Andrew M. King

Antimuscarinic drug toxicity is a common pediatric emergency, which produces central and peripheral symptoms. Treatment of agitation and hyperactive antimuscarinic delirium, with first-line agents like cholinesterase inhibitors or benzodiazepines, is imperative to prevent severe toxicity. Intravenous physostigmine salicylate is a cholinesterase inhibitor that is commonly used to treat central antimuscarinic delirium. Its chemical structure facilitates crossing of the blood–brain barrier. Overlapping nationwide physostigmine and benzodiazepine shortages have prompted consideration of therapeutic alternatives. Rivastigmine is a long-acting cholinesterase inhibitor with a similar chemical structure to physostigmine. It represents a potential therapeutic option for antimuscarinic delirium. Rivastigmine offers potential benefits over physostigmine including a longer duration of action, slower rate of central nervous system penetration, more favorable side effect profile, and availability in multiple formulations. A paucity of literature exists describing the use of rivastigmine for central antimuscarinic delirium. We describe the effective use of oral rivastigmine in a child with central antimuscarinic delirium.

Objectives. To identify opioids associated with a spike in opioid-related mortality in Wayne County, Michigan, from July 2016 through February 2017. Methods. We reviewed records from the Wayne County Medical Examiner’s Office of 645 people who died because of accidental nonmedically prescribed opioid overdoses from July 2015 through July 2017. We analyzed basic demographics, locations of death, and all opioid toxicology results. Decedents who died in hospitals were excluded. Results. Of the 645 people who died because of nonmedically prescribed opioid overdoses, 65% were male and 63% were White, with an average age of 43 years. Carfentanil was detected in 129 (20%) cases. During the 8-month mortality spike, carfentanil was detected in 114 of 419 cases (average = 27.2%; range = 6.4%–45.2%). Substances most frequently detected with carfentanil included morphine (57%), 6-monoacetylmorphine (38%), fentanyl (43%), norfentanyl (33%), tetrahydrocannabinol (34%), and cocaine (29%). Conclusions. The Wayne County spike in mortality temporally corresponded with the detection of carfentanil and a proportional increase in opioid overdose deaths with detectable carfentanil. Public Health Implications. The abrupt decrease in carfentanil-detected mortality coincided with an announcement indicating an impending ban on fentanyl analogs from China, which suggests that source control is an effective countermeasure.

Morbidity and mortality from poison- and drug-related illness continue to rise in the USA. Medical toxicologists are specifically trained to diagnose and manage these patients. Inpatient medical toxicology services exist but their value-based economic benefits are not well established.

Acute drug-induced hypertension, sympathomimetic toxicity, and other hyperadrenergic states can be caused by both xenobiotic toxicity and withdrawal. This manuscript is a selective review of the recent literature regarding pharmacologic causes of hypertensive emergencies and other hyperadrenergic states.

“Mud bogging” is an off-road motorsport in which drivers navigate vehicles over a muddy pit or track. Immobilization of these vehicles occurs frequently and may cause exhaust pipes to become clogged with mud. Subsequent permeation of carbon monoxide throughout the cabin places occupants at risk for serious toxic effects. The hazards of mud bogging were recently highlighted by the death of Shain Gandee, a cast member of the MTV series Buckwild.¹ We report two incidents, each affecting two people, in which serious carbon monoxide poisoning occurred as a result of mud bogging.