The transmission of the influenza virus from patient to emergency physician: No flu for you.

BACKGROUND: Significant morbidity and mortality is attributed to infection with the influenza virus annually and care is often sought in Emergency Departments (ED). The exposure of Emergency Department healthcare personnel and subsequent illness is speculated to be high but has not been quantified. METHODS: All physicians and mid-level providers in a large tertiary care ED who cared for an Influenza-positive patient were identified and surveyed. Information was gathered regarding each provider's report of an Influenza-like illness during the study period as well as laboratory testing results, sick contacts and subsequent missed work. General descriptive information of Influenza-positive patients was extracted through a retrospective chart review. RESULTS: 1020 Influenza-positive patients were cared for by 106 physicians and advanced practice nurses. Patients testing positive for Influenza-A were more likely to be admitted (p = .003). The majority of patients (83%) were cared for by an attending only. Our provider survey response rate was 87%. 1 in 4 providers reported suffering from an Influenza-like illness during the study period and no providers subsequently missed work days. Only 4 (5%) of those providers sought medical care to receive testing. Overall, 2% of ED providers tested positive for Influenza. CONCLUSIONS: Among Emergency Department providers, transmission of clinically significant Influenza illness was low.

Rhabdomyolysis - Go big or go home.

OBJECTIVE: To evaluate the occurrence of renal injury in hospitalized patients with the diagnosis of rhabdomyolysis among a series of patients presenting to an urban emergency department. METHODS: A retrospective chart review between January 2006 and February 2017 was conducted on patients aged 21-65 years old that were admitted with a diagnosis of Rhabdomyolysis. We included patients with an initial serum creatinine (Cr) level < 1.3 mg/dL and an initial serum creatine phosphokinase (CPK) level > 1000 U/L. We excluded patients with preexisting renal disease, hypertension, diabetes, patients currently on medications in the statin class, patients with muscular dystrophy and neuromuscular disorders. RESULTS: One hundred and fifteen patients (100 men, 15 women) were enrolled, with a mean age of 36 years old. The mean CPK at presentation was 18,965 U/L and the highest CPK was 168,300 U/L. The mean Cr upon presentation was 0.95 mg/dL. The average length of stay of our patients was 4.6 days. The longest length of stay was 30 days and the shortest was 1 day. Seven patients had hospital stays longer than 10 days. None of the patients had prolonged admissions due to rhabdomyolysis alone. The patient admitted for 30 days had a protracted admission due to liver failure and sepsis thought to be unrelated to Rhabdomyolysis. No patients that fit our inclusion criteria developed renal insufficiency (Cr > 1.3 mg/dL) or failure regardless of their CPK upon presentation, peak CPK or therapies received during their hospitalization. CONCLUSION: Patients in our data set that presented to the Emergency Department with a CPK of >1000 U/L and a Cr of <1.3 mg/dL that were hospitalized with a diagnosis of rhabdomyolysis are not at risk for developing renal insufficiency or failure if treated promptly with fluid rehydration, regardless of their initial CPK values.

Acute Appendicitis: Clinical Clues and Conundrums Related to the Greatest Misses.

