Acute adverse effects of F(ab')2AV and FabAV use for rattlesnake Envenomations: A four-year poison center study.

Rattlesnake envenomations account for many of the Crotalid envenomations in the United States annually. Two antivenoms are currently available to treat Crotalid envenomation in this country: Crotalidae-polyvalent ovine immune Fab antivenom (CroFab®; FabAV) and Crotalidae equine immune F(ab')2 antivenom (ANAVIP®; F(ab')2AV). Few studies have compared the adverse effect rates for each. We performed a retrospective chart review of rattlesnake envenomations called to the California Poison Control System from October 2018 to August 2022. Those treated at healthcare facilities with either antivenom were included. Those treated with both antivenoms were excluded. Records were obtained from the poison center electronic medical records system. Demographic and clinical data were abstracted. "Severe" adverse events were defined as multi-organ system involvement, swelling of the patient's airway, and/or hemodynamic instability. All others were categorized as "non-severe." A total of 481 cases were included with 360 treated with FabAV and 121 with F(ab')2AV. The median age was 47 and 46 years, and 72 % and 73 % were male, respectively. Clinical signs and symptoms of envenomation were similar in each group. The FabAV group received a median of six vials. The F(ab')2AV group received a median of 10 vials, based on the recommended loading doses of FabAV and F(ab')2AV. Following antivenom administration, 18 individual acute non-severe AEs were reported in 12 FabAV-treated patients. Two acute non-severe AEs were reported in two F(ab')2AV-treated patients. Rash or urticaria was the most commonly reported adverse effect in both groups after antivenom administration. Five patients (1.5 %) had severe adverse events reported in the poison center records following FabAV administration, and none were reported following F(ab')2AV administration (p = 0.025). Overall, our poison center data suggests the rate of adverse events is low following the use of either antivenom. Our findings are limited by the lack of consistent timing data, a smaller F(ab')2AV cohort, retrospective format, and use of poison center data.

Emergency Department Take-Home Naloxone Improves Access Compared with Pharmacy-Dispensed Naloxone.

BACKGROUND: Opioid overdose is a major cause of mortality in the United States. In spite of efforts to increase naloxone availability, distribution to high-risk populations remains a challenge. OBJECTIVE: To assess the effects of multiple different naloxone distribution methods on patient obtainment of naloxone in the emergency department (ED) setting. METHODS: Naloxone was provided to patients in three 12-month phases between February 2020 and February 2023. In Phase 1, physicians could offer patients electronic prescriptions, which were filled in a nearby in-hospital discharge pharmacy. In Phase 2, physicians directly provided patients with take-home naloxone at discharge. In Phase 3, distribution was expanded to allow ED staff to hand patients take-home naloxone at time of discharge. The total number of prescriptions, rate of prescription filling, and amount of take-home naloxone kits provided to patients were then statistically analyzed using 95% confidence intervals (CI) and chi-squared testing. RESULTS: In Phase 1, 348 naloxone prescriptions were written, with 133 (95% CI 112.5-153.5) filled. In Phase 2, 327 (95% CI 245.5-408.5) take-home naloxone kits were given to patients by physicians. In Phase 3, 677 (95% CI 509.5-844.5) take-home naloxone kits were provided to patients by ED staff. There were statistically significant increases in naloxone distribution from Phase 1 to Phase 2, and Phase 2 to Phase 3. CONCLUSIONS: Take-home naloxone increases access when compared with naloxone prescriptions in the ED setting. A multidisciplinary approach combined with the removal of regulatory and administrative barriers allowed for further increased distribution of no-cost naloxone to patients.

Oral Ingestion of an Iron-Containing Hand Warmer in a Pediatric Patient.

