Diamox overdose

[coffeebythelake]

Glaucoma patient for trabeculectomy.
Actually only found out postop when nurse noticed pt was odd.
Altered cognition, imbalance, other non-focal neuro deficits
Had a mild AKI from diuresis, bicarb low, LFTs ok
Notably related onset of symptoms to within a day of starting diamox
Also determined to be taking at least 2x (perhaps 4x) the prescribed dose
-- immediately suspected OD, with much lower suspicion for ddx including cerebellar stroke

Poison control center confirmed ssx c/w diamox overdose
Stopped rx, hydrated, trended labs -- Admitted to hospitalist service for correction
Anyone with interesting overdose stories (aside from the usual culprits)?

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[woopedazz]

I worked up a guy who presented with vague symptoms in the Emergency Department. Several months of abdominal pain, N&V, confusion, that would come and go; worse when he spent stints at home alone, better when he was out working. It had gotten really bad in the past week and all he'd been able to do is lay on the couch and not keep anything down. He was getting really confused and called an ambulance.

Everything was pretty normal; he seemed a tad on the confused side, but nothing else that jumped out.

Ran some bloods and his GFR was low, WCC way down. ABG = High anion gap.

Further chatting with him revealed he was using loads of recreational drugs at home which seemed to be when his symptoms got worse. He was also using some sort of household polish/solvent to purify one of his drugs prior to consumption. He happened to have it in his backpack so I looked it up.

Chronic low-dose ethylene glycol poisoning. Confirmed on lab studies.

 

[abolt18]

On my ED rotation, lady brought in my EMS, somnolent and diaphoretic. Occasional myoclonus of extremities. Brother gave vague hx of drug OD in the past, but didn't know her prescriptions at all. She ended up in the ICU before we found out she had an enormous amount of tramadol in her system. Developed a fever upon going to ICU as well.

Serotonin syndrome was the final diagnosis.

 

[Planktonmd]

I had a chronic pain patient who inadvertently after her lap cholecystectomy was prescribed X100 her usual dose of Baclofen by the surgeon while in the hospital.
She went into a coma, was intubated and when she woke up 3 days later her chronic pain was CURED!
I mean completely gone and she was able to discontinue all her opiates and remain opiate free for at least a year!
She thought we were geniuses.

 

[coffeebythelake]

I had a chronic pain patient who inadvertently after her lap cholecystectomy was prescribed X100 her usual dose of Baclofen by the surgeon while in the hospital.
She went int a coma, was intubated and when she woke up 3 days later her chronic pain was CURED!
I mean completely gone and she was able to discontinue all her opiates and remain opiate free for at lease a year!
She thought we were geniuses.

This might be a new pain protocol here.

 

[deleted162650]

I had a chronic pain patient who inadvertently after her lap cholecystectomy was prescribed X100 her usual dose of Baclofen by the surgeon while in the hospital.
She went int a coma, was intubated and when she woke up 3 days later her chronic pain was CURED!
I mean completely gone and she was able to discontinue all her opiates and remain opiate free for at lease a year!
She thought we were geniuses.

“Doc, I’ve never felt so relaxed!”

 

[Planktonmd]

This might be a new pain protocol here.

I actually thought about publishing it... but decided it was not a great idea!

 

[IMGASMD]

I actually thought about publishing it... but decided it was not a great idea!

Lots of great discoveries are by accident right? Maybe you can even have someone to do a real trial with the new protocol?

 

[migm]

Had a person take over 20 grams of lithium ER... and about 40 grams (yes grams) of lorazepam... not a clinical conundrum.

 

[nimbus]

I worked up a guy who presented with vague symptoms in the Emergency Department. Several months of abdominal pain, N&V, confusion, that would come and go; worse when he spent stints at home alone, better when he was out working. It had gotten really bad in the past week and all he'd been able to do is lay on the couch and not keep anything down. He was getting really confused and called an ambulance.

Everything was pretty normal; he seemed a tad on the confused side, but nothing else that jumped out.

Ran some bloods and his GFR was low, WCC way down. ABG = High anion gap.

Further chatting with him revealed he was using loads of recreational drugs at home which seemed to be when his symptoms got worse. He was also using some sort of household polish/solvent to purify one of his drugs prior to consumption. He happened to have it in his backpack so I looked it up.

Chronic low-dose ethylene glycol poisoning. Confirmed on lab studies.

