Clinical toxicology : the official journal of the American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists
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On theoretical grounds, hydroxocobalamin is an attractive antidote for cyanide poisoning as cobalt compounds have the ability to bind and detoxify cyanide. This paper reviews the pharmacokinetic and pharmacodynamic aspects of hydroxocobalamin, its efficacy in human cyanide poisoning and its adverse effects. ⋯ Limited data on human poisonings with cyanide salts suggest that hydroxocobalamin is an effective antidote; data from smoke inhalation are less clear-cut. Although clinically important reactions to hydroxocobalamin have not been seen, some, non-life threatening, adverse reactions can occur.
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Sulfonylureas are used extensively for treating type-2 diabetes mellitus. Sulfonylurea poisoning can produce sustained and profound hypoglycemia refractory to IV dextrose, particularly in children and the elderly. ⋯ Although relatively limited, the available data suggest that octreotide should be considered first-line therapy in both pediatric and adult sulfonylurea poisoning with clinical and laboratory evidence of hypoglycemia. Maintenance doses of octreotide may be required to prevent recurrent hypoglycemia.
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Clin Toxicol (Phila) · Sep 2012
ReviewRole of liquid chromatography-high-resolution mass spectrometry (LC-HR/MS) in clinical toxicology.
Gas chromatography (GC) and liquid chromatography (LC) coupled with mass spectrometry (MS) are widely used to confirm drug screening results and for urine screening in presumed intoxicated patients. These techniques are better suited to targeted analysis than to general unknown screening and, due to the complexity of testing, results are seldom available rapidly enough to contribute to the immediate care of the patient. High resolution (HR)/MS with time-of-flight (TOF) or orbitrap instruments offer potential advantages in clinical toxicology. COMPARISON OF GC-MS, LC-MS/MS AND LC-HR/MS: For unknown analyses, GC-MS and LC-MS/MS require comparison of full-scan spectra against preestablished libraries. Operation in full-scan mode greatly reduces sensitivity and some drugs present in low but significant concentrations may be missed. Selected ion monitoring (SIM) in GC/MS and selected reaction monitoring (SRM) in LC-MS/MS, where only targeted ions are monitored, increase sensitivity but require prior knowledge of what compound is to be measured. LC-HR/MS offers mass assignment with an accuracy of 0.001 atomic mass units (amu) compared with 1 amu in conventional MS. Tentative identification is thus directed to a very limited set of compounds (or even one unique compound) based on the exact molecular formula rather than a fragmentation pattern, since HR/MS can discriminate between compounds with the same nominal molecular mass. LC-MS/MS has clear advantages over GC/MS in ease and speed of sample preparation and the opportunities for its automation. LC-HR/MS is more suitable to clinical toxicology because the drugs present in a sample are rarely known a priori, and tentative identifications of unknowns can be made without the availability of a reference standard or a library spectrum. Blood can be used in preference to urine which is more relevant to the patient's current clinical situation. ⋯ LC-HR/MS offers unique opportunities for time-sensitive clinical analysis of blood samples from intoxicated patients and for comprehensive screening in a wide range of situations and materials. While the identification is not as definitive as that obtained by conventional fragmentation MS, the presumptive identification can be confirmed later with standards and spectral library matches. Optimum utilization of the presumptive diagnosis requires close collaboration between the laboratory analysts and their clinical counterparts.
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Clin Toxicol (Phila) · Jul 2012
ReviewThe clinical toxicology of γ-hydroxybutyrate, γ-butyrolactone and 1,4-butanediol.
Gamma-hydroxybutyrate (GHB) and its precursors, gamma-butyrolactone (GBL) and 1,4-butanediol (1,4-BD), are drugs of abuse which act primarily as central nervous system (CNS) depressants. In recent years, the rising recreational use of these drugs has led to an increasing burden upon health care providers. Understanding their toxicity is therefore essential for the successful management of intoxicated patients. We review the epidemiology, mechanisms of toxicity, toxicokinetics, clinical features, diagnosis, and management of poisoning due to GHB and its analogs and discuss the features and management of GHB withdrawal. ⋯ GHB poisoning can cause potentially life-threatening CNS and respiratory depression, requiring appropriate, symptom-directed supportive care to ensure complete recovery. Withdrawal from GHB may continue for up to 21 days and can be life-threatening, though treatment with benzodiazepines is usually effective.
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Clin Toxicol (Phila) · Apr 2012
ReviewLevamisole in cocaine: unexpected news from an old acquaintance.
Levamisole is a pharmaceutical with anthelminthic and immunomodulatory properties that was previously used in both animals and humans to treat inflammatory conditions and cancer. Levamisole has been identified as a cocaine adulterant in the United States since 2003. By 2009, the United States Drug Enforcement Administration (DEA) estimated that 69% of the cocaine seized contained levamisole. ⋯ These potential effects make levamisole an interesting choice as a cocaine adulterant. It seems unlikely that levamisole use as a cocaine adulterant will soon reach an end. More information is needed about the diagnosis and treatment of levamisole-induced complications, and the efforts of the medical and public health community is needed to face this challenging problem.