Load and go: Assessing safety outcomes of patients discharged from the emergency department after receiving phenobarbital for alcohol withdrawal.

Objectives: Phenobarbital (PB) is a long-acting GABA A-agonist with favorable pharmacokinetics (long half-life and duration of effect) that allows effective treatment of alcohol withdrawal (AW) after administration of a single loading dose. Current evidence suggests that in the setting of AW, PB administration may be associated with decreased hospital admissions and hospital length of stay. The aim of this study was to evaluate the safety outcomes of AW patients who were treated and discharged from the emergency department (ED) after receiving PB for AW. Methods: This retrospective chart review included a convenience sample of 33 AW patients who presented to four EDs within an 18-month span. Descriptive statistics (frequencies and percentages) were used to describe demographics, distribution of resources and referrals, and the safety outcomes of PB administration for low-risk AW patients. Patients were selected for inclusion in consultation with a medical toxicologist, treated with PB, and discharged from the ED. Electronic medical records were utilized to gather information on the patient cohort. Results: All patients were treated with at least a single loading dose of 5‒10 mg/kg (ideal body weight) of intravenous or per os PB during their ED stay. Only one patient had an unanticipated event after discharge, which was related to driving against advice. Two additional patients had ED revisits for recurrent alcohol use within 72 h, and 16 patients had recurrent alcohol use within 30 days. All 33 patients were provided with resources for linkage to treatment. None required hospital admission. Conclusion: ED PB "load and go" may be a safe, effective AW treatment that could help treat AW, facilitate linkage to specific rehabilitation treatments, and decrease hospital admissions.

Lithium Toxicity: A Case Report of Toxicity Resulting in a Third-degree Heart Block.

Introduction: Lithium is a medication used to treat bipolar disorder. It has a narrow therapeutic index, which frequently causes toxicity in patients. Case Report: We present an unusual case of a 66-year-old female with a history of bipolar disorder on chronic lithium, who developed a third-degree heart block, encephalopathy, and acute renal failure because of lithium toxicity. Conclusion: This case highlights a rare but life-threatening case of complete heart block in the setting of lithium toxicity. The patient was treated with hemodialysis and pacemaker placement.

Severe outcomes following pediatric cannabis intoxication: a prospective cohort study of an international toxicology surveillance registry.

INTRODUCTION: An increasing number of jurisdictions have legalized recreational cannabis for adult use. The subsequent availability and marketing of recreational cannabis has led to a parallel increase in rates and severity of pediatric cannabis intoxications. We explored predictors of severe outcomes in pediatric patients who presented to the emergency department with cannabis intoxication. METHODS: In this prospective cohort study, we collected data on all pediatric patients (<18 years) who presented with cannabis intoxication from August 2017 through June 2020 to participating sites in the Toxicology Investigators Consortium. In cases that involved polysubstance exposure, patients were included if cannabis was a significant contributing agent. The primary outcome was a composite severe outcome endpoint, defined as an intensive care unit admission or in-hospital death. Covariates included relevant sociodemographic and exposure characteristics. RESULTS: One hundred and thirty-eight pediatric patients (54% males, median age 14.0 years, interquartile range 3.7-16.0) presented to a participating emergency department with cannabis intoxication. Fifty-two patients (38%) were admitted to an intensive care unit, including one patient who died. In the multivariable logistic regression analysis, polysubstance ingestion (adjusted odds ratio = 16.3; 95% confidence interval: 4.6-58.3; P < 0.001)) and cannabis edibles ingestion (adjusted odds ratio = 5.5; 95% confidence interval: 1.9-15.9; P = 0.001) were strong independent predictors of severe outcome. In an age-stratified regression analysis, in children older than >10 years, only polysubstance abuse remained an independent predictor for the severe outcome (adjusted odds ratio 37.1; 95% confidence interval: 6.2-221.2; P < 0.001). As all children 10 years and younger ingested edibles, a dedicated multivariable analysis could not be performed (unadjusted odds ratio 3.3; 95% confidence interval: 1.6-6.7). CONCLUSIONS: Severe outcomes occurred for different reasons and were largely associated with the patient's age. Young children, all of whom were exposed to edibles, were at higher risk of severe outcomes. Teenagers with severe outcomes were frequently involved in polysubstance exposure, while psychosocial factors may have played a role.