On my ED rotation, lady brought in my EMS, somnolent and diaphoretic. Occasional myoclonus of extremities. Brother gave vague hx of drug OD in the past, but didn't know her prescriptions at all. She ended up in the ICU before we found out she had an enormous amount of tramadol in her system. Developed a fever upon going to ICU as well.

Serotonin syndrome was the final diagnosis.

These undifferentiated patients are why EM docs will always have job security.

 

[right500]

I had a chronic pain patient who inadvertently after her lap cholecystectomy was prescribed X100 her usual dose of Baclofen by the surgeon while in the hospital.
She went into a coma, was intubated and when she woke up 3 days later her chronic pain was CURED!
I mean completely gone and she was able to discontinue all her opiates and remain opiate free for at least a year!
She thought we were geniuses.

With all seriousness, could her gall bladder issue have been the cause of her chronic pain? Maybe I missed the joke and that was the point. Totally anecdotal, but I had a family member whose chronic pain was cured by a cholecystectomy (emergent ex-lap). Turns out she had large bile crystals building in her tissues (similar to gouty tophi) due to cholestasis.

 

[deleted59964]

had a trauma patient once, single vehicle accident - car vs tree.
became clear it probably wasn't an accident when I got a call from the lab about the paracetamol (acetaminophen) level.

(well done to ED - btw)

 

[chocomorsel]

Had a person take over 20 grams of lithium ER... and about 40 grams (yes grams) of lorazepam... not a clinical conundrum.

Where the hell did she get all these? Stashing them for decades? Hey
Did she make it? Sounds like not. There’s not enough reversal probably in the whole hospital.
And the lithium would be lethal. How did she even make it to hospital?

 

[coffeebythelake]

Where the hell did she get all these? Stashing them for decades? Hey
Did she make it? Sounds like not. There’s not enough reversal probably in the whole hospital.
And the lithium would be lethal. How did she even make it to hospital?

hemodialysis and supportive measures?

 

[chocomorsel]

hemodialysis and supportive measures?

Dialysis can help. But that is a huge dose. Greater than the LD50 if she was 90kg or less. Charcoal if still in the window of time? Of which I don’t know.
Combined with the Lorazepam, which is undialyzable, it seems very very unlikely for one to survive. I have a very difficult time believing that somebody stashed 40g of Ativan in order to OD with at one time. I looked up the highest Ativan tablet dose and I found 10 mg. One would need 4000 tablets to get to 40g.

A veterinarian may have higher doses possibly? It just sounds very difficult to believe.

 

[Planktonmd]

With all seriousness, could her gall bladder issue have been the cause of her chronic pain? Maybe I missed the joke and that was the point. Totally anecdotal, but I had a family member whose chronic pain was cured by a cholecystectomy (emergent ex-lap). Turns out she had large bile crystals building in her tissues (similar to gouty tophi) due to cholestasis.

She had chronic back pain and failed back surgery

 

[bigdan]

I was covering our MICU one night and attended to a patient from an outside hospital that “ran out of Naloxone” on a patient with “witnessed heroin overdose”. Reportedly, paramedics found him unresponsive with a needle still in an upper extremity vein upon arrival. He got a total of TWELVE milligrams of Naloxone from EMS and the OSH, with no improvement in his sensorium nor respiratory efforts.

I go to see him with the resident, who suggests Naloxone gtt. He’s a young guy, but still tachycardia and hypertensive, beyond just youthful response to illness. The patient has literally no exam. Doesn’t breathe over the set rate, doesn’t move to ANY painful stim. I check a TOF, which has 4 equal, robust twitches. Curiously, I notice pupils the size of dinner plates. I ask what the tox screen showed...but one was never done.

60 minutes later, one drug comes back positive in the screen. Cocaine. His “buddy” gave him cocaine to mainline. Resident says “We should probably not do the Naloxone gtt now, right?”.

Right - let’s not.

 

[MoMoGesiologist]

I was covering our MICU one night and attended to a patient from an outside hospital that “ran out of Naloxone” on a patient with “witnessed heroin overdose”. Reportedly, paramedics found him unresponsive with a needle still in an upper extremity vein upon arrival. He got a total of TWELVE milligrams of Naloxone from EMS and the OSH, with no improvement in his sensorium nor respiratory efforts.

I go to see him with the resident, who suggests Naloxone gtt. He’s a young guy, but still tachycardia and hypertensive, beyond just youthful response to illness. The patient has literally no exam. Doesn’t breathe over the set rate, doesn’t move to ANY painful stim. I check a TOF, which has 4 equal, robust twitches. Curiously, I notice pupils the size of dinner plates. I ask what the tox screen showed...but one was never done.

