精神科疾患の既往歴がある27歳，女性。自宅ベッド上で意識がない状態で発見された。発見時，部屋には処方薬および市販薬の空包が散在していた。解剖検査では，急死を示唆する所見を示した。薬物定量検査の結果，大腿血中濃度は，デキストロメトルファン（DXM）およびジフェンヒドラミン（DPH）がそれぞれ3.6 µg/mL， 6.2 µg/mLと文献上の致死域に達しており，エスシタロプラム（ECP）が0.42 µg/mLと文献上の中毒域で検出され，これら薬剤の複合作用により急死した可能性が考えられた。現場状況から，DXMの服用量は致死的でないと推定されたが，CYP2D6阻害作用を示すDPHとECPと同時に過量服用したことで致死的な濃度に達した可能性が考えられた。また，DXMとECPの併用が致死的なセロトニン症候群を引き起こし，死亡に至った可能性も否定はできなかった。

【目的】マムシ咬傷の診療機会は少なくガイドラインもないため，救急医は治療法に迷うことがある。当院の症例から，治療法の評価を行った。【方法】5年間のマムシ咬傷21例を患者背景，治療，転帰につき後方視的に調査した。初期治療は咬傷部の小切開，抗菌薬，破傷風トキソイド，セファランチンの投与を基本とし，腫脹GradeⅢ以上でマムシ抗毒素を投与した。【結果】最大GradeⅢ以上の症例は18例あり，受傷からGradeⅢまでは1～48（中央値5.3）時間。平均入院期間は6.4日で，20例が自宅退院し，1例はリハビリ転院した。抗毒素は1例を除くGradeⅢ以上の全症例に投与されたが，アナフィラキシーや血清病は発症せず。【考察】全例の良好な退院転帰は各治療の相乗効果の可能性を示唆する。有害事象を生じなかったことと，重篤化すれば死亡し得ることを考慮すれば，今回の治療方針も好適なものと考え得る。

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.