Carbon monoxide poisoning following use of a water pipe/hookah

Dtsch Arztebl Int 2014; 111(40): 674-9;   DOI: 10.3238/arztebl.2014.0674

Background: Water pipe (hookah) smoking has become a common activity in Germany, particularly among adolescents and young adults; in 2011, its lifetime prevalence was as high as 68.8%. Similar trends can be seen in other European countries. Water-pipe smokers are exposed to the same health-endangering substances as cigarette smokers, and the inhaled amount of carbon monoxide (CO) can be as much as ten times as high. In CO intoxication, carboxyhemoglobin is formed and causes direct injury at the cellular level, leading to hypoxia and nonspecific neurological manifestations. There have only been ten reported cases around the world of CO intoxication due to the use of a water pipe, and none of these were fatal. It should be recalled, however, that accidental CO intoxication is common and is associated with high morbidity and mortality.

Case presentation and course: We present a series of four young adults, aged 16 to 21, three of whom were hospitalized because of transient unconsciousness. The carboxyhemoglobin (CO-Hb) content of the blood in the symptomatic patients ranged from 20.1% to 29.6%, while the asymptomatic patient had a CO-Hb content of 16.7%. Water-pipe smoking was the cause of CO intoxication in all four cases. The CO-Hb values were successfully brought down by the administration of highly concentrated oxygen and all patients were discharged in asymptomatic condition.

Conclusion: This case series reveals that CO intoxication due to water-pipe smoking is probably more common than is generally realized. Emergency room staff should be aware of this problem and inquire specifically about water-pipe smoking in patients with nonspecific neurological manifestations.

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Cardiogenic shock after use of fluoroamphetamine confirmed with serum and urine levels

Clinical Toxicology  Online on October 28, 2014;  (doi:10.3109/15563650.2014.974262)

Context. 4-Fluoroamphetamine (4-FA) is a para-substituted phenethylamine-type synthetic stimulant that has in recent years gained popularity through internet blogs and market share according to confiscated drug data. No serious toxicity has previously been reported. We report a case of a young man who developed severe toxicity and cardiogenic shock after using 4-FA, with laboratory confirmation. Case details. An 18-year-old man presented to the emergency department with vomiting, shortness of breath, chest tightness, and altered mental status about 5 h after using a new and unfamiliar street drug. Two days prior, he had received naltrexone intramuscular injection as part of an opioid addiction treatment program and was taking fluoxetine and trazodone. Five hours after presentation, he developed cardiogenic shock requiring intraaortic balloon pump, inotropic and ventilatory support. An echocardiogram showed left ventricular (LV) hypokinesia, sparing the apex and ejection fraction (EF) = 10%. Comprehensive toxicology serum testing revealed FA, naproxen, trazodone, and cotinine. The 4-FA urine level was 64,000 ng/ml and serum level was 118 ng/ml. With slow recovery, the patient was discharged after 2 weeks of hospitalization.

DISCUSSION. Although no previously reported 4-FA clinical poisoning cases have been published for comparison, by examining 4-FA pharmacology compared with other stimulant drugs, and given this patient’s presentation and echocardiogram suggestive of reverse takotsubo cardiomyopathy we suspect the toxic mechanism was an acute cardiomyopathy caused by 4-FA catecholamine-induced myocarditis and/or small vessel myocardial ischemia.

CONCLUSION. Recreational use of 4-FA may present with life threatening toxicity including cardiomyopathy, cardiogenic shock, and pulmonary edema.

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Derek Sinden accused of dressing as a woman and robbing woman, 82, at Toombul Tony Keim October 29, 2014

A MAN dressed in women’s clothing followed an 82-year-old home from a Brisbane shopping centre and violently robbed her before using her credit cards to go on a shopping spree, a jury has heard.
A Brisbane District Court jury was told Derek Sinden, 45, robbed Margaret Baker after following her home from the Toombul Shopping Centre, on Brisbane’s northside, before rendering her unconscious and robbing her about 1pm on January 12 this year.

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‘Bizarre act’ led to death of Karl Wright, inquest hears Kathleen Donaghey October 29, 2014

A CORONER has ruled out suicide as the cause of death of a mechanic found bound and gagged in his sleeping bag.
Detectives concluded that Karl Robert Wright, 43, had intentionally killed himself when his body was found on his Sunshine Coast property last year.
His mother Paula discovered the disability pensioner in a sleeping bag and on a mattress in his man shed on July 29, 2013.

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Woman injured as three men attack her with a machete at a Broadbeach service station

Gold Coast Bulletin Lucy Kinbacher October 30, 2014

A HOUSE visit to collect money is believed to be the reasoning behind a vicious machete attack at Broadbeach this morning.
Police are currently investigating a ‘debt collection’ incident which left a woman with injuries to her face and wrist and damage to her car at a service station.

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New CLSI document – EP05-A3 Evaluation of Precision of Quantitative Measurement Procedures

EP05-A3: Evaluation of Precision of Quantitative Measurement Procedures; Approved Guideline—Third Edition (October 2014)

This document provides guidance for evaluating the precision performance of quantitative measurement procedures. It is intended for manufacturers of quantitative measurement procedures and for laboratories that develop or modify such procedures.

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Fatal alfentanil/morphine mixture: A case report

Toxicologie Analytique et Clinique Available online 17 September 2014;  DOI: 10.1016/j.toxac.2014.08.002

A 23 year-old man, health care professional, was found dead in the toilets of a local hospital. Medical supplies for injection (syringe, needles) were found near the body at the scene, in a waste. External body examination revealed a single point of injection located at the left elbow crease and the lack of any traumatic injury. During examination, the pathologist collected cardiac blood and urine. These specimens were tested for ethanol, volatiles, pharmaceuticals and drugs of abuse, using headFspace GC/FID and GC/MS, Elisa, LC-DAD, GC/MS and LC/MS/MS. Ethanol tested positive in blood (0.99 g/L) and urine (0.19 g/L). Using a dedicated LC/MS/MS procedure, alfentanil was identified in both blood (19 ng/mL) and urine (25 ng/mL). Morphine was identified in blood, at 36 ng/mL (free morphine) and 39 ng/mL (total morphine). In urine, total morphine concentration was 81 ng/mL. No other drug was detected. Given the ratio (0.92) free morphine to total morphine in blood and the low concentrations of both alfentanil and morphine in urine, it was considered that the death occurred rapidly after drugs administration. The manner of death was considered as acute intoxication of both alfentanil and morphine, in presence of ethanol.

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