Gender differences in clinical characteristics of emergency department patients involving illicit drugs use with analytical confirmation.

BACKGROUND: To compare gender differences in socio-demographics, clinical manifestations, and laboratory test results of individuals who visited emergency departments (EDs) involving drug use. METHODS: We retrospectively collected the data from 10 hospitals in Taiwan on drug-related ED visits from May 2017 to December 2020. We then examined the gender differences in their socio-demographics, clinical manifestations, urine toxicological results, and other laboratory tests results using chi-square or multivariable logistic regression. RESULTS: Among individuals with drug-related ED visits, there were 546 (73.7%) men and 195 (26.3%) women. The most commonly used drugs were meth/amphetamine, followed by synthetic cathinones, and ketamine and its analogs. Compared to men, women were younger (32.03 ± 10.86 vs. 36.51 ± 10.84 years, p < 0.001) and more likely to use new psychoactive substances (NPS) (p = 0.011). Men were more likely to have human immunodeficiency virus infection (p < 0.001), whereas women were more likely to report psychiatric comorbidities (p = 0.003). Women were less likely to have aggressive behaviors (odds ratio (OR): 0.59, 95% CI: 0.39-0.88). After adjusting for socio-demographics and drug types, women were still less likely to have aggressive behaviors than men (adjusted OR: 0.59, 95% CI: 0.38-0.93). The likelihood of rhabdomyolysis and intensive care unit admission was higher in men (p < 0.001). CONCLUSION: We found considerable gender differences in clinical characteristics among ED-visiting drug users, which could offer valuable information for the future development of more tailored gender-specific drug prevention and treatment strategies.

Impact of the COVID-19 pandemic on emergency medical service response to out-of-hospital cardiac arrests in Taiwan: a retrospective observational study.

BACKGROUND: Emergency medical service (EMS) personnel have high COVID-19 risk during resuscitation. The resuscitation protocol for patients with out-of-hospital cardiac arrest (OHCA) was modified in response to the COVID-19 pandemic. However, how the adjustments in the EMS system affected patients with OHCA remains unclear. METHODS: We analysed data from the Taichung OHCA registry system. We compared OHCA outcomes and rescue records for 622 cases during the COVID-19 outbreak period (1 February to 30 April 2020) with those recorded for 570 cases during the same period in 2019. RESULTS: The two periods did not differ significantly with respect to patient age, patient sex, the presence of witnesses or OHCA location. Bystander cardiopulmonary resuscitation and defibrillation with automated external defibrillators were more common in 2020 (52.81% vs 65.76%, p<0.001%, and 23.51% vs 31.67%, p=0.001, respectively). The EMS response time was longer during the COVID-19 pandemic (445.8±210.2 s in 2020 vs 389.7±201.8 s in 2019, p<0.001). The rate of prehospital return of spontaneous circulation was lower in 2020 (6.49% vs 2.57%, p=0.001); 2019 and 2020 had similar rates of survival discharge (5.96% vs 4.98%). However, significantly fewer cases had favourable neurological function in 2020 (4.21% vs 2.09%, p=0.035). CONCLUSION: EMS response time for patients with OHCA was prolonged during the COVID-19 pandemic. Early advanced life support by EMS personnel remains crucial for patients with OHCA.

Oxidative storm in a patient with acute rotenone-containing plant poisoning.

A 64-year-old woman presented with coma, seizure, and lactic acidosis after ingesting 80 yam bean seeds. This rotenone-containing seeds cause cellular asphyxia via blockage of the mitochondrial electron transport. Subsequent oxidative stress results in the formation of lipid peroxidation (LPO). Rotenone analysis via liquid chromatography mass spectrometry revealed the following: 31,590 ng/mL in cooked yam bean seed and 100 ng/mL in the blood. We attempted to use N-acetylcysteine to alleviate oxidative stress and documented the continuous decline in the plasma concentration of LPO.

Spontaneous bilateral haemothorax with haemopericardium secondary to rivaroxaban.

WHAT IS KNOWN AND OBJECTIVE: Although the risk of major bleeding with non-vitamin K antagonist oral anticoagulant (NOAC) is low, life-threatening bleeding can occur. CASE SUMMARY: We report a case of an 81-year-old female with deep vein thrombosis who developed bilateral spontaneous haemothorax and haemopericardium after rivaroxaban therapy. Diagnostic thoracentesis revealed a grossly bloody pleural effusion. She was treated with factor eight inhibitor bypassing agent, but the result was not satisfactory. WHAT IS NEW AND CONCLUSION: To our knowledge, this is the first case report of a concomitant presentation of spontaneous bilateral haemothorax and haemopericardium due to rivaroxaban use. This case highlights the potential risk of major haemorrhagic complication of NOAC, which could be life-threatening and require emergent reversal.

