acute overdose

Theophylline level >60 mg/L) with chronic toxicity

severe toxicity – dysrhythmia, hypotension or seizures. [10].

Valproic acid (> 700mcg/ml) [11]

 REFERENCES

1.      https://www.dynamed.com/management/dialysis-for-acute-poisonings

2.      Serjeant L, Evans J, Sampaziotis F, Petchey WG. Haemodialysis in acute paracetamol poisoning. BMJ Case Rep. 2017;2017:bcr2016218667. Published 2017 Jan 17. doi:10.1136/bcr-2016-218667

3.      https://emedicine.medscape.com/article/813155-followup

4.      https://litfl.com/carbamazepine-toxicity-tox-library/

5.      http://www.tsim.org.tw/journal/jour12-5/P12_241.PDF

6.      https://www.hindawi.com/journals/cricc/2018/3868051/

7.      急診醫學會 AILS第三版，p. 258

8.      Warden CR, Benjamin DR. Acute renal failure associated with suspected Amanita smithiana mushroom ingestions: a case series. Acad Emerg Med. 1998;5(8):808–812. doi:10.1111/j.1553-2712.1998.tb02508.x

9.      急診醫學會 AILS第三版，p. 348

10.  https://litfl.com/theophylline-tox-library/

11.  Nasa P, Sehrawat D, Kansal S, Chawla R. Effectiveness of hemodialysis in a case of severe valproate overdose. Indian J Crit Care Med. 2011 Apr;15(2):120-2. doi: 10.4103/0972-5229.83020. PMID: 21814378; PMCID: PMC3145297.

-- edited 21th December 2019, Yu-Jang Su.