Bizarre treatment recommendations survive editorial process at major emergency medicine journals
December 5, 2012, 2:25 am
Acute Cyanide Intoxication Due to Apricot Seed Ingestion. Akil M et al. J Emerg Med 2012 Nov 13. pii: S0736-4679(12)01122-5. doi: 10.1016/j.jemermed.2012.05.041. [Epub ahead of print]
This case report describes a 3-year-old girl who became unconscious after apparently eating “8-12 pieces of apricot seeds”. In hospital, she was diagnosed with cyanide toxicity on clinical grounds, and treated with activated charcoal, hydroxocobalamin, and lactulose. The authors report that the girl’s mental status “progressively improved” after treatment with the antidote.
Well, apricot pits do contain amydalin which — when the pits are chewed and ingested — is hydrolyzed to cyanide. But was this really a case of cyanide toxicity? I remain unconvinced.
Unfortunately, even considering that this case report was published as a “Letter to the Editor”, it is so incomplete and misleading that it leads me at least to question the editorial standards of the Journal of Emergency Medicine. Not only was there no cyanide level measured, but the patient did not exhibit one of the hallmarks of cyanide poisoning, namely metabolic acidosis. In addition, the authors do not report the results of any tests to rule-out alternative causes of altered mental status, such as hypoglycemia or ethanol intoxication. Finally, the authors claim that “Active charcoal is also effective in cyanide intoxication”, citing the 2007 edition of Nelson Textbook of Pediatrics. Although I could not check that edition, the 2011 Nelson makes no such claim, which I do not believe is supported by any literature. The problem of course is that it seems extremely unwise to administer activated charcoal — an intervention without proven benefit — to a child who has ingested cyanide, and is likely to be unconscious and seizing in the near future. By the way, there is no indication in the paper that this child was intubated. I am amazed that JEM let this absurd statement through.
Speak of questionable editorial practices, there is an interesting letter in the current Annals of Emergency Medicine from Skolnik et al, questioning a treatment recommendation in an article several issues ago. In discussing treatment of methanol toxicity, the authors of that article advocated “gastric lavage with sodium bicarbonate within 2 hours of ingestion”. Skolnik et al point out that they could find “no evidence of any benefit from such a practice in the medical literature”. Again, I am amazed that Annals let this bizarre suggestion survive the editing process. So much for peer review.