You Dropped the Bomb on Me: A Case Series of Carbon Tetrachloride Toxicity.

Carbon tetrachloride (CCl4) is a halogenated hydrocarbon that is a colorless, clear liquid with a sweetish, ether-like, nonirritant odor. It was previously used in dry cleaning agents, refrigerants, and fire extinguishers. CCl4 toxicity is rarely observed. Two patients with acute hepatitis following exposure to a CCl4-containing antique fire extinguisher are presented. A son (patient 1) and father (patient 2) were admitted to the hospital with acute, unexplained elevated transaminases. After extensive questioning, they reported recent exposure to a large amount of CCl4 when an antique firebomb shattered in their home. Both patients cleaned the debris without personal protective equipment and slept in the contaminated area. The patients presented to the emergency department (ED) at varying times between 24 and 72 hours after CCl4 exposure. Both patients received intravenous N-acetylcysteine (NAC); patient 1 also received oral cimetidine. Both recovered uneventfully without sequelae. Extensive workup for other causes of elevated transaminases was unremarkable. Serum analyses for CCl4 were also unremarkable due to the delay between exposure and hospital presentation. CCl4 is a potent hepatotoxin. CCl4 metabolism via cytochrome CYP2E1 produces its toxic metabolite, the trichloromethyl radical. This radical covalently binds to hepatocyte macromolecules and causes lipid peroxidation and oxidative damage with ensuing centrilobular necrosis. Treatment is not well established, but NAC is likely beneficial via glutathione repletion and antioxidant effects. Cimetidine blocks cytochrome P450 and, thus, metabolite formation. Cimetidine may also promote the stimulation of regenerative processes acting on DNA synthesis. CCl4 toxicity is rare and infrequently reported in current literature but should be maintained in the differential of acute hepatitis. Two patients presenting nearly identically - at two different ages but from the same household - offered a clue to this enigmatic diagnosis.

African Bush Viper Envenomation: A Case Report.

Atheris squamigera envenomation is an infrequently documented occurrence in the United States (US). Cases of envenomation may induce severe coagulopathies, renal failure, and potentially life-threatening hemorrhage. Currently, there are no antivenoms specific to the Atheris genus, but there have been documented cases of the use of antivenoms for other species. A 26-year-old man presented to the emergency department (ED) complaining of swelling and discomfort in his left foot after being bitten by an Atheris squamigera that he kept as a pet.After performing a physical exam, it was noted that the patient's envenomation was likely mild. Throughout his hospital stay, he developed lab abnormalities, most notably an elevated D-dimer and low fibrinogen. His clinical symptoms improved after a short stay, and he did not require antivenom treatment. This case highlights a rare, but potentially life-threatening envenomation that may be encountered in the US due to the continued practice of exotic pet ownership and sales. Moreover, procurement of antivenom for non-native species poses a unique challenge to US physicians responsible for treating these patients.

Predictors of severe outcome following opioid intoxication in children.

INTRODUCTION: While the opioid crisis has claimed the lives of nearly 500,000 in the U.S. over the past two decades, and pediatric cases of opioid intoxications are increasing, only sparse data exist regarding risk factors for severe outcome in children following an opioid intoxication. We explore predictors of severe outcome (i.e., intensive care unit [ICU] admission or in-hospital death) in children who presented to the Emergency Department with an opioid intoxication. METHODS: In this prospective cohort study we collected data on all children (0-18 years) who presented with an opioid intoxication to the 50 medical centers in the US and two international centers affiliated with the Toxicology Investigators Consortium (ToxIC) of the American College of Medical Toxicology, from August 2017 through June 2020, and who received a bedside consultation by a medical toxicologist. We collected relevant demographic, clinical, management, disposition, and outcome data, and we conducted a multivariable logistic regression analysis to explore predictors of severe outcome. The primary outcome was a composite severe outcome endpoint, defined as ICU admission or in-hospital death. Covariates included sociodemographic, exposure and clinical characteristics. RESULTS: Of the 165 (87 females, 52.7%) children with an opioid intoxication, 89 (53.9%) were admitted to ICU or died during hospitalization, and 76 did not meet these criteria. Seventy-four (44.8%) children were exposed to opioids prescribed to family members. Fentanyl exposure (adjusted OR [aOR] = 3.6, 95% CI: 1.0-11.6; p = 0.03) and age ≥10 years (aOR = 2.5, 95% CI: 1.2-4.8; p = 0.01) were independent predictors of severe outcome. CONCLUSIONS: Children with an opioid toxicity that have been exposed to fentanyl and those aged ≥10 years had 3.6 and 2.5 higher odds of ICU admission or death, respectively, than those without these characteristics. Prevention efforts should target these risk factors to mitigate poor outcomes in children with an opioid intoxication.

