Primary care physicians may be unprepared to diagnose and treat rare, yet potentially fatal, illnesses such as acute radiation syndrome (ARS). ARS, also known as radiation sickness, is caused by exposure to a high dose of penetrating, ionizing radiation over a short period of time. The time to onset of ARS is dependent on the dose received, but even at the lowest doses capable of causing illness, this will occur within a matter of hours to days. This article describes the clinical manifestations of ARS, provides guidelines for assessing its severity, and makes recommendations for managing ARS victims.

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The American College of Medical Toxicology established the Toxicology Investigators Consortium (ToxIC) Case Registry in 2010. The Registry contains all medical toxicology consultations performed at participating sites. The Registry has continued to grow since its inception, and as of December 31, 2015, contains 43,099 cases. This is the sixth annual report of the ToxIC Registry, summarizing the additional 8115 cases entered in 2015. Cases were identified by a query of the Registry for all cases entered between January 1 and December 31, 2015. Specific data reviewed for analysis included demographics (age, race, gender), source of consultation, reason for consultation, agents and agent classes involved in exposures, signs, symptoms, clinical findings, fatalities, and treatment. By the end of 2015, there were 50 active sites, consisting of 101 separate health-care facilities; 51.2 % of cases involved females. Adults between the ages of 19 and 65 made up the majority (64.2 %) of Registry cases. Caucasian race was the most commonly reported (55.6 %); 9.6 % of cases were identified as Hispanic ethnicity. Inpatient and emergency department referrals were by far the most common referral sources (92.9 %). Intentional pharmaceutical exposures remained the most frequent reason for consultation, making up 52.3 % of cases. Of these intentional pharmaceutical exposures, 69 % represented an attempt at self-harm, and 85.6 % of these were a suicide attempt. Nonopioid analgesics, sedative-hypnotics, and antidepressant agents were the most commonly reported agent classes in 2015. Almost one-third of Registry cases involved a diagnosed toxidrome (32.8 %), with a sedative-hypnotic toxidrome being the most frequently described. Significant vital sign abnormalities were recorded in 25.3 % of cases. There were 98 fatalities reported in the Registry (1.2 %). Adverse drug reactions were reported in 4.3 % of cases. Toxicological treatment was given in 65.3 % of cases, with 33.0 % receiving specific antidotal therapy. Exposure characteristics and trends overall were similar to prior years. While treatment interventions were required in the majority of cases, fatalities were rare.

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Background Thallium is a highly toxic compound and is occasionally involved in intentional overdoses or criminal poisonings. Accidental poisonings also occur, but are increasingly rare owing to restricted use and availability of thallium. We report a fatal suicidal ingestion of thallium sulfate rodenticide in which multi-dose activated charcoal (MDAC) and Prussian Blue (PB) were both used without changing the outcome. Case report A 36 year old man ingested an unknown amount of thallium sulfate grains from an old rodenticide bottle. He presented to an emergency department (ED) 45 minutes later with abdominal pain and vomiting. On examination he was agitated with a blood pressure of 141/ 60 mmHg and a heart rate of 146 beats per minute (bpm). He received MDAC during his initial ED management and was started on PB 18 hours post arrival; he was intubated on the following day for airway protection. The patient continued to be tachycardic and hypertensive and subsequently developed renal failure. On hospital day three, the patient developed hypotension that did not respond to fluids. The patient required vasopressors and was transferred to a tertiary care center to undergo continuous renal replacement therapy (CRRT). The patient died shortly after his transfer. His last blood thallium concentration was 5369 mcg/L, a spot urine thallium >2000 mcg/L, and a 24-hour urine thallium was >2000 mcg/L. Conclusion Though extremely rare, thallium intoxication can be lethal despite early administration of MDAC and use of Prussian blue therapy. Rapid initiation of hemodialysis can be considered in cases of severe thallium poisoning, to remove additional thallium, to correct acid-base disturbance, or to improve renal function.

Our results suggest a need for additional radiological-nuclear preparedness training for emergency medicine residents and faculty. Training should include radiation detection, decontamination, explaining differences between radiation exposure and contamination, and teaching patient management, including DTPA and Prussian blue.