Introduction In the United States (US), appendicitis is the most common acute abdominal emergency requiring surgery. Patients with appendicitis continue to display a complex and atypical range of clinical manifestations, providing a subsequent high risk for emergency physicians to miss acute abdominal pathology on a patient's initial visits. Due to the risk of potential perforation, the proper and timely clinical identification of acute appendicitis is vital. The current study aims to identify clinical characteristics that could be useful in identifying patients at risk for having acute appendicitis that was misdiagnosed on their initial visits. Methods Medical charts consisting of patients between the ages of 19 and 55 years on their second visit were flagged and reviewed by the emergency department quality assurance (EDQA) committee. The retrospective chart review included patients who presented to the emergency department (ED) with the chief complaint of an abdominal-related complaint, were discharged, returned within 72 hours, and were diagnosed with a pathologically confirmed appendicitis. All patients were managed operatively, with pathology results reviewed for evidence of acute appendicitis. Those with confirmed pathologic appendicitis upon return were considered to have a "misdiagnosis." Any patients managed nonoperatively and those with negative pathology were excluded from the study and considered not to have appendicitis. Results Fifty-five patients were identified through the EDQA committee from May 2011 to January 2014. After exclusion criteria were applied, 18 patients met the inclusion criteria for this study (7 males, 11 females). The mean age was 36.2 (range: 19-55). The most common presenting complaint on the initial visit was pain in the epigastric region of the abdomen (50%, n = 9). Twenty-two percent (n = 4) of patients had pain in the right lower quadrant documented in the physician's note on the initial visit and 83% (n = 15) had right lower quadrant pain documented on the second visit. Two patients (11%) did not have right lower quadrant tenderness on either visit. The most common discharge diagnosis on the initial visit was undifferentiated abdominal pain (50%), followed by gastritis (28%). Opioid pain medication was administered or prescribed to 39% (n = 7) of the patients. The average return time was 23.9 hours. Conclusion The administration of opioid pain medication is associated with many of the return visits to the emergency department for missed appendicitis. Finally, discharge diagnosis and planning are imperative, as detailed early appendicitis instructions or extended ED observation can include more cases and decrease litigation risk.

Pulmonary Edema Occurring after Nitric Acid Exposure.

Nitric acid (HNO3) is a strong acid and oxidizing agent used for various applications including production of ammonium nitrate in the fertilizer industry. Nitrogen oxides formed when nitric acid interacts with the environment have been implicated in inhalation injuries. This describes a case of a 49-year-old male who presented to the emergency department complaining of an acute onset of shortness of breath approximately 12 hours after being exposed to nitric acid fumes. He presented with a room air oxygen saturation of 80 percent with moderate to severe respiratory distress. His plain film chest radiograph showed bilateral pulmonary infiltrates and pulmonary edema. Over a seven-day hospital course, he had an improvement in his clinical status and chest X-ray with normal pulmonary function tests one month after discharge. Although exposure to the fumes of nitric acid is known to cause delayed pulmonary edema, it is rarely reported in the medical literature. This case serves as a reminder to consider exposure to fumes of nitric acid in a patient presenting with pulmonary edema and highlights the importance of obtaining a work history.

Acute hypersensitivity reactions associated with administration of crotalidae polyvalent immune Fab antivenom.

STUDY OBJECTIVE: Acute hypersensitivity reactions are well known to occur with the administration of the Antivenin (Crotalidae) Polyvalent (Wyeth Laboratories, Marietta, PA). Crotalidae polyvalent immune Fab (ovine) (CroFab; FabAV, Protherics, Inc., Brentwood, TN) was introduced in 2001, and early studies reported a hypersensitivity reaction rate up to 19%. We describe the incidence of acute hypersensitivity reactions to FabAV in patients bitten by rattlesnakes. METHODS: This was a nonconcurrent observational cohort study, with data obtained by chart review of all patients admitted to our service for rattlesnake bites from July 2000 to June 2004. The study was conducted at an urban Level I trauma center and urban children's hospital. All patients treated with FabAV were included. Those who received no antivenom or who were treated with Antivenin (Crotalidae) Polyvalent were excluded. The main outcome variable was whether an acute hypersensitivity reaction developed. RESULTS: Ninety-three patients were included in the review (72 male and 21 female patients). The mean age was 34.5 years (range 16 months to 91 years), and the mean dose of antivenom was 12 vials (range 4 to 32 vials). The incidence of acute hypersensitivity reactions was 5 of 93, or 5.4%. Four patients developed a mild reaction that was easily treated and were able to finish the full course of antivenom. Only 1 patient developed a reaction that prevented further antivenom administration. CONCLUSION: FabAV appears to be associated with a lower incidence of acute hypersensitivity than initially reported. Most reactions are mild and easily treated and do not preclude further dosing of antivenom.