Perioperative Management of Patients on Maintenance Medication for Addiction Treatment: The Development of an Institutional Guideline.

With a brief summary of selected literature identified by a multidisciplinary panel of subject matter experts, the authors share their experience with the development of an institutional perioperative pain management guideline for patients on maintenance medication for addiction treatment (MAT), stressing the importance of perioperative continuation of opioid agonists such as methadone and partial agonists such as buprenorphine; and the discontinuation of opioid antagonists, such as naltrexone. The authors' protocol is appended as an example of a standardized approach to perioperative management of patients on MAT.

Influence of Pennsylvania liquor store closures during the COVID-19 pandemic on alcohol withdrawal consultations.

INTRODUCTION: Alcohol withdrawal syndrome (AWS) is a serious consequence of alcohol use disorder (AUD). Due to the current COVID-19 pandemic there was a closure of Pennsylvania (PA) liquor stores on March 17, 2020. METHODS: This is a retrospective, observational study of AWS patients presenting to a tertiary care hospital. We used descriptive statistics for continuous and categorical variables and compared AWS consults placed to the medical toxicology service for six months preceding liquor store closure to those placed between March 17, 2020 and August 31, 2020. We compared this to consults placed to the medical toxicology service placed from October 1, 2019 through March 16, 2020. Charts were identified based on consults placed to the medical toxicology service, and alcohol withdrawal was determined via chart review by a medical toxicologist. This study did not require IRB approval. We evaluated Emergency Department (ED) length of stay (LOS), weekly and monthly consultation rate, rate of admission and ED recidivism, both pre- and post-liquor store closure. RESULTS: A total of 324 AWS consults were placed during the ten month period. 142 (43.8%) and 182 (56.2%) consults were pre- and post-liquor store closure. The number of consults was not statistically significant comparing these two time frames. There was no significant difference by patient age, gender, or race or by weekly or monthly consultation rate when comparing pre- and post-liquor store periods. The median ED LOS was 7 h (95% Confidence Interval (CI) Larson et al. (2012), Pollard et al. (2020) [5, 11]) and did not significantly differ between pre- and post-liquor store periods (p = 0.78). 92.9% of AWS patients required admission without significant difference between the pre- and post-liquor store closure periods (94.4% vs. 91.8%, p = 0.36). There was a significant increase in the number of AWS patients requiring a return ED visit (Odds Ratio 2.49; 95% CI [1.38, 4.49]) post closure. CONCLUSION: There were nearly 2.5 times greater odds of ED recidivism among post-liquor store closure AWS patients compared with pre-closure AWS patients.

Characteristics of Transgender Patient Cases Managed by a Toxicologist: an Analysis of the Toxicology Investigator's Consortium (ToxIC) Registry: January 2017-June 2019.