Introduction: Amantadine hydrochloride is an antiviral medication used as therapy for parkinsonism and as a cognitive enhancer. We report 2 cases of massive, acute ingestion of amantadine hydrochloride confirmed with serial serum levels.Case Reports: A 47-year-old woman presented to the emergency department (ED) 30 minutes after ingesting 10 g of amantadine (150 mg/kg) by her report. Initial ECG revealed a sinus rhythm with rate of 93 bpm, and a QRS of 84 msec. While in the ED, the patient sustained a pulseless cardiac arrest and the monitor revealed ventricular tachycardia. She was successfully defibrillated. Postdefibrillation ECG showed a sinus rhythm (rate ϭ 82 bpm), QRS of 236 msec, and QTc of 567 msec. The serum potassium was 1.0 mEq/L (1.0 mmol/L). The patient was given 300 ml (300 cc) 3% sodium chloride IV over 10 minutes. Ten minutes after completion of the hypertonic saline infusion, the patient's ECG abnormalities resolved and the QRS was 88 msec. Her potassium was repleted over the next 11 hours postpresentation, and she also received an IV bolus of 4 g of magnesium sulfate immediately after the cardiac arrest. No further hypotension, dysrhythmia, conduction delay, or ectopy was noted during the patient's hospital stay. The second case involved a 33-year-old female patient who presented 1 hour after ingesting 100 tablets of amantadine hydrochloride (100 mg/tab). Initial ECG revealed sinus tachycardia with a QRS of 113 msec, an R wave in lead aVR of 4-5 mm and a QTc of 526 msec. Her serum potassium was 3.0 mEq/L (3.0 mmol/L), her serum calcium was 9.4 mg/dl (2.35 mmol/L), and serum magnesium was 2.1 mg/dl (0.86 mmol/L) on labs drawn at initial presentation. The patient was intubated for airway protection, and her potassium was repleted and corrected over the next 9 hours. Her ECG abnormalities improved 8 hours after initial presentation and normalized at approximately 14 hours postingestion. The patient was discharged home 11 days after her ingestion.Conclusion: Acute amantadine toxicity manifests with life-threatening cardiotoxicity. Concurrent, often profound, hypokalemia may complicate the administration of sodium bicarbonate in the management of cardiac dysrhythmias.

Background and Objectives The Georgian National Center for Disease Control and Public Health (NCDC) and United Nations Children's Fund (UNICEF) completed a Multiple Indicator Cluster Survey (MICS) from September to December 2018 that included a nationally representative assessment of 1,578 children's blood lead levels (BLLs). The study found that 41% of children (age 2-7 years) had BLLs equal to or exceeding the U.S. Centers for Disease Control's reference level of 5 µg/ dL and that16% of the 1,578 children had BLLs exceeding 10 µg/dL [1-3]. Low-level lead exposure can result in a number of adverse health outcomes in the neurological and cardiovascular systems [4-6]. To investigate potential sources of lead exposure present in the homes of assessed children a team comprised of staff from the NCDC and the nongovernmental organization Pure Earth (NY, USA) conducted site visits to 25 Georgian homes and four bazaars in July 2019 assessing a range of media for lead content including soil, dust, paint, water, spices, toys, and cookware. Methods Sixteen of the 25 homes were selected on the basis of having a child with a BLL > 30 µg/dL, while nine were selected on the basis of having a child with a BLL < 5 µg/dL. The mean BLL in the < 5 µg/dL group was 2.81 µg/dL (range: 1.6-4.01) while the mean BLL in the > 30 µg/dL group was 35.43 µg/dL (range: 32.29-38.57). The mean age for children in the comparison group was 4.2 years (range: 2.7-5.7), while that for the elevated group was 5.1 years (range: 4.1-6.1). The sex of the children was not recorded. The homes were located in the following five regions: Adjara (n = 9); Guria (n = 5); Imereti (n = 7); Shida Kartli (n = 3); and Tbilisi (n = 1). Spices were procured in bulk and assessed from bazaars in Adjara (n = 2), Imereti (n = 1), and Tbilisi (n = 1). Bazaar assessments were not initially contemplated in the study design and were only conducted after spices were found to be adulterated with lead during home assessments. The bazaars were selected based on logistical convenience. As a result, no bazaars were assessed in Guria or Shida Karti. The study relied heavily on field-portable instrumentation confirmed in part by laboratory wet techniques. In total, 682 portable X-Ray Fluorescence (pXRF) measurements were taken, including those from cookware (n = 53); paint (n = 207); soil (91); spices (n = 128); toys (n = 78); and ' other' (n = 125) a category comprised of a