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Interesting Case Conference December 1, 2009

Interesting Case Conference December 1, 2009. Evan Schwarz, MD. The Case. 35 y/o male with past medical history of bipolar disease found down at home He had called cousin earlier that night saying he wanted to go to sleep Mom found him down and unresponsive around 2 am

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Interesting Case Conference December 1, 2009

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  1. Interesting Case ConferenceDecember 1, 2009 Evan Schwarz, MD

  2. The Case • 35 y/o male with past medical history of bipolar disease found down at home • He had called cousin earlier that night saying he wanted to go to sleep • Mom found him down and unresponsive around 2 am • EMS called and brought patient to the ED • Unable to obtain further history from patient as he is obtunded and no family currently present

  3. The Case • PMH: • Bipolar disease • ?Schizophrenia • Suicide attempt X 2 in the past • NKDA • SH: • Lost job 5 months ago • ROS: • Unable to obtain • But family denies any recent fevers, infectious symptoms, or recent complaints

  4. Physical Exam • BP 93/38 Pulse 120 96.8 Resp 17 Sats 92% • Appearance • Well nourished, unresponsive, no signs of trauma • C/V • Tachycardic with irregular rhythm, 2+ pulses, cap refill < 2 sec • Pulm • Clear to auscultation, shallow respirations • Ext • No abrasions, no ecchymosis, no swelling • Musculoskeletal • Decreased tone, no rigidity • Skin • No rashes, not flushed

  5. PE • GI: • Dry Mucous Membranes • Neuro • Pupils miotic, approx 3 mm and unreactive • Face symmetric • No spontaneous movements • No tremors or fasciculations • Areflexia • No clonus or babinski

  6. Since we have some ED internsWhat do you want to do next?

  7. Immediate management • Peripheral access obtained • Narcan? • Patient intubated • NS started • Blood suctioned from OG tube • Labs drawn • EKG done

  8. EKG Rate 131, QRS 92 ms, QTc 493 ms Doesn’t quite do justice to the rhythm strip

  9. Labs • 7.44/33/158/22 base deficit -1.2 (post intubation) 8.7 144 114 3 100 14 230 3.4 19 0.7 40 Acetaminophen < 1.2 Salicylates < 3 Valproic acid < 2.8 Ethanol < 10 UDS: +amphetamines, benzodiazepines, methamphetamine

  10. Differential?

  11. So luckily we did have a little more information • Patient’s medications • Chloral hydrate solution 500 mg/5 ml • Doxepin 100 mg • Clonazepam 1 mg • Hydroxyzine 25 mg • Perphenazine 2 mg • Venlafaxine 37.5 mg • Lamotrigine 200 mg

  12. And he had this laying next to him

  13. Chloral Hydrate toxicity • By the time Tox sees him in the ED he has sluggish pupils and minimal reflexes • Admitted to the ICU • Supportive care with hydration is recommended • PPI for gastritis with serial H/H • Discuss precautions for possible TCA co-ingestion and Venlafaxine withdrawal if remains intubated multiple days

  14. Clinical Coarse • Pt self extubates himself the next day • No significant GI bleed • Tachycardia resolves • Pt has no idea how so much chloral hydrate got into his system • Transferred to psychiatric facility

  15. Chloral Hydrate • Halogenated hydrocarbon • Introduced in 1832 • Metabolized by alcohol dehydrogenase • Trichloroethanol • Active metabolite • Lipid soluble • Responsible for hypnotic effect • ½ life of 4-12 hours • ½ life increased in kids Chloral Hydrate Chloroform

  16. Metabolism INACTIVE ACTIVE ENTEROHEPATIC CIRCULATION

  17. Cardiac Sensitization Syndrome • Cardiac dysrhythmias are main cause of death • Reduce myocardial contractility • Shorten refractory period • “Sudden sniffing death syndrome” • Inhaled hydrocarbons • Huffers • Increase sensitivity to catecholamines • V-tach • V-fib • Torsades de pointes

  18. Other toxicities • Sedation • GI toxicity • Hemorrhagic gatritis • Gastric and intestinal necrosis • Strictures (delayed)

  19. Mickey Finn • Combination of ethanol and chloral hydrate • Most likely named for Chicago bartender in 1896 • Used knockout drops to incapacitate and rob some of his customers • Eventually bar shut down in early 1900s “The Revenge”

  20. Chloral Hydrate + Alcohol Trichloroacetic acid Trichloroethanol X X Trichloroacetic acid G.franks page 1101

  21. Some Interesting Articles Famous Deaths

  22. Gastric perforation

  23. Gastric perforation • 68 y/o women with history of depression • Ingested 10 grams of chloral hydrate in suicide attempt • On arrival patient has increasing abdominal girth and peritonitis • CXR shows free air • Trichloroethanol level peaked at 103 mg/L

  24. Severe esophageal ulceration • 8 month old with eye injury • Supposed to get 0.4 gm chloral hydrate • Received 8 grams that was not properly diluted • 10 minutes later is severely obtunded • Erythema noted to mouth and sloughing of mucosa noted on day 2 • EGD revealed ulceratilnos and sloughing • Started on TPN and made full recovery

  25. Cardiac Arrhythmias • In addition to atrial arrhythmias can have ventricular arrhythmias • Treatment: Beta Blocker • Arrhythmias are resistant to lidocaine, magnesium Zahedi et al. Successful Treatment of Chloral Hydrate Cardiac Toxicity with Propranolol. Am J Emerg Med 1999;17:490-91.

  26. Chlorination process is the most widely used method of drinking water disinfection • Causes conversion of nontoxic organic compounds into toxic, mutagenic compounds • Chloral hydrate as been reported as one of the main genotoxic and cacinogenic compounds • Formed in the reaction of organic matter and chlorine • WHO guidelines • Chloral hydrate concentration 10 microg/L-1

  27. Methods • Polish study • Collected raw surface water from 3 rivers • Collected infiltrated water, ozonated water, and organic free water • Collected tap water from different cities in Poland • Identification of chloral hydrate used methods recommended by the US EPA

  28. Results • Conflicted results on level of organic material in water being proportional to the amount of chloral hydrate formed • In study testing tap water from one Water Plant, found correlation between levels of chloral hydrate and chloroform

  29. Results

  30. Other Conclusions • The reaction of chlorine with organic matter takes place as long as chlorine is available in water • Biologically active filters do not remove all CH precursors

  31. References • 1. Dabrowska A, Nawrocki J. Controversies about the occurrence of chloral hydrate in drinking water. Water Research 43 (2009): 2201-08. • 2. Frankland A, et al. Fatal Chloral Hydrate Overdoses Unnecessary Tragedies. The Canadian Journal of Psychiatry. Vol 46 (8) 763-64. • 3. Lee D, et al. Acute gastric perforation in a chloral hydrate overdose. Am J Emerg Med. 1998;16(5):545-46. • 4. Lin Y, Ma J. Severe esophageal burn following chloral hydrate overdose in an infant. J Formos Med Assoc 2006;105(3):235-37. • 5. Merdinkjl, et al. Kinetics of chloral hydrate and its metabolites in male human volunteers. Toxicology 245 (2008) 130-140. • 6. Sing K, et al. Chloral hydrate toxicity from oral and intravenous administration. Clinical Toxicology 1996;34(1):101-6. • 7. Goldfranks eighth edition • 8. Zaheid A, et al. Successful treatment of chloral hydrate cardiac toxicity with propranolol. Am J Emerg Med 1999;17:490-91.

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