60 minutes later, one drug comes back positive in the screen. Cocaine. His “buddy” gave him cocaine to mainline. Resident says “We should probably not do the Naloxone gtt now, right?”.

Right - let’s not.

So... was he not moving at all and unresponsive because cocaine caused a brain bleed or something?

 

[bigdan]

Ya. SAH and intraparenchymal bleeds.

We scanned his head as soon as the cocaine was noted. His brain exploded.

 

[MoMoGesiologist]

Ya. SAH and intraparenchymal bleeds.

We scanned his head as soon as the cocaine was noted. His brain exploded.

So... no one did a head scan on the unresponsive person who wasn’t getting better with narcan...?

I wasn’t there and I miss things all the time in retrospect... but ... that sounds bad

Nice catch on your part though, props!

 

[bigdan]

So... no one did a head scan on the unresponsive person who wasn’t getting better with narcan...?

I wasn’t there and I miss things all the time in retrospect... but ... that sounds bad

Nice catch on your part though, props!

Brother - the **** that comes in from “outside hospital” is sometimes nothing less than criminal negligence.

 

[coffeebythelake]

Brother - the **** that comes in from “outside hospital” is sometimes nothing less than criminal negligence.

classic OSH

 

[deleted162650]

classic OSH

 

[fakin' the funk]

Patient with clonidine patch.
Got a mild UTI (like barely a fever, no WBC etc), super sweaty --> clonidine overdose
Bradycardic and hypotensive, improved after patch removal and some dopamine in ICU.

 

[DM27]

Patient with clonidine patch.
Got a mild UTI (like barely a fever, no WBC etc), super sweaty --> clonidine overdose
Bradycardic and hypotensive, improved after patch removal and some dopamine in ICU.

One of my favorite inductions in a cardiac patient with chronic pain is to just take a hair dryer to the Fentanyl patch.

 

[Groove]

Glaucoma patient for trabeculectomy.
Actually only found out postop when nurse noticed pt was odd.
Altered cognition, imbalance, other non-focal neuro deficits
Had a mild AKI from diuresis, bicarb low, LFTs ok
Notably related onset of symptoms to within a day of starting diamox
Also determined to be taking at least 2x (perhaps 4x) the prescribed dose
-- immediately suspected OD, with much lower suspicion for ddx including cerebellar stroke

Poison control center confirmed ssx c/w diamox overdose
Stopped rx, hydrated, trended labs -- Admitted to hospitalist service for correction
Anyone with interesting overdose stories (aside from the usual culprits)?

We have some pretty interesting ones in the ED from time to time.

One was transferred in to us from a rural ED during training that I can still remember. Lady in her 60s or so, a few chronic comorbidities that I can't remember. No family present, little history like most of our patients. She was in too much respiratory distress to tell me much useful information and rapidly desat and got intubated. She seemed to have an ARDS type picture on CXR with a horrible metabolic acidosis. So, we hunt down the usual MUDPILES route and low and behold...she turns out to have salicylate induced pulmonary edema. It was one of the worst cases of salicylate poisoning I've ever seen and the only time in my career that I've seen salicylate induced pulmonary edema. The family shows up right before we wheel her up to the ICU and tell us she's been gobbling up BC powders for the past 2 weeks for her arthritis.

My least favorite are the CCB overdoses. Ugh....man those people tank hard and fast. I had a psych pt a few months ago telling me she'd eaten #20-30 240mg ER verapamil tablets "because the voices told me to". I look at her VS..stable, look down at my watch...5:30pm and ask her again what time she ate these things? She goes "Well it took me awhile doc, but sometime between 1pm and 2pm....voices told me to take all of them!" I go back to my desk and calculate...muttering to myself "No damn way this lady took 5 grams of verapamil several hours ago and is here with rock solid VS....wait, did she say ER?" Right about that time the nurse runs up "You might want to check on her again...BP is in the 80s!" Anyway, she ends up circling the toilet during a massive resus and ended up on one of those high dose insulin infusions where nursing always freaks out. It's like....1U/kg/hr or something. I've never been able to fully wrap my brain around the mechanism of insulin infusion for CCB poisoning whereas I can easily understand lipid emulsion therapy. I think she stayed on the insulin drip for 1-2 days in the ICU. I hate those overdoses.