Mass Carbon Monoxide Poisoning at a Daycare: A Public Health Lesson.

INTRODUCTION: Carbon monoxide (CO) poisoning is a leading cause of preventable toxicity-related deaths in the United States. We describe a case series of 16 individuals who were exposed to CO due to a malfunctioning furnace at a Pennsylvania daycare, a state which did not mandate CO detectors in daycares. METHODS: An institutional review board-approved retrospective analysis was performed, and de-identified patient records were examined. Collected data included age, sex, race, ethnicity, CO concentrations, arrival time, time to hyperbaric oxygen center contact, and time to transfer and discharge. RESULTS: Emergency medical services transported 16 patients to a tertiary care emergency department (ED) with both adult and pediatric departments. Fourteen patients were 10 years of age or younger. Fifteen patients arrived within one hour. Sixty-two percent (N=10) were male, and 94% (N=15) identified as Hispanic. Emergency physicians, medical toxicologists, clinicians, interpreters, and volunteers from across the hospital system were mobilized to the ED to assist with management. CONCLUSION: This large-scale daycare CO poisoning represents a potentially avoidable mass casualty incident among children and daycare staff and necessitated significant coordination of care. CO detectors in Pennsylvania daycares would provide early warning for staff, prevent or minimize toxicity, inform first responders, and better prepare EDs to handle similar situations.

Polyethylene Glycol Misuse Causing Acute Renal Failure and Metabolic Acidosis Requiring Dialysis: A Case Report.

Laxative misuse is a well-known occurrence, most often identified in patients struggling with eating disorders. Polyethylene glycol (PEG) 3350 is a readily available, well-tolerated osmotic laxative. High doses of PEG 3350 may cause gastrointestinal upset, diarrhea, dehydration, and electrolyte imbalance, although systemic toxicity is infrequently reported. This case report highlights the exceedingly rare metabolic derangements associated with profound levels of protracted PEG misuse. A 60-year-old female presented to the emergency department with altered mental status. She was found to have acute renal failure (ARF), anion gap metabolic acidosis (AGMA), and rhabdomyolysis secondary to excessive PEG 3350 use, requiring continuous renal replacement therapy (CRRT). Renal function improved after three days of CRRT, and no alternative causes beyond PEG ingestion were found to account for her mental status changes or metabolic anomalies. This report illustrates the importance of considering osmotic laxative misuse in the setting of pre-renal and intrinsic renal failure.

Equine Pergolide Toxicity: A Case Series.

Veterinary medication exposure may result in human toxicity, with approximately 6,000 exposures to veterinary-only medications reported to poison centers in 2022. There is a paucity of literature on the management of poisoned patients secondary to pharmaceuticals intended for equine use. Pergolide is a dopamine and serotonin receptor agonist and is currently approved to treat equine Cushing's disease. It was previously approved in the United States (US) to treat Parkinson's disease in humans; however, it was withdrawn from the market in 2007 due to its association with valvular heart disease. We report two cases of pergolide toxicity in horse owners following unintentional ingestions. Both patients experienced similar clinical presentations resulting from their unintentional pergolide ingestions. Veterinary medication ingestion presents a unique challenge to clinicians as the drug may have limited human toxicity data and/or recommended animal dosing may differ greatly from human dosing. Case reports of human toxicity may assist with anticipating the clinical course and guiding medical decision-making.

Mind the Decimal Point: A Case of Diazoxide Overdose-Induced Ileus.

Diazoxide is the only medication approved by the United States Food and Drug Administration for the treatment of hyperinsulinism-induced hypoglycemia. Overdose is infrequently reported. This case describes a preterm four-week-old male who was prescribed diazoxide and chlorothiazide for perinatal stress-induced hyperinsulinism. The patient presented to the emergency department with feeding intolerance and abdominal distension following an accidental 10-fold diazoxide overdose. On presentation, vital signs were remarkable for tachycardia and intermittent tachypnea. Physical exam revealed a grossly distended abdomen. Laboratory abnormalities included a glucose of 216 mg/dL, sodium of 132 mmol/L, and chloride of 98 mmol/L. Abdominal X-ray interpretation found moderate gaseous distension suggestive of generalized ileus. The patient was admitted to the neonatal intensive care unit (NICU), and a nasogastric tube was placed. He received intravenous dextrose fluids, and enteral feeds were resumed as serial X-rays showed interval improvement. The patient remained in the NICU for several days to monitor bowel movements and resolution of ileus and he was discharged after improvement. While diazoxide overdose is rarely reported, and ileus due to such is documented even less frequently, 10-fold medication dose errors are common among infants. The source of the 10-fold mistake is often decimal points, leading zeros, or trailing zeros. Utilizing the smallest possible syringe for the prescribed dose may reduce the incidence of medication errors.