N-acetylcysteine and ascorbic acid therapy for acute hepatic injury after hexavalent chromium ingestion.

WHAT IS KNOWN AND OBJECTIVE: Hexavalent (VI) chromium is a powerful oxidant that can produce cellular oxidative stress and multi-organ system dysfunction. The role of antioxidants such as N-acetylcysteine (NAC) and ascorbic acid in alleviating organ damage in humans remains unclear. CASE DESCRIPTION: We present a 47-year-old male who ingested 30 mL of plating solution and developed hepatic injury. He was treated with NAC and ascorbic acid with improvement in hepatic function. However, his clinical conditions and jaundice worsened again after discontinuing these therapies. WHAT IS NEW AND CONCLUSION: Our findings suggest a potential role for antioxidant therapy for acute hexavalent chromium poisoning.

Brain Computed Tomography in Stimulant Poisoning with Altered Consciousness.

BACKGROUND: Stimulant poisoning frequently causes altered mental status (AMS) and can result in severe cerebral vascular complications. The role of noncontrast brain computed tomography (CT) in acute stimulant-poisoned patients presenting with AMS remains unclear. OBJECTIVES: We examined the results and impacts of brain CT in acute stimulant-poisoned patients with AMS. METHODS: We performed a retrospective single-center study that included all adult patients who presented to the emergency department with stimulant poisoning and AMS (Glasgow coma scale [GCS] score <15) between January 1, 2010 and December 31, 2017. Patients who had concomitant head trauma or who presented with focal neurologic symptoms were excluded. The primary outcome was the rate of acute abnormalities on brain CT. The secondary outcomes were to identify factors that affected the decision to perform brain CT in stimulant-poisoned patients with AMS and whether obtaining the brain CT scan itself affected the patients' prognoses. RESULTS: The analysis included 66 patients, of whom 6 died from the poisoning. Noncontrast brain CT was performed in 31 patients and none had acute abnormalities. Patients who underwent brain CT were found to have worse GCS scores, higher body temperatures, higher intubation rates, higher admission rates, longer admission periods and intensive care unit stays, and a higher mortality rate. After adjusting for the propensity score, performing brain CT itself did not independently affect the patients' clinical outcomes. CONCLUSIONS: Nontrauma stimulant-poisoned patients presenting with AMS and without focal neurologic symptoms were unlikely to have acute abnormalities on brain CT. Patients who underwent brain CT scans had worse consciousness and greater disease severity.

Mortality after major bleeding in Asian atrial fibrillation patients receiving different direct oral anticoagulants: a nationwide, propensity score study.

In this research, we assessed mortality after major bleeding events in atrial fibrillation (AF) patients taking four direct oral anticoagulants (DOACs). Drawing data from the Taiwan National Health Insurance Research Database between 2016 and 2019, we focused on AF patients on DOACs who had major bleeding episodes. Using propensity score stabilized weighting, we established four comparable pseudo-DOAC groups. Among 2770 patients (460 dabigatran, 1322 rivaroxaban, 548 apixaban, 440 edoxaban), 85.3% were prescribed low-dose regimens. The 7-day mortality rate was 9.0%, surging to 16.0% by the 30th day. Compared with dabigatran, there was a distinct divergence in 7-day mortality of factor Xa inhibitors (p = 0.012), with hazard ratios of 1.83 (95% CI 1.11-3.00, p = 0.017) for rivaroxaban, 2.13 (95% CI 1.23-3.66, p = 0.007) for apixaban, and 2.41 (95% CI 1.39-4.19, p = 0.002) for edoxaban. This pattern remained consistent when analyzing the subgroup that received lower dosages of DOACs. In conclusion, factor Xa inhibitors were associated with a significantly higher risk of 7-day mortality following major bleeding events than dabigatran among AF patients.

Reassessing clinical presentations of emamectin benzoate poisoning: A comprehensive study.