INTRODUCTION: The Toxicology Investigators Consortium (ToxIC) database, created in 2010 by the American College of Medical Toxicology (ACMT), compiles data recorded by medical toxicologists. In January 2017, the data field for transgender (and if transgender, male-to-female or female-to-male) was added to the ToxIC form. Little is known regarding trends in poisonings among transgender patients. We sought to review consultations managed by a bedside toxicologist and provide descriptive data in trends among types of exposures within the transgender demographic. METHODS: A retrospective ToxIC database evaluation of cases in which the patient identified as transgender were reviewed from January 2017-June 2019 and descriptive demographics reported. RESULTS: The registry contained 113 cases that involved transgender patients. Of those with complete data, 41 (36.6%) were male-to-female, 68 (60.7%) were female-to-male, and 3 (2.7%) identified as gender non-conforming. Of those with complete data, the most common reason for encounter was intentional use of a pharmaceutical drug (N = 97, 85.8%), of which 85 (87.6%) were classified as intentional pharmaceutical use intended for self-harm. Analgesics were the most common class of drugs used out of those reported (N = 24, 22%). Forty-six (90.2%) patients aged 13-18 with complete data were identified as encounters due to self-harm. Attempt at self-harm was the most common reason for intentional pharmaceutical encounter among the sample of transgender patients with complete data (N = 85, 87.6%); with female-to-male patients having an N = 53 (77.9%). CONCLUSION: Among transgender patients in the ToxIC registry, the most common primary reason for the encounter was intentional use of a pharmaceutical drug intended for self-harm. In this small cohort, there were some age and transition differences in prevalence. These findings may inform poisoning prevention practices as well as sex- and gender-based management of patients in this vulnerable population.

Altered Mental Status and Cyanosis in a Pediatric Patient with Methemoglobinemia.

Methemoglobinemia results from increased amounts of oxidized hemoglobin in the blood with an ensuing change in oxygen dissociation curve and lack of oxygen delivery to tissue. A previously well, male toddler was brought to the Pediatric Emergency Department (PED) by Emergency Medical Services (EMS) with abrupt onset of altered mental status and cyanosis after a suspected ingestion of "Rush" nail polish remover. He was quickly diagnosed with methemoglobinemia by both clinical presentation and chocolate-colored blood appearance. He emergently received intravenous (IV) methylene blue (MB) with immediate and sustained improvement requiring no further doses. Though inhalation of nitrites and subsequent methemoglobinemia is frequently reported in adolescents, we were unable to find any cases in the literature detailing ingestion of this product and the resulting clinical manifestations. Our objective with this report is to describe a rare case of a toddler with an accidental ingestion of "Rush" nail polish remover, a nitrite compound. Our patient presented to the PED with abrupt onset of altered level of consciousness, hypotension, and cyanosis resulting from acquired methemoglobinemia. This case report demonstrates the importance of emergency clinicians being able to make clinical judgements and decisions based on the history and physical exam when methemoglobinemia is suspected.

Sex Differences in Substance Use and Misuse: A Toxicology Investigators' Consortium (ToxIC) Registry Analysis.

BACKGROUND: Variations between male and female populations are previously reported in classes of harmfully used/misused drugs, severity of substance use disorder and risk of relapse. The aim of this study was to provide a review of bedside medical toxicologist managed, sex-specific poisonings in adults that present with harmful drug use/misuse. METHODS: ToxIC Registry cases ≥19 and ≤65 years old, with harmful drug use or misuse during the timeframe June 2010-December 2016, were studied. Demographics, primary agents of toxic exposure, administration route and complications were analyzed. Descriptive methods were used in the analysis. RESULTS: The database included 51,440 cases. Of these, 3426 cases were analyzed in which the primary reason for the encounter was harmful substance use/misuse. Females were found to harmfully use/misuse pharmaceutical drugs (N=806, 65.6%) more than nonpharmaceutical drugs (N=423, 34.4%). Males more frequently used nonpharmaceutical drugs (N=1189, 54.1%) than pharmaceutical drugs (1008, 45.9%). Analgesics were used by females (N= 215, 18.2%) and males (N=137, 6.6%). Sedative hypnotics were used by females (N=165, 14%) and males (N=160, 7.8%). Psychoactive agents were used by males (N=325, 15.8%) and females (N=67, 5.7%). Sympathomimetics were used by males (N=381, 18.5%) and females (N=151, 12.8%). The majority of both male and female participants, 1712 (57.9%), utilized an oral route of administration. However, 312 (16.5%) of males utilized inhalation vs 73 (6.8%) of females inhaled their substance. CONCLUSION: There were sex-specific differences among patients evaluated for harmful substance use/misuse by toxicologists. Considering these differences in regards to management and preventive approaches may be indicated.

Mobitz Type II Atrioventricular Heart Block After Candlenut Ingestion.

