A 27-year-old woman with a history of psychiatric disorders was found unconscious in her bed at home. At the time of discovery, empty packets of prescription and over-the-counter medications were home. At the time of discovery, empty packets of prescription and over-the-counter medications were that the femoral blood levels of dextromethorphan (DXM) and diphenhydramine (DPH) reached the fatal concentrations of 3.6 and 6.2 µg/mL, respectively. In addition, escitalopram (ECP) was detected at 0.42 µg/mL, which is a toxic concentration based on the literature, suggesting that the combined action of these drugs may have caused sudden death. Although the DXM dose was estimated not to be fatal based on field information, it is possible that DXM may have reached a fatal concentration when simultaneously overdosed with DPH and ECP, which exhibit CYP2D6 inhibitory effects. Therefore, the combination of DXM and ECP may have caused fatal serotonin syndrome and death.

Aim:Emergency physicians are often puzzled regarding how to treat mamushi bites, not only because they have limited opportunities to do so, but also because there are no guidelines. This study aimed to evaluate the appropriate treatment through cases at our hospital.

Methods:The characteristics, treatment and outcomes of 21 cases of mamushi bites in the last 5 years were retrospectively studied. Incision in the bite area, administration of antibiotics, tetanus toxoid and cepharanthine was performed as primary treatment. In cases with Grade III or higher swelling, anti-mamushi antivenom was administered.

Results:Eighteen cases developed Grade III or higher swelling, with a bite to swelling time of 1-48 (median:5.3) hours. The average duration of hospitalization was 6.4 days. Twenty cases were discharged home and one case was transferred for rehabilitation. The results of administration of the antivenom were adequate in all but one case, with no cases of anaphylaxis or serum sickness.

Discussion:The favorable prognosis in all the cases was probably related to the synergistic effect of each therapy. Considering the absence of adverse events and the fact that mamushi bites can become severe or lead to death, our treatment policy seems appropriate.

An 89-year-old woman with a pacemaker was found at home face-down on top of the quilt on her charcoal-based kotatsu. She was able to respond to voices by moving her head, but could not speak herself. She was transferred to our hospital and administered oxygen en route. Blood tests showed a COHb level of 15.9%. According to her pacemaker’s manufacturer, hyperbaric oxygen therapy(HBOT)was performed at 1.5 ATA for 1 hour. After HBOT, her family said that her state of consciousness had returned to the same condition as before. Due to the patient’s advanced age, she was transferred to a rehabilitation hospital on the ninth day of hospitalization.

Since there are currently no HBOT guidelines for patients with pacemakers, we suggest that such guidelines should be created. When HBOT is performed on patients with the pacemaker, the safety of the pacemaker must be considered along with its indications.

A 68-year-old man presented to our emergency department with loss of consciousness after experiencing an irritant odor while molding fiber-reinforced plastic (FRP) without the use of appropriate respiratory protective equipment in a poorly ventilated environment. The patient was asymptomatic upon arrival at our hospital;however, based on his symptoms and a safety data sheet provided by his work manager, he was diagnosed with acute styrene poisoning. The patient was admitted to the intensive care unit and closely monitored. He was discharged on the third day of hospitalization without complications. Styrene may be generated during FRP molding. Styrene exposure can cause mucous membrane irritation and central nervous system dysfunction. Acute styrene poisoning should be considered in individuals who develop consciousness or respiratory issues during FRP production.

Cerbera odollam, commonly known as the “suicide tree”, is a highly cardiotoxic plant. In Japan, reports of poisoning are rare, and public awareness is limited. We report a case of a 34-year-old woman who ingested 10 seeds of C. odollam in a suicide attempt but avoided a fatal outcome after presenting with diverse electrocardiogram (ECG) abnormalities.

The patient experienced nausea 1.5 hours after ingestion and was brought to the emergency department 21 hours later. On arrival, her ECG revealed various abnormalities, including atrioventricular block, bradycardia, and tachycardia. She was admitted to the intensive care unit for respiratory, circulatory, and electrolyte management to prevent symptom progression. After 35 hours, her ECG spontaneously returned to sinus rhythm.

Although rare, poisoning from C. odollam is highly dangerous and potentially life-threatening. It should be considered in the differential diagnosis when evaluating patients with diverse ECG abnormalities.