Hand warmer packets are common products used to provide a portable, nonflammable heat source via the exothermic oxidation of iron. We present the first reported case of pediatric hand warmer packet ingestion in a three-year-old male who developed an elevated serum iron concentration (peak 335 ug/dL) and gastrointestinal injury after ingesting the contents of a HOTHANDS hand warmer packet. He was treated with endoscopic gastric foreign body removal and lavage, as well as proton-pump inhibitors and whole bowel irrigation. Hand warmer packs contain reduced elemental iron powder, which has been shown to have a more favorable safety profile when compared to iron salts. The mechanism of toxicity for reduced iron is unknown, though it is thought to be due to conversion to more toxic iron ions in an acidic environment. While the current adult literature suggests that ingestion of a single hand warmer packet is without significant risk, our case demonstrates that even a partial ingestion carries a significant risk of both iron toxicity and direct gastrointestinal caustic injury in a young child. This case demonstrates the need for multidisciplinary care and consideration of urgent endoscopic foreign body removal and gastric lavage followed by whole bowel irrigation to mitigate the potential of severe iron toxicity.

Emergency Department-Initiated Buprenorphine Treatment in a Population with a High Rate of Homelessness: An Observational Study.

BACKGROUND: Buprenorphine is an effective treatment for opioid use disorders. A previous randomized trial comparing emergency department (ED)-initiated buprenorphine to standard care showed dramatic improvement in follow-up. This is encouraging, but must be replicated to understand the generalizability of buprenorphine treatment. OBJECTIVES: Evaluate the efficacy of an ED-initiated buprenorphine protocol similar to a previous randomized trial in a different population. METHODS: This ED-based descriptive study described the results of a project implementing an opioid use disorder treatment protocol that included buprenorphine. Patients with opioid use disorder were offered treatment with buprenorphine, a buprenorphine prescription whenever possible, and a follow-up visit to a clinic providing addiction treatment. The primary outcome was engagement in formal addiction treatment 30 days after the index visit. RESULTS: Of the 210 patients who accepted referral for outpatient medication-assisted treatment, 95 (45.2%) achieved the primary outcome. Two-thirds of these patients received a buprenorphine prescription at discharge; 40% were homeless. A regression analysis revealed one statistically significant predictor of the primary outcome: patients who were housed were 2.49 times more likely to engage in opioid use disorder treatment than patients who were homeless (p = 0.02). CONCLUSIONS: In this descriptive study of an ED-initiated buprenorphine protocol, follow-up was less than that reported in a previous randomized controlled trial. Two important differences between our study and the randomized trial are the high rate of homelessness and the fact that not every patient received a prescription for buprenorphine. The efficacy of ED-initiated treatment may depend on certain population characteristics.

Unintentional Pediatric Lithium Exposure: A 15-Year Retrospective Analysis.

OBJECTIVES: Lithium is an uncommon pediatric exposure, and the effects of accidental or exploratory ingestions are not well characterized. This study examined the clinical effects and outcomes of unintentional lithium ingestions treated in a health care facility for patients up to 16 years old. METHODS: The database from a single-state Poison Control System was queried for all pediatric lithium exposures managed in a health care facility between January 2006 and December 2021. Inclusion criteria were 16 years or younger and acute lithium exposure treated in a health care facility. Those older than 16 years, nonoral exposures, intentional, chronic, or nonlithium exposures, and out-of-state patients were excluded. RESULTS: One hundred eighteen cases were included, and 619 were excluded. The median age was 2 years (range, 0.5-15 years). One hundred fifteen (97%) were 7 years or younger. Sixty-eight (57.6%) were boys. One hundred thirteen (96%) were exploratory ingestions. Lithium carbonate was the most common formulation, with a median reported dose of 525 mg (range, 100-13,500 mg). Sixty-seven (57%) had serum lithium concentrations available: 19 (28%) were detectable (>0.1 mEq/L) and 4 were supratherapeutic (>1.2 mEq/L).One hundred (85%) patients were coded as having no effects. Four (3%) patients had coded effects-1 mild, 2 moderate, and 1 major; all were polydrug ingestions and recovered fully with basic supportive care. The loss to follow-up rate was 12%.A small minority received treatment with intravenous fluids and/or whole bowel irrigation. Thirteen (11%) were admitted, 3 to the ICU. No morbidity or mortality was reported. CONCLUSIONS: The majority of unintentional pediatric lithium ingestions examined were exploratory and resulted in no significant symptoms. Only a small minority had detectable serum lithium concentrations. All isolated lithium exposures were asymptomatic. Unintentional exposures appear to be benign, even with detectable lithium levels. Further study is needed to better risk stratify for home care versus health care facility evaluation.

