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Acute carbon monoxide (CO) poisoning due to smoking hookah has been reported and may present similarly to other causes of acute carbon monoxide poisoning with nausea, headache, and loss of consciousness [1]. In the acute poisoned patient, immediate removal from the carbon monoxide source is paramount in addition to administration of oxygen and possible hyperbaric oxygen therapy (HBO) in certain situations. However, cases of chronic CO poisoning, treatment options, and long-term adverse health effects are far less reported but may include atherosclerosis and vague neurologic symptoms [2]. We present a case of a patient who chronically smoked hookah creating a condition of chronic carboxyhemoglobinemia which was discovered during work up for unexplained polycythemia. While being seen in the hematology clinic, he was found to have a blood carboxyhemoglobin of level 33.6% despite being asymptomatic. This is the highest recorded hookah-related carboxyhemoglobin concentration in the medical literature; and the significant chronic carboxyhemoglobinemia explained his polycythemia. This case illustrates that a social history is crucial when assessing the patient with severe carboxyhemoglobinemia as HBO is not indicated in chronic CO poisoning in an asymptomatic patient.

Previous self-harm attempts are a known risk factor for subsequent suicide completion in adults but is unestablished among adolescents and young adults. Our objective was to determine the mortality rate for patients 10–24 years of age following discharge from the hospital after a non-lethal, intentional overdose. A retrospective cohort study was conducted of patients aged 10–24 years seen between 2017 and 2022 by the medical toxicology consultation service (MedTox) at a large tertiary care center who experienced a non-lethal, intentional overdose and survived this encounter. The National Death Index (NDI) was examined to determine whether any of these patients subsequently died. We characterized MedTox consultations by age, sex, and substances used. Among those who died, we descriptively characterized the patient's demographics, exposure, and clinical characteristics. There were 1295 consultations for 1147 patients. Females accounted for 71 % of encounters, and most consults were for those aged 14–17 years (51 %), followed by those 18–21 years (25 %). Most commonly identified substances included acetaminophen (26 %), diphenhydramine (9 %), and ibuprofen (8 %). We identified 4 (<1 %) deaths identified from the NDI: two patients died by asphyxiation, one died by intentional overdose, and one died due to complications from chronic medical conditions. Our observed mortality was lower compared to other studies (0.7 % - 13.3 %), which may have been due to protective factors (e.g., multidisciplinary evaluations) built into the institutional protocols at this center. Future studies will attempt to qualitatively and quantitatively identify individual- and system- level mechanisms in the pathway between self-harm and long-term health outcomes.

Carbon monoxide toxicity is a common concern in emergency departments. This case report describes a neonate with a falsely elevated carboxyhemoglobin level, initially raising concern for carbon monoxide exposure. The neonate was transferred to a tertiary care hospital and admitted, with hyperbaric oxygen therapy considered. Ultimately, it was determined that actual carbon monoxide exposure was unlikely, and the elevated carboxyhemoglobin was attributed to natural breakdown of fetal hemoglobin by heme oxidase. This case highlights the importance of considering this physiological phenomenon when evaluating elevated carboxyhemoglobin levels in neonates. Recognizing this led to the deferral of hyperbaric oxygen therapy, reducing unnecessary resource utilization and preventing undue stress for the family.

Overdose-related hospital utilization is influenced by both pharmacologic effects and psychosocial context. This multicenter subanalysis from the Drug Overdose Toxico-Surveillance (DOTS) Reporting Program assessed differences in care based on the intentionality of opioid and stimulant overdoses. Data from 17 U.S. emergency departments (April 2023–September 2024) included 777 patients with confirmed opioid or stimulant overdoses, categorized as intentional (e.g., self-harm) or unintentional (e.g., recreational use, therapeutic error). Primary outcomes were hospital admission and length of stay; secondary outcomes included ICU utilization, gender distribution, and substances involved. Statistical analysis included chi-square and t-tests. Of 777 patients, 51 (6.6 %) were classified as intentional overdoses. Hospital admission was more common in intentional cases (67 %) than unintentional (56 %; p = 0.02). Unintentional overdoses were more often discharged directly from the emergency department (52 % vs. 37 %; p = 0.031). Intentional overdoses more frequently resulted in hospital stays exceeding four days, whereas most unintentional cases were discharged within one day. ICU admission rates did not differ significantly. The intentional group had a balanced gender distribution, while males represented 74 % of unintentional cases. Opioids were the most common substances, though intentional cases had more undifferentiated exposures. Intentionality significantly influenced admission rates and hospital length of stay, likely reflecting psychosocial rather than physiological factors. These findings highlight the need for standardized disposition strategies that consider both medical and psychiatric needs. Future research should focus on tools to guide evidence-based, equitable resource use in overdose care.