Curanderismo: consequences of folk medicine.

Curanderismo, folk medicine, is an important and common aspect of Hispanic culture. Its use is not well understood by US medical physicians and is often overlooked when Hispanic patients present to US hospitals. We present a case of isopropyl alcohol toxicity in a 4-year-old child due to the use of a curanderismo treatment of "espanto" (evil spirits).

Isolated atomoxetine overdose resulting in seizure.

BACKGROUND: Atomoxetine (Strattera), has recently been approved for the treatment of Attention Deficit Hyperactivity Disorder (ADHD) in adolescents and adults. Atomoxetine acts by inhibiting the reuptake of norepinephrine. There are limited reports of the effects of atomoxetine in overdose. We report a case of isolated atomoxetine overdose resulting in seizure and mild cardiac toxicity. CASE REPORT: A 17-year-old female ingested 2840 mg of atomoxetine in an attempt to kill herself. She presented to an Emergency Department 2-3 hours after ingestion and soon after arrival had a tonic clonic seizure that lasted one minute. An initial electrocardiogram (ECG) revealed a sinus tachycardia with a rate of 110 beats per minute (bpm) and a QRS interval of 93 ms. She was transferred to a pediatric toxicology referral center and had progressive improvement in her symptoms. Gas chromatography and mass spectometry of the urine detected the following drugs: atomoxetine, naproxen, and nicotine. A quantitative serum atomoxetine level of 1995 ng/ml and a quantitative serum naproxen level of 12 mcg/L (30-90 mcg/L anti-inflammatory or analgesic range) were obtained. The patient had no further complications and was without symptoms within 24 hours of hospitalization. Repeat ECG 14 hours following ingestion revealed QRS interval of 79 ms. CONCLUSION: We report a case of atomoxetine overdose resulting in seizure and mild widening of the QRS interval on ECG. It is important to be aware of the potential for atomoxetine to cause central nervous system and cardiac toxicity.

Poison control center surge capacity during an unusual increase in call volume--results from a natural experiment.

INTRODUCTION: Poison Control Centers (PCCs) play an integral role in the preparation for and management of poison emergencies. Large-scale public health disasters, caused by both natural and human factors, may result in a drastic increase in the number of inquiries received and handled by PCCs in short periods of time. In order to plan and prepare for such public health emergencies, it is important for PCCs to assess their ability to handle the surge in call volume and to examine how the unusually large number of calls could affect the level of services. On 26 January 2006, the New York City Poison Center experienced a sudden loss of telephone service. The disruption in telephone service led to the need to reroute calls from that geographical catchment area to the New Jersey Poison Information and Education System (NJPIES) for several hours. METHODS: Data from the NJPIES was abstracted from the telephone switch's internal reporting system and the NJPIES's electronic record system and processed with a standard spreadsheet application. RESULTS: Compared to the same time and day in the previous week, the total number of calls received by the NJPIES during the four hours after the disruption increased by 148%. A substantial rise in the number of calls was observed in almost every 15-minute increment during this four-hour (h) time period (with some of these increments increasing as much as 525%). Meanwhile, the percentage of calls answered by the NJPIES decreased, and the percentage of calls abandoned during a 15-minute increment reached as high as 62%. Furthermore, the average time for handling calls was longer than usual in most of these 15-minute increments. CONCLUSIONS: Limitations of the telephone technology, which impacted the ability of the NJPIES to respond to the surge of calls, were observed. While the NJPIES was able to handle the unusual increase of incoming calls using available poison specialists and staff, the experience gained from this natural experiment demonstrates the need for PCCs to have a pre-planned surge capacity protocol that can be implemented rapidly during a public health emergency. A number of challenges that PCCs must meet in order to have adequate surge capacity during such events were identified.

Methadone-induced Torsades de Pointes Masquerading as Seizures.