BACKGROUND: The mechanism of emamectin benzoate (EMB-a macrocyclic lactone insecticide like abamectin) action involves the disruption of glutamate-gated chloride channels and GABA receptors in insects, leading to paralysis and death. EMB overdose can breach the blood-brain barrier, resulting in severe poisoning and altered consciousness. AIM: Review EMB poisoning presentations in patients and reevaluate clinical manifestations. MATERIALS AND METHODS: This retrospective study reviewed (August 31, 2008-August 31, 2023) medical university hospital records. We analyzed symptoms, patient characteristics, vital signs, Glasgow Coma Scale scores, laboratory findings, and outcomes. RESULTS: Ten patients (males: 6, females: 4, median age = 64.5 years) experienced EMB poisoning. Common symptoms included sore throat, gastrointestinal distress, dyspnea, and altered consciousness; two patients showed laryngeal corrosive injuries. Management involved activated charcoal administration, gastric lavage, and intensive care unit admission. DISCUSSION: Sore throat and corrosive injuries were distinctive presentations of EMB poisoning, warranting vigilance. Potential mechanisms of corrosive injury include skin and eye irritation effects of EMB, the solvents of which might exert corrosive action. CONCLUSION: EMB poisoning manifests as diverse symptoms, including sore throat, gastrointestinal symptoms, central nervous system depression, and potential aspiration pneumonia. Recognizing and promptly managing EMB poisoning are crucial for enhancing patient outcomes and minimizing complications.

Hypermagnesemia in a constipated female.

BACKGROUND: Hypermagnesemia is a rare condition that is usually iatrogenic. Magnesium oxide (MgO) ingestion by constipated patients with prolonged colonic retention contributes to hypermagnesemia. Treatment of hypermagnesemia includes discontinuation of the magnesium use, gastrointestinal (GI) decontamination, and removal of magnesium from the serum by dialysis. Calcium acts as an antagonist in hypermagnesemia. CASE REPORT: A 72-year-old woman presented with constipation and MgO ingestion. The patient was brought to our department due to altered mental status and progressive general weakness. Laboratory tests showed a magnesium level of 6.2 mEq/L. Bradycardia and hypotension developed with rebound hypermagnesemia after incomplete dialysis. Abdomen computed tomography showed hyperdense MgO tablets retained in the colon. A magnesium-free laxative was used for GI decontamination. Despite the use of high-dose inotropics and an elevated trigger for transcutaneous pacing, the cardiac performance improved minimally. Although our patient responded to calcium administration with hemodynamic improvement, prolonged hypotension and decreased perfusion led to hypoxic encephalopathy. CONCLUSION: This report demonstrates that MgO tablets retained in the GI tract without adequate decontamination result in continuous absorption and rebound of hypermagnesemia. This report also addresses the importance of GI decontamination in the treatment of hypermagnesemia.

Comparison of the safety, effectiveness, and usability of swab robot vs. manual nasopharyngeal specimen collection.

Background: Healthcare workers face a risk of infection during aerosol-generating procedures, such as nasal swabbing. Robot-assisted nasopharyngeal sampling aims to minimize this risk and reduce stress for healthcare providers. However, its effectiveness and safety require validation. Methods: We conducted a controlled trial with 80 subjects at two teaching hospitals and compared robot-collected vs manually-collected nasopharyngeal swabs. The primary outcomes included specimen quality and success rate of nasopharyngeal swab collection. We also recorded the pain index, duration of the collection, and psychological stress using a post-collection questionnaire. Results: During the study period, from September 23 to October 27, 2020, 40 subjects were enrolled in both the robotic and manual groups. The cycle threshold (Ct) value for nasopharyngeal specimens was statistically higher in the robotic group compared to the manual group (30.9 vs 28.0, p < 0.01). Both groups had Ct values under 35, indicating good quality specimens. In the robotic group, 3 out of 40 subjects required a second attempt at specimen collection, resulting in a success rate of 92.5 %. Further, although the pain levels were lower in the robotic group, the difference was not statistically significant (2.8 vs 3.6, p = 0.07). The manual group had a shorter sampling time, which was 29 s (201 vs 29, p < 0.05). However, when factoring in the time needed to put on personal protective equipment, the average time for the manual group increased to 251 s (201 vs 251, p < 0.05). Participants' questionnaire results show comparable psychological stress in both groups. Medical staff expressed that using a robot would reduce their psychological stress. Conclusions: We propose a safe and effective robotic technology for collecting nasopharyngeal specimens without face-to-face contact, which may reduce the stress of physicians and nurses. This technology can also be optimized for efficiency, making it useful in situations where droplet-transmitted infectious diseases are a concern.

Clinical characteristics of new psychoactive substances: A multicenter study.

