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A 39-year-old male presented to the emergency room following parenteral injection of a household insecticide. The patient suffered from delayed, local complications as well as a dystonic-like reaction involving the neck musculature that was relieved by intramuscular diphenhydramine. Exposure to cholinesterase inhibitor insecticides has been associated with a number of serious toxicities due to accumulation of acetylcholine at various sites. It has been suggested that dystonic reactions are caused by an imbalance between cholinergic and dopaminergic pathways in the central nervous system. Therefore, a possible explanation of the dystonic reaction in this case is the increased cholinergic activity relative to dopaminergic activity induced by the insecticide.

Cardiac arrest apparently induced by penicillin TO THEEDITOR: Potassium penicillin G has been used extensively with few reports of serious adverse effects occurring when usual doses are given to the non allergic patient.' However, the rapid intravenous infusion of the antibiotic has been associated with cardiac arrhythmias and subsequent asystole." The potassium content of the drug has been implicated and is often overlooked when the agent is administered. The following describes a case of cardiac arrest apparently induced by a large intravenous bolus dose of potassium penicillin G to a pediatric patient.An II-month old, 8.5-kg male was admitted for surgical correction of a congenital cleft lip and palate. The patient was healthy with a past history significant for otitis media treated with amoxicillin. The patient had no documented drug allergies and no medications were taken in the period immediately prior to admission.Two doses of potassium penicillin V 125 mg po were given as surgical prophylaxis the night before surgery. The following morning, anesthesia was induced and, prior ro making the incision, the surgeon instructed the anesthesiologist to administer potassium penicillin G 250 OOOU iv. As is the practice at this institution, a vial containing the drug had been taped to the chart. However, when removed, the label adhered to the tape, leaving the vial unmarked. The anesthesiologist asked for verification of the contents and, assured that it was penicillin G, administered the drug as an intravenous bolus through a peripheral line over approximately two minutes. Ventricular arrhythmias consistent with hyperkalemia became apparent on the electrocardiogram; asystole ensued less than two minutes after the dose. Cardiopulmonary resuscitation was immediately initiated; a ventricular rhythm returned, which spontaneously regressed to supraventricular tachycardia. The patient was monitored closely in the pediatric intensive care unit for 48 hours. Serial electrocardiograms and neurologic exam ina-(ions were within normal limits and the patient's recovery was uneventful.

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