The authors herein present the case of a 53-year-old female who was being treated as an outpatient for seizure disorder but was also receiving high-dose methadone therapy. She presented to the emergency department (ED) for what appeared to be a seizure and was found to have a prolonged QT interval, as well as runs of paroxysmal polymorphic ventricular tachycardia with seizure-like activity occurring during the arrhythmia. The markedly prolonged QT interval corrected after treatment with intravenous magnesium; subsequent electroencephalogram, neurology and cardiology consultations confirmed the cause of the recurrent seizure-like episodes to be secondary to the cardiotoxic effects of methadone.

Intraventricular conduction delay after bupropion overdose.

Bupropion overdose mainly is characterized by tachycardia, agitation, and seizures. The few reports of QRS complex widening after bupropion overdose that have been published in peer-reviewed literature are notable for failure to have confirmed elevated plasma bupropion concentrations or failure to have excluded other causes of QRS widening. We describe two patients in whom bupropion overdose was confirmed with elevated plasma bupropion concentrations and in whom other cardiotoxic ingestions were excluded with comprehensive analytical toxicology testing. Our findings are in keeping with ex vivo studies in which bupropion antagonizes cardiac voltage-gated sodium channels. Bupropion overdose should be considered in the differential diagnosis of unexpected QRS widening.

Analysis and validation of putative substances involved in fatal poisonings.

Each year, poison control centers throughout the United States respond to over 4 million calls for help in treating individuals exposed to toxic substances. Although most cases develop no or minimal clinical effects, a small proportion of patients who receive medical care for overdoses with poison center consultation expire. When such cases are investigated by a medical examiner, the postmortem toxicology results may show substances other than those considered in the consultation with the poison center. We sought to determine the characteristics of discordance in fatal cases between the toxic substances reported to a regional poison control center and postmortem toxicology results. We conducted a retrospective study of the New Jersey regional poison control center records of all fatal cases between the years 1986 and 2006. Substances reported as putative agents to the poison center were compared to the postmortem toxicology results obtained by the medical examiner. The frequencies and characteristics surrounding discordance were examined. Of the 708 fatal cases reported to our poison center within the study period, complete postmortem toxicological evaluations were available for 206 (29.0%). Comparison of putative agents between information obtained by history and at postmortem evaluation showed discordance in 41 (19.9%). In a substantial number of fatal cases receiving poison center consultation, substances were found at the time of postmortem examination that were not considered in the poison center consultation. The reasons for this discordance may include a lack of thorough history-taking or a cognitive bias to the substances initially reported.

Methamphetamine toxicity secondary to intravaginal body stuffing.

BACKGROUND: People who ingest packets of illicit drugs or insert them into body cavities in an attempt to smuggle them are termed body packers. People who do this in an attempt to hide the drugs when encountered by law enforcement are called body stuffers. Severe toxicity and death occurs in body packers and body stuffers, and this is usually secondary to leaking of drug from packets in the gastrointestinal tract. This is well reported with cocaine and heroin and occurs less commonly with methamphetamine. We report an unusual case of intravaginal body stuffing that lead to severe methamphetamine toxicity in a young woman. CASE REPORT: A 20-year old female, who was in police custody, developed multiple seizures, altered mental status, tachycardia and hypertension shortly after admitting to having drugs enclosed in plastic bags in her vagina. She was hospitalized for 4 days with gradual improvement in her symptoms with the exception of a resting tachycardia. Gas chromatography and mass spectrometry of the urine at this time confirmed the presence of methamphetamine and the amphetamine metabolite, co-intoxicants were excluded based on comprehensive urine drug screening using GCMS. Quantitative serum levels of methamphetamine and amphetamine were 3100 ng/ml and 110 ng/ml, repectively. CONCLUSION: We report an unusual case of intravaginal body stuffing that lead to severe methamphetamine toxicity in a young woman. This case highlights the potential for severe methamphetamine poisoning secondary to intravaginal stuffing. If either body packing or stuffing is suspected, a vaginal exam may be warranted.