BACKGROUND: New psychoactive substances (NPS) are synthetic alternatives to illicit drug abuse that are not under international control but may pose a public health threat. Moreover, the symptoms and signs of NPS users may be quite variable. This study aimed to figure out the clinical characteristics of NPS users presented to the emergency department (ED). METHODS: A total of 1385 cases were tested via urine toxicity screening from March 25, 2019, to January 28, 2020, in six medical centers, and ten hospitals, in Taiwan. A total of 123 non-NPS cases and 77 NPS-use cases were enrolled in this study. We compared the patient data-vital signs, presentation, co-morbidities, behaviors, symptoms, electrocardiograms, laboratory data, length of stays-and outcomes of NPS users and non-NPS drug users. RESULTS: NPS users were 5.7 years younger than the non-NPS drug users (37 vs. 42.7 years, p = 0.022). Presently, NPS users had a 2.6-fold (27.2%) higher rate of suicide and a 2.9-fold (11.7%) greater possibility of violence than non-NPS drug users. Moreover, in NPS users, eye-opening was affected at a scale of 3.1 versus 3.4 (p = 0.048) in non-NPS drug users in the evaluation of consciousness and they experienced a 4.3-fold greater feeling of palpitation (p = 0.024) and had 8.1-fold higher chance of presenting facial flush (p = 0.032) than non-NPS drug users. CONCLUSION: NPS users are relatively younger, are more likely to experience facial flush and palpitation and engage in more self-harm, violence, and suicide than non-NPS drug users. Physicians need to pay attention to people who have altered, bizarre mental statuses with the clinical characteristics described above.

Postintubation hemodynamic effects of intravenous lidocaine in severe traumatic brain injury.

BACKGROUND: The risks of intravenous (IV) lidocaine before rapid sequence induction (RSI) have become a great concern. No study has investigated the hemodynamic effects of IV lidocaine during endotracheal intubation in patients with severe traumatic brain injury. OBJECTIVE: We investigated whether the use of IV lidocaine before RSI was associated with postintubation hemodynamic changes in patients with severe traumatic brain injury. METHODS: In this retrospective cohort study, adults who presented with isolated traumatic brain injury and definite intracranial hemorrhage were included. Patients who presented with other major injuries received prehospital intubation, had initial mean arterial pressure (MAP) less than 70 mm Hg, and/or had incomplete medical records were excluded. RESULTS: A total of 101 patients (82.2% men; mean age, 48.6 ± 19.6 years) were enrolled. Forty-six patients received IV lidocaine in addition to RSI before intubation (group 1), and 55 received RSI without IV lidocaine before intubation (group 2). There were no significant intergroup differences in baseline characteristics, the number of RSI doses, or the RSI dose used, with the exception of sex, diagnosis of subarachnoid hemorrhage, and diagnosis of subdural hemorrhage. Our results demonstrated no significant intergroup differences in MAP changes or the proportion of patients with hypotension (MAP <70 mm Hg) after intubation. Intravenous lidocaine remained unrelated to significant hypotension after adjusting for variables by logistic regression analysis. CONCLUSION: Intravenous lidocaine in addition to RSI before endotracheal intubation was not associated with significant hemodynamic changes in patients with severe traumatic brain injury.

Triage vital signs predict in-hospital mortality among emergency department patients with acute poisoning: a case control study.

BACKGROUND: To document the relationship between triage vital signs and in-hospital mortality among emergency department (ED) patients with acute poisoning. METHODS: Poisoning patients who admitted to our emergency department during the study period were enrolled. Patient's demographic data were collected and odds ratios (OR) of triage vital signs to in-hospital mortality were assessed. Receiver operating characteristic curve was used to determine the proper cut-off value of vital signs that predict in-hospital mortality. Logistic regression analysis was performed to test the association of in-hospital mortality and vital signs after adjusting for different variables. RESULTS: 997 acute poisoning patients were enrolled, with 70 fatal cases (6.7%). A J-shaped relationship was found between triage vital signs and in-hospital mortality. ED triage vital signs exceed cut-off values independently predict in-hospital mortality after adjusting for variables were as follow: body temperature <36 or >37°C, p < 0.01, OR = 2.8; systolic blood pressure <100 or >150 mmHg, p < 0.01, OR: 2.5; heart rate <35 or >120 bpm, p < 0.01, OR: 3.1; respiratory rate <16 or >20 per minute, p = 0.38, OR: 1.4. CONCLUSIONS: Triage vital signs could predict in-hospital mortality among ED patients with acute poisoning. A J-curve relationship was found between triage vital signs and in-hospital mortality. ED physicians should take note of the extreme initial vital signs in these patients.

Clinical Presentations and Predictors of In-Hospital Mortality in Illicit Drug Users in the New Psychoactive Substances (NPS) Endemic Era in Taiwan.