The candlenut is a highly accessible seed marketed as a natural weight-loss supplement. However, there is little known about the exact mechanism of action for weight loss nor for the many adverse symptoms it causes, such as nausea, vomiting, fatigue, cardiac dysrhythmias, and even death. In this case report, the authors present a 44-year-old woman who developed a second-degree, Mobitz type II atrioventricular block after consumption of a candlenut supplement. She presented to the emergency department with syncope and her cardiac rhythm indicated a second-degree heart block soon after ingesting candlenuts recommended by her treating physician. Interestingly, a detectable digoxin concentration obtained on hospital day 2 was measured but of unclear significance given no obvious exposure to a cardioactive glycoside. The patient's rhythm normalized on hospital day 2 and she was discharged uneventfully.

Emergency Medicine Resident Self-assessment of Clinical Teaching Compared to Student Evaluation Using a Previously Validated Rubric.

PURPOSE: The quality of clinical teaching in the emergency department from the students' perspective has not been previously described in the literature. Our goals were to assess senior residents' teaching ability from the resident/teacher and student/learner viewpoints for any correlation, and to explore any gender association. The secondary goal was to evaluate the possible impact of gender on the resident/student dyad, an interaction that has previously been studied only in the faculty/student pairing. METHODS: After approval by an institutional review board, a 1-year, grant-funded, single-site, prospective study was implemented at a regional medical campus that sponsors a 4-year dually approved emergency medicine residency. The residency hosts both medical school students (MSs) and physician's assistant students (PAs). Each student and senior resident working concurrently completed a previously validated ER Scale, which measured residents' teaching performance in 4 categories: Didactic, Clinical, Approachable, and Helpful. Students evaluated residents' teaching, while residents self-assessed their performance. The participants' demographic characteristics gathered included prior knowledge of or exposure to clinical teaching models. Gender was self-reported by participants. The analysis accounted for multiple observations by comparing participants' mean scores. FINDINGS: Ninety-nine subjects were enrolled; none withdrew consent. Thirty-seven residents (11 women) and 62 students (39 women) from 25 MSs and 6 PA schools were enrolled, completing 517 teaching assessments. Students evaluated residents more favorably in all ER Scale categories than did residents on self-assessments (P < 0.0001). This difference was significant in all subgroup comparisons (types of school versus postgraduate years [PGYs]). Residents' evaluations by type of student (MS vs PA) did not show a significant difference. PGY 3 residents assessed themselves higher in all categories than did PGY 4 residents, with Approachability reaching significance (P = 0.0105). Male residents self-assessed their teaching consistently higher than did female residents, significantly so on Clinical (P = 0.0300). Students' evaluations of the residents' teaching skills by residents' gender did not reveal gender differences. IMPLICATIONS: MS and PA students evaluated teaching by EM senior residents statistically significantly higher than did EM residents on self-evaluation when using the ER Scale. Students did not evaluate residents' teaching with any difference by gender, although male residents routinely self-assessed their teaching abilities more positively than did female residents. These findings suggest that, if residency programs utilize resident self-evaluation for programmatic evaluation, the gender of the resident may impact self-scoring. This cohort may inform future study of resident teaching in the emergency department, such as the design of future resident-as-teacher curricula.

Women and the Experience of Pain and Opioid Use Disorder: A Literature-based Commentary.

It is generally understood that pain experience and opioid abuse have relied on male-dominated models. However, sex and gender play a role in both pain experience and opioid use disorder. Using the previously validated Texas Tech University Health Sciences Center Sex and Gender Specific Health PubMed Advanced Search Tool, the authors used pertinent literature to develop this literature-based commentary on sex and gender differences in pain experience and opioid use disorder. Women report their experience of pain more frequently, have increased rates of diagnoses related to pain, have increased pain sensitivity, and have a variable response to pain and analgesia. This variable response is due to anatomic, physiologic, hormonal, psychological, and social factors that differ by sex and gender. Women have been found to be at greater risk for opioid abuse in all age groups. This may be due to the differences in pain experience, as well as sex and gender differences in prescribing patterns, cultural norms, and the increased likelihood to experience dependency and withdrawal. Approaches to the treatment of opioid use disorder are also subject to sex and gender differences-an area in need of further investigation.