The diagnostic utility of procalcitonin is limited in the setting of methamphetamine toxicity.

Procalcitonin (PCT) is a biomarker with greater specificity for bacterial infection than other current laboratory markers. However, PCT can also be elevated in the setting of several noninfectious conditions. A recent case report describes a patient with elevated PCT in the context of acute methamphetamine intoxication, but without evidence of infection. Thus far, no studies have evaluated the diagnostic utility of PCT in patients with active methamphetamine use. We seek to test the hypothesis that PCT has diminished utility in patients who use methamphetamine presenting to the Emergency Department (ED). We performed a retrospective cohort study of patients presenting to an academic ED between May 2017 and July 2019. We included patients ≥18 years of age with a positive urine methamphetamine test and at least two PCT results. Pregnant patients were excluded. Cases were classified as microbiologically documented infection, clinically documented infection, possible infection, or no infection by clinician review. A positive PCT value was defined as ≥0.5 ng/ml. The performance of PCT as a diagnostic test for bacterial infection in this population was then evaluated using sensitivity, specificity, false positive rate, false negative rate, and area under the receiver operating characteristic curve. We identified 143 patients, including 75 with recorded PCT levels ≥0.5 ng/ml and 93 with microbiologically or clinically documented bacterial infection. The sensitivity and specificity of PCT for bacterial infection in this study population was 60% and 64%, respectively. The false positive rate was 36% while the false negative rate was 40%. The area under the ROC curve was 0.65. Additionally, we describe 8 patients with confirmed absence of infection but with elevated PCT, 4 of whom had serum values >10 ng/ml. The results suggest that PCT has poor diagnostic utility for bacterial infection in patients with active methamphetamine use presenting to the ED.

Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation.

INTRODUCTION: Emergency department (ED) patients undergoing emergent tracheal intubation often have multiple physiologic derangements putting them at risk for post-intubation hypotension. Prior work has shown that post-intubation hypotension is independently associated with increased morbidity and mortality. The choice of induction agent may be associated with post-intubation hypotension. Etomidate and ketamine are two of the most commonly used agents in the ED, however, there is controversy regarding whether either agent is superior in the setting of hemodynamic instability. The goal of this study is to determine whether there is a difference in the rate of post-intubation hypotension who received either ketamine or etomidate for induction. Additionally, we provide a subgroup analysis of patients at pre-existing risk of cardiovascular collapse (identified by pre-intubation shock index (SI) > 0.9) to determine if differences in rates of post-intubation hypotension exist as a function of sedative choice administered during tracheal intubation in these high-risk patients. We hypothesize that there is no difference in the incidence of post-intubation hypotension in patients who receive ketamine versus etomidate. METHODS: A retrospective cohort study was conducted on a database of 469 patients having undergone emergent intubation with either etomidate or ketamine induction at a large academic health system. Patients were identified by automatic query of the electronic health records from 1/1/2016-6/30/2019. Exclusion criteria were patients <18-years-old, tracheal intubation performed outside of the ED, incomplete peri-intubation vital signs, or cardiac arrest prior to intubation. Patients at high risk for hemodynamic collapse in the post-intubation period were identified by a pre-intubation SI > 0.9. The primary outcome was the incidence of post-intubation hypotension (systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg). Secondary outcomes included post-intubation vasopressor use and mortality. These analyses were performed on the full cohort and an exploratory analysis in patients with SI > 0.9. We also report adjusted odds ratios (aOR) from a multivariable logistic regression model of the entire cohort controlling for plausible confounding variables to determine independent factors associated with post-intubation hypotension. RESULTS: A total of 358 patients were included (etomidate: 272; ketamine: 86). The mean pre-intubation SI was higher in the group that received ketamine than etomidate, (0.97 vs. 0.83, difference: -0.14 (95%, CI -0.2 to -0.1). The incidence of post-intubation hypotension was greater in the ketamine group prior to SI stratification (difference: -10%, 95% CI -20.9% to -0.1%). Emergency physicians were more likely to use ketamine in patients with SI > 0.9. In our multivariate logistic regression analysis, choice of induction agent was not associated with post-intubation hypotension (aOR 1.45, 95% CI 0.79 to 2.65). We found that pre-intubation shock index was the strongest predictor of post-intubation hypotension. CONCLUSION: In our cohort of patients undergoing emergent tracheal intubation, ketamine was used more often for patients with an elevated shock index. We did not identify an association between the incidence of post-intubation hypotension and induction agent between ketamine and etomidate. Patients with an elevated shock index were at higher risk of cardiovascular collapse regardless of the choice of ketamine or etomidate.

