A Case of Burning Throat Pain.

BACKGROUND: Throat pain is a common complaint in the emergency department. The related diagnoses are varied, from simple gastroesophageal reflux disease to catastrophic aortic dissection. This case highlights the importance of pertinent patient history and frequent reassessments in order to recognize the latter. CASE REPORT: A 58-year-old woman was found to have a type A aortic dissection after initially presenting to the emergency department with a chief complaint of "burning" throat pain. Throughout the patient's evaluation in the emergency department, her symptoms evolved from the complaint of mild throat pain and water brash to development of chest pain and sudden right lower extremity cramping. Her history of hypertension, smoking, and a previous cerebral aneurysm prompted further intervention, including aggressive blood pressure control and emergent imaging. A computed tomography scan with angiography revealed the diagnosis of a type A aortic dissection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We highlight the importance of recognizing that patient presentation may change throughout the course of the emergency department stay, and that our case represents an atypical presentation of serious disease.

Clonidine Overdose in a Toddler Due to Accidental Ingestion of a Compounding Cream.

A 22-month-old girl without any significant medical history accidentally consumed a small amount of a therapeutic compounding cream that contained camphor, gabapentin, clonidine, ketoprofen, and lidocaine. Upon presentation to the emergency department, the child exhibited immediate onset of altered mental status with wide fluctuation in her vital signs, which included intermittent apnea requiring bag-valve mask assistance and endotracheal intubation. Serum laboratory analysis measured a clonidine level of 2.6 ng/mL and undetectable camphor, gabapentin, and ketoprofen levels. While on mechanical ventilation, the patient exhibited hypothermia, bradycardia, and hypotension; all of which responded to supportive care. After approximately 12 hours in the intensive care unit, the patient was successfully extubated and remained asymptomatic. This unique case of a patient with brief, unintentional oral exposure to a compounding cream, who demonstrated severe toxicity despite only a measured, supratherapeutic clonidine concentration, is discussed. Emergency physicians and pediatricians should be alert to the potential for exposure of pediatric patients to these medicinal compounds. Furthermore, parents must be made aware of the potential dangers of compounded medications and ensure their proper usage and storage.

Insidious Manifestations of Cutaneous T-cell Lymphoma.

Case Presentation: A 66-year-old gentleman presented with several months of a generalized pruritic skin eruption along his face, thorax, and extremities. Although he had been seen previously, no diagnosis was made until he presented to the emergency department (ED) with worsening lesions. The patient was ultimately diagnosed with cutaneous T-cell lymphoma. Discussion: Accurately diagnosing a rash in the ED is not always possible as more invasive studies may be needed. Emergency physicians can expedite these studies where there is a high suspicion for a diagnosis that may need urgent evaluation and management by specialists through hospital admission and appropriate consultations. The clinical images here are an example of a rare disease manifesting as a debilitating rash, requiring inpatient evaluation and management.

Anticonvulsant fatalities reported to the American Association of Poison Control Centers 2000 - 2019.

BACKGROUND: Anticonvulsants are frequently prescribed, and exposures are commonly reported to American Association of Poison Control Centers sites. The purpose of this study was to describe the epidemiology of fatalities associated with oral anticonvulsant use, including patient demographics, specific medications, and the circumstances surrounding the deaths. METHODS: This was a retrospective analysis of cases coded with oral anticonvulsants as a single substance and associated with a fatal outcome reported to the AAPCC National Poison Data System from 2000 to 2019. Polydrug ingestions and parenteral exposures were excluded. Patient characteristics, circumstances of the ingestion, specific medication, and chronicity of use were described. RESULTS: We identified 126 cases that were classified as fatalities associated with single anticonvulsant use. The five most implicated anticonvulsants were carbamazepine, gabapentin, lamotrigine, phenytoin, and valproic acid. The majority (68.3%) of fatal cases were suicides. Phenytoin was implicated in eight (89%) adverse reactions and seven (70%) therapeutic errors. Valproic acid caused one (11.1%) adverse reaction and was associated with one (10%) therapeutic error. Three (75%) unintentional fatalities were caused by carbamazepine. The plurality (42.1%) of fatal ingestions occurred in acute-on-chronic use. An additional 40 (31.7%) were acute. Chronic use accounted for 15 (11.9%) of fatal exposures, including 5/10 of fatalities attributed to therapeutic error. The chronicity of medication use was unknown in 18 (14.3%) of fatal ingestions. Narrative summaries were available in 14 cases. Four of the patients presented to the emergency department with minimal symptoms. The other 10 had varying degrees of central nervous system (CNS) depression. Seizures were observed in six cases. Hyperammonemia was reported in seven of nine valproic acid ingestions. CONCLUSIONS: Fatalities associated with isolated anticonvulsant use are uncommon and typically occur following intentional overdoses. Fatal adverse reactions and therapeutic errors are most associated with phenytoin use and disproportionately affect elderly patients.

A Case of Suspected Cocaine Adulterant-Associated Methemoglobinemia in the United States.

