flightless bird
somewhere over the rainbow
- Aug 18, 2022
- 216
The patient reported losing consciousness after ingestion and waking up in his own vomit and feces. He felt confused and called EMS. In the emergency department (ED), the patient acknowledged nausea, vomiting, and bowel incontinence. He complained of severe diffuse abdominal pain that was 8/10 in severity. He had used marijuana that day. He denied chest pain, shortness of breath, coingestion with other prescription drugs, over‐the‐counter drugs, street drugs, and ethanol. He had no auditory hallucinations, current suicidal ideation, or current homicidal ideation.
The patient presented to the ED appearing ill, ashen, discolored and in distress. He was afebrile, tachycardic to 108, with a respiratory rate at 22, and blood pressure in the 110s systolic. His oxygen saturations were 84% on 6 L nasal cannula. On examination, his skin was ashen gray and he had perioral cyanosis. Cranial nerves were intact, and his cardiopulmonary examination demonstrated mild tachycardia. There were no pulmonary abnormalities. He had diffuse tenderness on his abdomen without rebound, rigidity, or guarding. He had soiled himself and was actively retching.
In the ED, he was switched to a non‐rebreather mask. Minnesota Poison Control was contacted, and the patient was promptly treated with 1 mg/kg intravenous bolus of methylene blue over 5 minutes. Toxicology labs were obtained along with venous blood gas (VBG) with co‐oximetry and methemoglobin levels. He remained stable in the ED, then was transferred to the intensive care unit (ICU) for further evaluation and care. Initial methemoglobin level was found to be 26.3% (0.0‐1.5%). VBG demonstrated pH of 7.39, PCO2 to 33 mmHg with PO2 of 38 mmHg. Complete blood count demonstrated platelet count of 329 and leukocytosis to 23.3 with strong left shift of 18.75. Basic metabolic panel demonstrated a mild decrease in bicarbonate at 19 (22‐29 mmol/L) and increased anion gap 16 (7‐15). Urine drug screen was positive for tetrahydrocannabinol and amphetamines. He denied use of amphetamines, which may be a false positive from bupropion. 10
He was cared for in the ICU overnight on non‐rebreather, then high‐flow nasal cannula, and ultimately transitioned to room air. From a clinical perspective, the patient improved drastically after timely methylene blue treatment with progressively decreasing oxygen requirements. His repeat methemoglobin level trended down to 0.7% within 90 minutes of intravenous methylene blue administration (Figure 1). The patient was transferred to the general medicine floor the next day. He was discharged after 2 nights total in the hospital for further psychiatric care. The patient continues to do well at the time of this report without identifiable long‐term sequela.
Survival after self‐poisoning with sodium nitrite: A case report
Sodium nitrite ingestion poses a considerable public health threat. The incidence of sodium nitrite self‐poisoning in the United States has been trending upward since 2017. Our case report describes an intentional sodium nitrite ingestion with ...www.ncbi.nlm.nih.gov
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