Life-threatening pediatric dextromethorphan polistirex overdose.

Dextromethorphan polistirex is an extended-release formulation of dextromethorphan hydrobromide, marketed as Delsym® (Reckitt; Parsippany, NJ), with a duration of action roughly two to three times that of the standard formulation. The polistirex binder is responsible for the prolonged duration of action by slowing the release of active ingredient; the liberated dextromethorphan has unchanged pharmacokinetics and clinical effects. A 23-month-old male presented following a 900 mg (71.4 mg/kg) dextromethorphan polistirex ingestion 90 min prior. On arrival, he was unresponsive, tachycardic, and hypertensive with mydriasis, roving eye movements, rotary nystagmus, and opisthotonos. Approximately 90 min after arrival, he required intubation for airway protection. The blood dextromethorphan concentration from 75 min after arrival was 110 ng/mL (10-40 ng/ml therapeutic). He was extubated approximately 13 h after arrival and discharged that day. Most pediatric dextromethorphan overdoses produce mild symptoms that are not considered to be life-threatening. Life threatening overdoses are rare. The toxic dextromethorphan dose and blood concentration as well as the toxicokinetics of the polistirex formulation are not well defined. Our case suggests that a blood dextromethorphan concentration exceeding 100 ng/mL can be toxic in this age group, however further study is needed.

Symptomatic Diethylene Glycol Ingestion Successfully Treated with Fomepizole Monotherapy.

BACKGROUND: Diethylene glycol (DEG) is an industrial solvent with many uses, including brake fluids. It has also caused mass poisonings after use as an inappropriate substitute for propylene glycol or glycerin, though individual ingestions are rare. Like other toxic alcohols, DEG is metabolized by alcohol dehydrogenase and aldehyde dehydrogenase, with toxicity likely mediated by the resulting metabolites. Fomepizole, an alcohol dehydrogenase inhibitor, is used to prevent metabolite formation with other toxic alcohol exposures. Fomepizole is recommended for DEG poisoning, though supporting clinical evidence is limited. CASE REPORT: A 31-year-old man presented after ingestion of DEG-containing brake fluid and hydrocarbon-containing "octane booster." He was noted to be clinically intoxicated, with a mildly elevated anion gap metabolic acidosis and no osmolar gap. DEG level was later found to be elevated, consistent with his ingestion. He was treated with fomepizole alone, with resolution of metabolic acidosis and clinical findings over the next 2 days. No delayed neurologic sequelae were present at 52-day follow-up. Our case provides additional evidence supporting the use of fomepizole for DEG poisoning. Consistent with other toxic alcohols, DEG poisoning, especially early presentations, may benefit from empiric fomepizole administration. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: DEG poisoning is potentially life threatening, but treatable if identified early. An ingestion can be toxic despite a normal osmolar gap, leading to false reassurance. Finally, it is rare, so emergency physicians must be made aware of its potential dangers.

Two Cases of Thyrotoxicosis due to Redotex Ingestion, a Mexican Weight Loss Drug.