A 30-year-old male with a past history of polysubstance use presents to a drug rehabilitation facility after cocaine and heroin use just prior to arrival. While drinking at a water fountain at the facility, he became unresponsive. He was discovered to have an oxygen saturation of 50% on room air with an improvement to 87% on non-rebreather masks. Arterial blood gas revealed a methemoglobin level of 45.8%. The patient was given methylene blue with a repeat methemoglobin level of 0.00% within six hours. We attribute this presentation to local anesthetic-adulterated cocaine, a well-documented cause of methemoglobinemia in the United Kingdom rarely described in the United States.

A Case of a Negative Urine Pregnancy Test in a Multiple Gestation Pregnancy.

Urine pregnancy tests (UPTs) are a highly reliable method of detecting pregnancy, with reported 100% sensitivity and 99.2% specificity. This test relies on the detection of ß-human chorionic gonadotropin (ß-hCG) molecules in the urine through a two-site sandwich immunoassay. Although a nearly perfect test, it is common knowledge that this test can be falsely negative if performed too early in the pregnancy when urinary ß-hCG concentrations fall below detectable levels. Less commonly known is that the test may provide a false-negative result when urinary ß-hCG concentrations are extremely elevated, such as gestational trophoblastic disease or multiple gestations. Here, we present a case of a patient with a prior positive urine pregnancy test who presents with symptoms consistent with early pregnancy. Repeat testing resulted in a negative urine pregnancy test. Additional workup revealed significantly elevated serum quantitative ß-hCG and bedside ultrasound revealed multiple gestation intrauterine pregnancy. The patient ultimately delivered triplets by repeated caesarean section. It is important for physicians to understand and recognize the limitations of the urine pregnancy test in order to best facilitate care for patients who may have a false-negative pregnancy test result, as there are significant risks of improper patient management with a multiple gestation pregnancy or gestational trophoblastic disease.

Chronic Drug Use and Abdominal Pain.

There are a variety of gastrointestinal pathologies that may be emergently identified in the patient who chronically uses alcohol or other substances. Patients may present to an Emergency Department with abdominal complaints existing on a spectrum from vague and benign to systemically toxic and potentially life-threatening. This article highlights ethanol, opioids, and other common substances of abuse and how they may contribute to gastrointestinal complaints.

Comparing the Effectiveness of a Virtual Toxicology Escape Room at Two Emergency Medicine Residencies.

Introduction Physical distancing guidelines during the coronavirus disease 2019 (COVID-19) pandemic forced medical residency programs to move a large portion of required didactics to virtual settings. Toxicology, a core component of emergency medicine (EM) education, was forced to adapt to similar constraints. An in-person escape room style puzzle was modified to a virtual format for educational purposes, and shared with and evaluated by two different residency programs. Materials and methods A virtual escape room, "Escape the Toxin: Online!" was created to test knowledge of toxicologic ingestion and antidote utilizing Google Forms and delivered using Zoom teleconference software to two EM residency programs in the Philadelphia region. After small groups completed the gamified activity, their scores were calculated and they completed an anonymous evaluation. Results Residents at the program where a Medical Toxicology fellowship is located found the virtual escape room to be more effective and enjoyable compared to the second program. Despite some differences in perceived effectiveness, the majority of participants were able to correctly solve the puzzle and get to the antidote. Conclusion The majority of learners who participated from both residencies agreed that they would recommend this virtual program to other EM residents.

Severe Cardiomyopathy after Huffing Dust-Off™.

A 34-year-old man was found down in a parking lot after huffing fifteen cans of Dust-Off. Though lucid during the initial hospital evaluation, the patient experienced a generalized seizure followed by a torsades de pointes arrhythmia and was resuscitated. An echocardiogram revealed left and right ventricular dysfunction with an ejection fraction of 25%. This unique outcome of inhalant abuse has scarcely been reported in similar cases. The patient fully recovered and had a normal ejection fraction prior to discharge.

Impact of dual-polarization radar technology and Twitter on the Hattiesburg, Mississippi tornado.

OBJECTIVE: Dual-Polarization Radar and Twitter were analyzed to determine the impact on injuries sustained by the Hattiesburg EF-4 tornado. METHOD: Tracking data provided from the Dual-Pol radar systems in National Weather Service Jackson were reviewed. Twitter data from four local Twitter handles were obtained. The change in tweets and followers for the day of the storm were compared to historical averages. A Student t-test was utilized in determining statistical significance (p<0.05). Medical records from two local emergency departments were reviewed for patients treated up to 24 hours after the tornado. An Injury Severity Score (ISS) was calculated for trauma records related to the tornado. RESULTS: Radar detection of the tornado gave approximately 30 minutes of advanced warning time. Statistical significance in follower growth was seen in all four Twitter handles. Out of 50 patients, the average ISS was 3.9 with a range of 1 to 29. There were zero fatalities. CONCLUSIONS: An ISS average of 3.9 was significantly less than two previous tornadoes of similar strength that occurred prior to increased usage of Dual-pol radar and Twitter as a means for communicating severe weather information. Early detection from Dual-pol radar improved warning time. Tweets informed citizens to seek appropriate shelter. (Disaster Med Public Health Preparedness. 2013;7:585-592).