Amifampridine overdose leading to refractory status epilepticus.

3,4-Aminopyridine or Amifampridine belongs to the aminopyridine class of drugs which is used to treat multiple sclerosis and Lambert-Eaton Myasthenic Syndrome (LEMS). Aminopyridine pharmaceuticals inhibit presynaptic potassium channels. This increases available acetylcholine in the nerve cleft which leads to improved strength in this patient population. While overdoses have been reported of 4-Aminopyridine, no case reports of acute 3.4-Aminopyridine overdose are currently available. A 67 year old man presented to the emergency department 30 min after ingesting 100 mg of amifampridine in a suicide attempt. Within an hour of ingestion he experienced tachycardia, tachypnea, hypertension and tremor. The patient then started to experience seizures and had a cardiac arrest 3 h after the ingestion. The patient achieved return of spontaneous circulation but proceeded to have refractory seizures. Despite significant and escalating doses of anti-epileptic medications, the patient continued to have seizures until 18 h after ingestion. His anti-epileptic medications were weaned over the following days and he had no more seizures. This is a report of a novel overdose of 3,4-Aminopyridine, a medication that belongs to the aminopyridine class of pharmaceuticals that have been well used for many years. Aminopyridine overdoses are commonly thought to carry low morbidity and mortality; however, our patient had both a cardiac arrest and refractory status epilepticus. Ultimately, this case suggests that patients who overdose on 3,4-Aminopyridine could become critically ill and their presentation may be far more severe than that of other medications of the same class.

Ventricular fibrillation in a 21-year-old after inhalation of an isobutyl nitrite "popper" product.

BACKGROUND: Alkyl nitrite analogs known as "poppers" have been inhaled recreationally for decades. They are available to be purchased from gas stations marketed as "nail polish remover not for human consumption". These rapid-onset, short-acting, vasodilators cause the user to experience euphoria, dizziness, tachycardia and flushing. While chronic use may lead to problems such as methemoglobinemia or neuropathy, nitrites rarely lead to acute life-threatening side effects such as ventricular dysrhythmias. CASE REPORT: We report a case of ventricular fibrillation cardiac arrest in a 21-year-old male after inhaling from a solution labeled to contain isobutyl nitrite, a rarely reported adverse effect of "popper" use. The product was analytically confirmed to contain mainly isobutyl alcohol, volatile hydrocarbons, and isobutyl nitrite, as well as smaller quantities of other substances. The patient was also prescribed escitalopram and hydroxyzine may have contributed. Return of spontaneous circulation was achieved in the field after initiation of CPR and defibrillation. He was found to have no clear predisposition to arrythmias during his care or on follow up. CONCLUSION: Alkyl nitrite "popper" users and clinicians should be aware that products labeled to contain nitrites may contain volatile hydrocarbons along with nitrites and have the potential to cause arrhythmia.

Out-of-pocket payments made by patients transported by Helicopter Emergency Medical Services (HEMS).

OBJECTIVE: Recent news media have reported that Helicopter Emergency Medical Service (HEMS) programs use the practice of balanced billing, resulting in exorbitant charges not covered by insurance companies and financially burdening patients. To date, no study has described the billing practices of HEMS programs. We look to provide transparent billing practices and average patient payment of one midwestern non-profit HEMS program and report the reimbursement data of both federal and private insurance policies for transports. METHODS: Collated billing data were obtained from a HEMS program for two time periods from January 2017 through June 2018 (P1) and July 2018 through December 2019 (P2). From P1 to P2 the base charge per transport was increased. All transports that generated a bill during the periods were included and descriptive statistics were used to depict the findings. RESULTS: Per flight, base charge was $19,158 in P1 and $33,023 in P2. On average, patients paid $158.09 and $178.99 out-of-pocket, respectively. Reimbursement practices of insurance companies varied widely across time periods and among each other. CONCLUSION: The amount charged by this HEMS program and amount patients paid on average for flights was less than has been commonly reported in recent news media. More transparency in costs and payments between non-profit and for-profit HEMS agencies should occur.

Outcomes of law enforcement officer administered naloxone.