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.

Novel Use of Clonidine Patch to Treat Tizanidine Withdrawal.

Tizanidine is commonly prescribed for muscle spasticity and pain. Yet, withdrawal is rarely reported. Tizanidine stimulates presynaptic α-2 adrenergic and imidazoline receptors decreasing norepinephrine release. Abrupt cessation can cause withdrawal. Current treatment strategies include tapering oral tizanidine or substituting oral clonidine. A 52-year-old male with a history of hypertension, diabetes, coronary artery disease, and chronic back pain presented with altered mental status, agitation, hypertensive emergency (blood pressure: 250/145 mmHg), and tachycardia. The patient had been prescribed tizanidine for chronic back pain for two years and had recently run out with suspicion of misuse. Tizanidine withdrawal was diagnosed, and he improved with 0.1 mg oral clonidine three times daily weaned over five days while hospitalized. One month later the patient was admitted for persistent hypertension, tachycardia, diaphoresis, and anxiety. Alpha-2 agonist withdrawal was again diagnosed. Utilizing a clonidine patch taper may offer a reasonable approach in patients with tizanidine withdrawal.

Prevention of iatrogenic fluid overload with naloxone infusions: A patient safety initiative.

A higher number of patients admitted to hospital systems are requiring a naloxone infusion for treatment of opioid toxicity. Although naloxone is a safe antidote for the treatment of opioid toxicity, this is not without the risk of iatrogenic harm. During standard pharmacy medication safety review process, it was identified that our standard naloxone concentration protocol would deliver 4 times the standard maintenance fluid rate to our pediatric patient population. After this risk was identified, a multidisciplinary review process of our naloxone infusion protocol was performed to help mitigate the potential risk of fluid overload. Our updated naloxone infusion protocol will result in close to a 10-fold reduction in fluids required for our naloxone infusion protocol to better align with the American Society of Health-System Pharmacists' Standardize 4 Safety Initiative and reduce the potential for iatrogenic harm.

From Crashing Waves to Crashing Sodium: A Rare Case of Nearly Asymptomatic Severe Hyponatremia.

Hyponatremia refers to an abnormally low serum sodium level, and it is the most common electrolyte disorder encountered in the clinical setting. Despite its prevalence, hyponatremia can be challenging to clinically identify in some cases due to non-specific symptom presentation. In this case report, we illustrate the rare clinical course of a nearly asymptomatic patient with severe hyponatremia and discuss potential explanations for this uncommon presentation.

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.

Lung point-of-care (POCUS) ultrasound in a pediatric COVID-19 case.

The World Health Organization categorized coronavirus disease 2019 (COVID-19) as a pandemic due to its high contagion rate and widespread infectivity in February 2020. In the United States, one of the public health concerns is the adequacy of resources to treat infected cases. We describe a case of a previously well, 9-year-old obese boy who presented to the emergency department with shortness of breath, fever, abdominal pain, and cough with chest pain. He was diagnosed with COVID-19 through significant family contact, confirmed by polymerase chain reaction and found to be at high risk of venous thromboembolism due to abnormal d-dimer. Lung point-of-care ultrasound (POCUS) in the emergency department observed significant lung pathology, including pleural thickening, consolidation, and B lines. A chest X-ray found bilateral ground glass opacities and interstitial prominences consistent with viral pneumonia. Our case suggests that lung POCUS can provide adequate and rapid imaging to assess lung pathology of COVID-19 in a pediatric patient. As there is limited literature on use of lung POCUS in pediatric patients infected with SARS-CoV-2, our case emphasizes its function as a potentially efficient modality in bedside assessment.