Envenomation by the Green Bush Viper Atheris squamigera.

The Green Bush Viper, Atheris squamigera, is native to West and Central Africa and has few well reported envenomations. Bite victims experience dizziness, nausea, headache, regional lymphadenopathy, and localized edema. Most reports also detail severe effects including thrombocytopenia, coagulopathy, hemolysis, hemorrhage, or renal failure. Fatalities are reported, but poorly described. There is no specific antivenom for A. squamigera, but non-species specific antivenom has been reported helpful in several cases. We report the case of a 36-year-old woman who was bitten by a green bush viper and was treated with several non-species specific antivenoms. There were no complications to antivenom administration and the patient experienced a milder envenomation than detailed in previous reports.

Perinatal Carbon Monoxide Poisoning: Treatment of a 2-Hour-Old Neonate with Hyperbaric Oxygen.

A 41-year-old gravida 4 para 3 (G4P3) and 38 5/7 weeks pregnant woman presented to labor and delivery with dizziness, headache, and decreased fetal movement after 12 hours of exposure to carbon monoxide (CO) from a grill that was used inside for heat. The mother was hemodynamically stable, and her neurologic examination was intact. Her carboxyhemoglobin level, which was obtained 12 hours after removal from the CO exposure, was 7.4%. The fetus's heart rate was 173 beats per minute with moderate variability and one late appearing deceleration, not associated with contractions. The biophysical profile score was 2 of 8. The obstetrics team performed a routine cesarean section. The 1- and 5-minute Apgar's scores were 7 and 8, respectively. The arterial cord gas result was as follows: pH = 7.05, PCO 2 = 71 mm Hg, pO 2 = 19 mm Hg, bicarbonate = 14 mmol/L, and carboxyhemoglobin = 11.9%. The mother and infant were treated with hyperbaric oxygen therapy consisting of 100% oxygen at 2.4 atmosphere absolutes (ATA) for 90 minutes at 2.5 hours after delivery. Following one hyperbaric oxygen treatment, the infant was transitioned to room air and routine postpartum treatment and was discharged 3 days later in good condition. Hyperbaric oxygen treatment was well tolerated in this neonate.

Sentanyl: a comparison of blood fentanyl concentrations and naloxone dosing after non-fatal overdose.

INTRODUCTION: Non-pharmaceutical fentanyl and its analogs have driven striking increases in opioid-associated overdose deaths. These highly potent opioids can be found at low concentrations in biological specimens. Little is known regarding the concentrations of these substances among survivors of non-fatal overdoses. In a locale where fentanyl is responsible for the majority of non-fatal opioid overdoses, we compared the concentration of fentanyl in blood to naloxone dosing in the presence and absence of a concurrent sedative-hypnotic exposure. METHODS: In this pilot study, we enrolled adult patients presenting to the emergency department (ED) who: (1) arrived after an overdose requiring naloxone for the reversal of respiratory depression; and (2) who required venipuncture or intravenous access as part of their clinical care. Blood specimens (n = 20) underwent comprehensive toxicology testing, including the quantitation of fentanyl, fentanyl analogs, and naloxone, as well as the detection of common sedative-hypnotics and a wide range of other illicit and pharmaceutical substances. We then compared fentanyl concentrations to naloxone dosing in participants with and without a concomitant sedative-hypnotic exposure. RESULTS: Nineteen of twenty participants (95%) were exposed to fentanyl prior to their overdose; the remaining participant tested positive for heroin metabolites. No participants reported pharmaceutical fentanyl use. Fentanyl analogs - acetylfentanyl or carfentanil - were present in three specimens. In 11 cases, fentanyl and its metabolites were the only opioids identified. Among the fentanyl-exposed, blood concentrations ranged from <0.1-19 ng/mL with a mean of 6.2 ng/mL and a median of 3.6 ng/mL. There was no relationship between fentanyl concentration and naloxone dose administered for reversal. We detected sedative-hypnotics (including benzodiazepines, muscle relaxants, and antidepressants) in nine participants. Among the sedative-hypnotic exposed, fentanyl concentrations were lower, but naloxone dosing was similar to those without a concomitant exposure. CONCLUSIONS: In this study, we found that: 1) fentanyl was present in the blood of nearly all participants; 2) fentanyl concentrations were lower among study participants with concomitant sedative-hypnotic exposure; and 3) the dose of naloxone administered for overdose reversal was not associated with the measured fentanyl concentration in blood specimens. Our results underscore the role that tolerance and concomitant drug exposure play in the precipitation and resuscitation of management of opioid overdose.

Accidental Arthrotomy Causing Aseptic Monoarthritis Due to Agave Sap: A Case Report.

INTRODUCTION: Aseptic inflammatory arthritis has been reported from thorns or cactus needles after inadvertent arthrotomy. Agave sap irritants may cause an aseptic inflammatory arthritis mimicking a septic joint. CASE REPORT: A 27-year-old male presented with left knee pain and swelling two hours after suffering an accidental stab wound to his left lateral knee by an agave plant spine. Synovial fluid white blood cell count was 92,730 mm3 with 75% neutrophils and no crystals. Surgical washout was remarkable for turbid fluid and no foreign body. Synovial fluid and blood cultures remained without growth. At two-week follow-up, the patient had recovered. CONCLUSION: Penetrating injuries from agave thorns can cause an inflammatory arthritis that mimics septic arthritis.

Despair in the time of COVID: A look at suicidal ingestions reported to the California Poison Control System during the pandemic.

BACKGROUND: Despite concern that the global pandemic will worsen depression and suicide rates, there remain little data on its actual effect. The purpose of this study was to determine the effect of the COVID-19 pandemic on suicidal ingestions reported to the California Poison Control System (CPCS). METHODS: This was a cross-sectional comparison of suicidal ingestions reported to the CPCS during the 2020 COVID-19 pandemic compared to suicidal ingestions reported during the same period in 2018 and 2019. RESULTS: The CPCS received 19,607 call for suicidal ingestions during the study periods, of which 13,800 were in the pre-COVID era (2018 and 2019) and 5,807 were in the COVID era. The median (IQR) number of suicidal ingestions per month decreased from 2,286 (2,240-2,364) to 1,940 (1,855-2,045; p = 0.02). This decrease was consistent and significant across all age groups except those age 70 or older. Ingestions without adverse events decreased by 101 cases/month (95% confidence interval [CI] = 136.8 to 65; p = 0.0003), minor outcomes decreased by 156.6 cases/month (95% CI = 226.2 to 87.1; p = 0.001), and moderate outcomes decreased by 96 cases/month (95% CI = 143.9 to 48.1; p = 0.00021). Major outcomes decreased from 793 (4.99%) cases in the pre-COVID era to 315 (4.60%) cases in the COVID era (risk ratio = 0.92, 95% CI = 0.81 to 1.05). The number of deaths decreased by 3.7 cases/month (95% CI = -8.3 to 0.92, p = 0.10). CONCLUSIONS: Despite concern for worsening suicidality, calls regarding suicidal ingestions to the nation's largest poison control center decreased during the COVID era compared to the pre-COVID era. This study provides evidence that the pandemic's effects on modern society remain difficult to predict. Further effort is needed to understand how pandemic will affect American's mental health.