Predictors of mortality in illicit drug users involving Novel Psychoactive Substances (NPS) and multiple substances have not been elucidated. We aimed to define predictors of mortality in the NPS endemic era's illicit drug users to strengthen patient care in emergency treatment. This was a retrospective study. LC-MS/MS-confirmed positive illicit drug users who visited the emergency departments (ED) of six medical systems were enrolled. Demographic information, physical examinations, and laboratory data were abstracted for mortality analysis. There were 16 fatalities in 355 enrolled patients. The most frequently used illicit drugs were amphetamines, followed by opioids, cathinones, and ketamine. The most frequently detected cathinones among the 16 synthetic cathinones were eutylone, followed by mephedrone. The combined use of cathinones and ketamine was most commonly observed in our results. Univariate analysis revealed that the mortality patients were older, with deep coma, faster heart rate and respiratory rate, lower blood pressures and O2 room air saturation, more seizures, abnormal breath sounds, and had urine incontinence compared to the survivor patients. The mortality patients also had acute kidney injury, higher potassium, blood sugar, liver function test, and lactate level. The results of multiple logistic regression demonstrated that SBP < 90 mmHg, dyspnea, blood sugar > 140 mg/dl, and HCO3 < 20.6 mmHg were independent predictors of in-hospital mortality. Regardless of the pattern of the use of illicit drugs, the predictors allow for risk stratification and determining the optimal treatment.

Intentional avermectin pesticide ingestion: a retrospective multicenter study.

CONTEXT: Avermectin pesticides are widely used in agriculture, and are thought to have low toxicity in humans. However, information on their toxicity after accidental or deliberate ingestion is limited. OBJECTIVE: The aim of this study was to evaluate the clinical manifestations of avermectin pesticide ingestion and identify factors associated with severe outcomes (death, intubation, or sustained hypotension requiring inotrope therapy). MATERIALS AND METHODS: This multicenter retrospective study included patients who visited the emergency departments of six teaching hospitals due to acute avermectin pesticide ingestion between January 2012 and May 2020. Patients who reported ingestion of any other pesticides, drugs, or substances were excluded. RESULTS: In total, 64 patients (median age, 72 years) were included: 60 had ingested emamectin pesticides, and 4 had ingested abamectin. Almost all (98%) were cases of self-harm. The most common presentation was drowsiness (47%), with a median Glasgow Coma Scale (GCS) score of 14, followed by shortness of breath (SOB)/dyspnea (33%) and nausea/vomiting (22%). Concurrent methanol exposure (via the solvent) was confirmed or suspected in five patients. Seventeen patients (27%) were intubated. Three patients who developed respiratory failure were not intubated because of a "do-not-resuscitate" (DNR) order. Four patients developed sustained hypotension requiring inotrope therapy. Fifty patients (78%) were admitted, of whom 27 (42%) required intensive care unit (ICU) admission. Four patients died, three of whom had a DNR order. Based on our definition, 20 patients (31%) had severe outcomes. A multivariate logistic regression model showed that a GCS score < 13 (OR 68.1, 95% CI 3.8-999) and the presence of SOB/dyspnea (OR 50.2, 95% CI 3.0-849.9) were associated with severe outcomes. CONCLUSIONS: Most patients who intentionally ingested avermectin pesticides required inpatient treatment. Forty-two percent needed ICU care and 31% had severe outcomes. A GCS score < 13 and SOB/dyspnea were independently associated with severe outcomes.

Fatal cardiac glycoside poisoning due to mistaking foxglove for comfrey.

CONTEXT: Accidental ingestion of foxglove (Digitalis purpurea) can cause significant cardiac toxicity. We report a patient who ingested foxglove mistaking it for comfrey and developed refractory ventricular arrhythmias. The patient died despite treatment with digoxin-specific antibody fragments (DSFab) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). CASE DETAILS: A 55-year-old woman presented to the emergency department with nausea, vomiting and generalized weakness eight hours after drinking "comfrey" tea. She had bradycardia (54 beats/min) and hyperkalemia (7.6 mEq/L). Electrocardiogram revealed a first-degree atrioventricular conduction block with premature atrial contractions, followed by polymorphic ventricular tachycardia three hours after arrival. A serum digoxin level was 151.2 ng/mL. The patient developed ventricular fibrillation while waiting for Digibind infusion. Resuscitation was performed and an emergent VA-ECMO was set up. A total of eight vials of Digibind were given over the next 16 hours. She temporarily regained consciousness, but remained hemodynamically unstable and subsequently developed lower limb ischemia and multiple organ failure, and she expired on hospital day seven. A botanist confirmed that the plant was foxglove. CONCLUSIONS: The diagnosis of cardiac glycoside plant poisoning can be difficult in the absence of an accurate exposure history. In facilities where DSFab is unavailable or insufficient, early VA-ECMO might be considered in severely cardiotoxic patients unresponsive to conventional therapy.