Bupropion is an antidepressant medication with expanding indications including smoking cessation, weight loss, attention-deficit/hyperactivity disorder, seasonal affective disorder, and amphetamine dependence. Despite its increasing popularity among providers, it has a well-known narrow therapeutic window which can lead to delayed onset of symptoms with extended-release formulations and devastating consequences in overdose. We have noticed some patients misusing bupropion via intravenous use and had difficulty guiding decisions regarding clinical monitoring in these patients. As this route entirely changes the kinetics of bupropion, this has caused concern within our group. We reviewed all the cases of intravenous bupropion use reported to a single poison center without any other coingestants. The majority (66.7%) of patients had moderate effects and one patient had a seizure. No deaths were reported. All patients were symptomatic by the time of initial call to the poison center if they had any reported symptoms due to bupropion. This case series describes the clinical effects reported, and the timing of these effects, after intravenous bupropion use.

Abstract Introduction: Dichlorvos is an organophosphate compound that is restricted in the United States. Information regarding dichlorvos skin manifestations and pediatric exposures are extremely limited. Case: A nonverbal 15-year-old male with a past medical history of autism spectrum disorder, congenital CMV, and intellectual disability was brought to the emergency department for vomiting. He developed rhinorrhea, blistering skin lesions (on inner thighs), tachypnea, decreasing mental status, and an oxygen requirement. He was started on empiric antibiotics, oxygen, and admitted to the hospital. On hospital day 3, a family member discovered a bottle of “Sniper 1000EC DDVP” insecticide (containing dichlorvos) on a shelf at home with the cap removed and half the product missing. The patient continued to recover and was discharged on hospital day 5. Cholinesterase concentrations sent on hospital day 4 returned with the following values: plasma cholinesterase 0.8 U/mL (ref 2.9 − 7.1) and RBC cholinesterase 2.7 U/mL (ref 7.9 − 17.1). Discussion: Although restricted in the United States, dichlorvos remains a potential source of morbidity. Systemic effects of dichlorvos exposure may be similar to other organophosphate compounds and include vomiting, rhinorrhea, respiratory failure, and decreased mental status. Local effects from dichlorvos or dichlorvos-containing products may lead to chemical burns.

There has been an increasing incidence of self-harm attempts in recent years in the United States. Particularly concerning, there has been a growing trend of self-harm in the adolescent and young adult population. In order to inform initiatives to address this trend, risk factors and substances used for self-harm need to be clarified. This is a descriptive retrospective observational study on all cases of self-harm poisoning in patients between the ages of 12 and 25 years reported at the state's only tertiary care center from January 2019 through March 2022. There was an increased incidence of 69% for self-harm poisonings for all ages and a 90% increase in ages 12–17 years between the years 2019 and 2021. Fifty percent of all cases occurred in patients aged 14–17 years, 69% were female, and 22% required an intensive care unit. The top three most common substances used are available without a prescription. There was a persistent increase in self-harm attempts via poisoning throughout the study period with a particularly vulnerable period in the adolescent age group.

Phenibut is a synthetically produced central nervous system (CNS) depressant that is structurally similar to the inhibitory neurotransmitter γ-aminobutyric acid (GABA). Phenibut has been identified as a drug of abuse with numerous clinical effects in overdose and a withdrawal syndrome with chronic use. The purpose of this study is to report the incidence of exposure calls regarding phenibut to a poison center, describe the reasons for its use and clinical effects. Study subjects were identified using Toxicall®, the electronic medical record utilized by the Minnesota Poison Control System. All phenibut exposure calls from January 2000 through December 2018 were included. Analysis was performed on incidence of exposure calls, reported reasons for use, signs and symptoms, coingestants, and outcome. There were 56 exposure calls over 19 years with 48 (85.7%) calls within the past five years. Over 50% of patients had CNS effects and 10.7% had withdrawal concerns. Twenty-seven patients (48%) had abuse as the reason for use and 13 (23%) used phenibut to treat anxiety. There were documented coingestants in 35.7% of patients. No patients died due to reported phenibut use, though 11 patients (19.6%) were intubated. Exposure calls to a regional poison center regarding phenibut have increased over the past five years. CNS depression was common, and associated with significant clinical outcomes including respiratory failure requiring intubation. As phenibut is easily attainable and exposures appear to be increasing, physicians should be aware of phenibut-associated CNS and respiratory depression and be prepared to manage airways appropriately.