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American Academy of Pediatrics Committee on Environmental Health Lead exposure in children: prevention, detection, and management Pediatrics 2005 Oct;116(4):1036 46 [PMID: 16199720] Burke BL Jr Lead poisoning treatment J Pediatr 2006 Sep;149 (3):428 [PMID: 16939771] Patrick L Lead toxicity, a review of the literature Part 1: Exposure, evaluation, and treatment Altern Med Rev 2006 Mar;11(1):2 22 [PMID: 16597190] Saper RB et al Heavy metal content of ayurvedic herbal medicine products JAMA 2004 Dec 15;292(23):2868 73 [PMID: 15598918]

Maintain a patent airway and assist respirations if necessary Treat coma, hyperthermia, and seizures as outlined at the beginning of this chapter For recent large ingestions, consider giving activated charcoal orally or by gastric tube

Patients with anticholinergic delirium may benefit from a dose of physostigmine, 05 1 mg intravenously, not to exceed 1 mg/min Dysphoria, agitation, and psychosis associated with LSD or mescaline intoxication may respond to benzodiazepines (eg, lorazepam, 1 2 mg orally or intravenously) or haloperidol (2 5 mg intramuscularly or intravenously) Monitor patients who have sniffed solvents for cardiac dysrhythmias (most commonly premature ventricular contractions, ventricular tachycardia, ventricular fibrillation); treatment with -blockers such as propranolol (1 5 mg intravenously) or esmolol (250 500 mcg/kg intravenously, then 50 mcg/kg/ min by infusion) may be more effective than lidocaine

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Halpern JH et al Psychological and cognitive effects of longterm peyote use among Native Americans Biol Psychiatry 2005 Oct 15;58(8):624 31 [PMID: 16271313] Manaboriboon B et al Dextromethorphan abuse in Thai adolescents: A report of two cases and review of literature J Med Assoc Thai 2005 Nov;88(Suppl 8):S242 5 [PMID: 16856446] Patel MM et al Methylenedioxymethamphetamine (ecstasy)related hyperthermia J Emerg Med 2005 Nov;29(4):451 4 [PMID: 16243206] Vural M et al Dilated cardiomyopathy associated with toluene abuse Cardiology 2006;105(3):158 61 [PMID: 16479101]

Acute mercury poisoning usually occurs by ingestion of inorganic mercuric salts or inhalation of metallic mercury vapor Ingestion of the mercuric salts causes a burning sensation in the throat, discoloration and edema of oral mucous membranes, abdominal pain, vomiting, bloody diarrhea, and shock Direct nephrotoxicity causes acute renal failure Inhalation of high concentrations of metallic mercury vapor may cause acute fulminant chemical pneumonia Chronic mercury poisoning causes weakness, ataxia, intention tremors, irritability, and depression Exposure to alkyl (organic) mercury derivatives from contaminated fish or fungicides used on seeds has caused ataxia, tremors, convulsions, and catastrophic birth defects

A variety of substances ranging from naturally occurring plants and mushrooms to synthetic substances such as phencyclidine (PCP), toluene and other solvents, and lysergic acid diethylamide (LSD) are abused for their hallucinogenic properties The mechanism of toxicity and the clinical effects vary for each substance Many hallucinogenic plants and mushrooms produce anticholinergic delirium, characterized by flushed skin, dry mucous membranes, dilated pupils, tachycardia, and urinary retention Other plants and mushrooms may contain hallucinogenic indoles such as mescaline and LSD, which typically cause marked visual hallucinations and perceptual distortion, widely dilated pupils, and mild tachycardia PCP, a dissociative anesthetic agent similar to ketamine, can produce fluctuating delirium and coma, often associated with vertical and horizontal nystagmus Toluene and other hydrocarbon solvents (butane, trichloroethylene, chemo, etc) cause euphoria and delirium and may sensitize the myocardium to the effects of catecholamines, leading to fatal dysrhythmias

There is no effective specific treatment for mercury vapor pneumonitis Remove ingested mercuric salts by lavage, and administer activated charcoal (see p 1362) For acute ingestion of mercuric salts, give dimercaprol (BAL) at once, as for arsenic poisoning Unless the patient has severe gastroenteritis, consider succimer (DMSA), 10 mg/kg orally every 8 hours for 5 days and then every 12 hours for 2 weeks Unithiol is a

chelator that can be given orally or parenterally, but is not commonly available in the United States Maintain urinary output Treat oliguria and anuria if they occur

Remove from exposure Neurologic toxicity is not considered reversible with chelation, although some authors recommend a trial of succimer or uniothiol (contact a regional poison center or medical toxicologist for advice)

Mozaffarian D et al Fish intake, contaminants, and human health: evaluating the risks and the benefits JAMA 2006 Oct 18;296(15):1885 99 [PMID: 17047219] Needleman HL Mercury in dental amalgam a neurotoxic risk JAMA 2006 Apr 19;295(15):1835 6 [PMID: 16622146] Saper RB et al Heavy metal content of ayurvedic herbal medicine products JAMA 2004 Dec 15;292(23):2868 73 [PMID: 15598918] Weil M et al Blood mercury levels and neurobehavioral function JAMA 2005 Apr 20;293(15):1875 82 [PMID: 15840862]

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