OBJECTIVE: Law enforcement officer (LEO) administered naloxone is an effective intervention for treating prehospital opioid overdoses. Our objective is to determine the rate and factors associated with adverse behavioral effects and efficacy following LEO naloxone administration. METHODS: This is a retrospective cohort study of patients treated with naloxone law enforcement over 5 years in one county EMS system. Law enforcement officers utilized intranasal 4 mg/0.1 mL for suspected opioid overdose. Data were acquired from forms completed by LEO following administration of naloxone. We performed descriptive statistics. Univariate regression analysis with a primary outcome of improved neurological status and a secondary outcome of patient irritability/combativeness post-naloxone. RESULTS: A total of 597 cases of LEO administered naloxone were reported. Naloxone was felt to be effective by the LEO in 370 (62%) of these cases with 6 (1%) exhibiting combativeness and 57 (10%) having the composite outcome of irritability or combativeness. The perceived rate of efficacy was higher when an opioid, rather than a non-opioid agent was suspected (239/346 [67%] vs. 83/165 [50%], OR 2.21, 95% CI 1.51-3.23), and for heroin and fentanyl specifically. Suspected fentanyl exposure was the only variable associated with our secondary outcome of irritability or combativeness (7/22 [32%] vs. 45/489 [9%], OR 4.60, 95% CI 1.78-11.8). CONCLUSIONS: LEO administered naloxone remains an effective intervention for overdose victims, with higher perceived efficacy when opioids are specifically implicated. Combativeness is rare following LEO naloxone administration. Further research is needed to understand a relationship between suspected fentanyl intoxication and post-naloxone behavioral disturbances.

Predictors of retained hemothorax in trauma: Results of an Eastern Association for the Surgery of Trauma multi-institutional trial.

BACKGROUND: The natural history of traumatic hemothorax (HTX) remains unclear. We aimed to describe outcomes of HTX following tube thoracostomy drainage and to delineate factors that predict progression to a retained hemothorax (RH). We hypothesized that initial large-volume HTX predicts the development of an RH. METHODS: We conducted a prospective, observational, multi-institutional study of adult trauma patients diagnosed with an HTX identified on computed tomography (CT) scan with volumes calculated at time of diagnosis. All patients were managed with tube thoracostomy drainage within 24 hours of presentation. Retained hemothorax was defined as blood-density fluid identified on follow-up CT scan or need for additional intervention after initial tube thoracostomy placement for HTX. RESULTS: A total of 369 patients who presented with an HTX initially managed with tube thoracostomy drainage were enrolled from 17 trauma centers. Retained hemothorax was identified in 106 patients (28.7%). Patients with RH had a larger median (interquartile range) HTX volume on initial CT compared with no RH (191 [48-431] mL vs. 88 [35-245] mL, p = 0.013) and were more likely to be older with a higher burden of thoracic injury. After controlling for significant differences between groups, RH was independently associated with a larger HTX on presentation, with a 15% increase in risk of RH for each additional 100 mL of HTX on initial CT imaging (odds ratio, 1.15; 95% confidence interval, 1.08-1.21; p < 0.001). Patients with an RH also had higher rates of pneumonia and longer hospital length of stay than those with successful initial management. Retained hemothorax was also associated with worse functional outcomes at discharge and first outpatient follow-up. CONCLUSION: Larger initial HTX volumes are independently associated with RH, and unsuccessful initial management with tube thoracostomy is associated with worse patient outcomes. Future studies should use this experience to assess a range of options for reducing the risk of unsuccessful initial management. LEVEL OF EVIDENCE: Therapeutic/care management study, level III.

Perceptions of Third-year Medical Students of a Non-resident Hospitalist Rotation.

Introduction Although medical students in the United States frequently rotate on a non-resident hospitalist team, there is a paucity of literature on their perceptions regarding such rotation. We sought to assess the perceptions of third-year medical students (M3s) regarding a non-resident hospitalist rotation. Methods We conducted a web-based survey of M3s who had previously rotated on a non-resident hospitalist service. We assessed their perceptions regarding patient assignments and complexities, rounding preferences, barriers to learning, and the benefits of the rotation. A descriptive analysis was performed on the responses. Results Out of 49 respondents, 47% preferred carrying a maximum of three patients during rounds and 57% preferred patients with fewer comorbidities. Fifty-one percent preferred rounding on all patients covered by the team as opposed to rounding on their assigned patients only. Despite several perceived benefits of the rotation, students also identified various barriers to learning while rotating in a non-resident hospitalist rotation. Conclusions Our study evaluated the perceptions of M3s regarding the ideal patient load, patient complexities, barriers to learning and various benefits of a non-resident hospitalist rotation. The students' perceptions can potentially be addressed and incorporated to make the non-resident hospitalist rotation more educational for the students.