BACKGROUND: Redotex™ is a Mexican weight-loss supplement that is not U.S. Food and Drug Administration-approved. It consists of the following five ingredients: tri-iodothyronine 75 µg, atropine 0.36 mg, diazepam 8 mg, aloin 16 mg, and d-norpseudoephedrine 50 mg per tablet. There are few case reports with clinically severe ingestions. We report two cases of clinical thyrotoxicosis due to use of Redotex. CASE REPORTS: A 29-year-old woman presented to the emergency department (ED) with anxiety and palpitations. She reported taking Redotex daily for 1 week. Her temperature was 37.1°C, blood pressure (BP) was 166/104 mm Hg, and heart rate (HR) was 140 beats/min. Laboratory analysis was significant for a bicarbonate level of 20 mmol/L (reference 22-29 mmol/L), free T4 0.75 ng/dL (reference 0.93-1.70 ng/dL), and thyroid-stimulating hormone (TSH) 0.05 uIU/mL (reference 0.27-4.20 uIU/mL). She was treated with 2 mg i.v. lorazepam and 20 mg oral propranolol. A 37-year-old woman presented with chest pain, palpitations, and nausea after taking Redotex 1 to 2 tablets daily for 6 weeks. Her HR was 134 beats/min and BP was 130/66 mm Hg. Thyroid function tests on initial presentation showed a TSH of 0.013 uU/mL, free T4 of 0.24 ng/dL, and free T3 of >30 pg/mL. She was treated with propranolol 1 mg i.v. twice per day and 2 doses of lorazepam 1 mg. Both patients had resolution of their symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: When taken chronically and at recommended doses, Redotex can present with clinically significant T3 thyrotoxicosis. This has not been seen in prior reports.

A BERIBERI UNHEALTHY LATTE: ENCEPHALOPATHY AND SHOCK FROM SEVERE NUTRITIONAL DEFICIENCY.

BACKGROUND: Thiamine deficiency is an uncommon cause of severe illness in the United States that can lead to significant morbidity because of high-output cardiac failure, peripheral neuropathy, and permanent neurologic impairment. We report the case of a middle-aged woman with extreme malnutrition caused by complications of Roux-en-Y gastric bypass (RYGB) surgery who presented with signs and symptoms of severe thiamine deficiency and septic shock. CASE REPORT: A 43-year-old woman who had undergone RYGB surgery and who had multiple complications presented to the emergency department with agitation, confusion, and lethargy. The physical examination revealed an obtunded woman appearing much older than her reported age with significant peripheral edema. She was hypoxemic, hypotensive, and febrile. The initial laboratory analysis revealed a serum lactate level above the measurable limit, a normal thyroid-stimulating hormone, and elevated levels of troponin and brain natriuretic peptide. A transthoracic echocardiogram showed high-output heart failure. The patient's family later revealed that for the past year her diet had consisted almost exclusively of frozen blended lattes. High doses of thiamine and folate were started. Her shock, hyperlactatemia, and respiratory failure resolved by hospital day 3 and her encephalopathy resolved soon thereafter. Why Should an Emergency Physician be Aware of This?: Thiamine deficiency is a rare but reversible cause of shock, heart failure, and encephalopathy. Identifying patients who are at risk for severe nutritional deficiencies may aid in more rapid treatment with relatively benign medications with little downside, in this case high-dose vitamin B1, and ultimately improve patient-oriented outcomes such as mortality, morbidity, and hospital length of stay.

The Treatment of Acute Pain in the Emergency Department: A White Paper Position Statement Prepared for the American Academy of Emergency Medicine.

BACKGROUND: Pain is one of the most common reasons patients present to the emergency department (ED). Emergency physicians should be aware of the numerous opioid and nonopioid alternatives available for the treatment of pain. OBJECTIVES: To provide expert consensus guidelines for the safe and effective treatment of acute pain in the ED. METHODS: Multiple independent literature searches using PubMed were performed regarding treatment of acute pain. A multidisciplinary panel of experts in Pharmacology and Emergency Medicine reviewed and discussed the literature to develop consensus guidelines. RECOMMENDATIONS: The guidelines provide resources for the safe use of opioids in the ED as well as pharmacological and nonpharmacological alternatives to opioid analgesia. Care should be tailored to the patient based on their specific acute painful condition and underlying risk factors and comorbidities. CONCLUSIONS: Analgesia in the ED should be provided in the most safe and judicious manner, with the goals of relieving acute pain while decreasing the risk of complications and opioid dependence.

A new F(ab')2 antivenom for the treatment of crotaline envenomation in children.

STUDY OBJECTIVE: To evaluate the efficacy and safety of a new F(ab')2 antivenom preparation in the treatment of Crotalinae envenomation in children. METHODS: We present a case series of children younger than 16 years who suffered Crotalinae envenomation and were treated with a new F(ab')2 antivenom. Envenomated children treated with the new antivenom were assessed for efficacy of the product, defined as improvement of any hemotoxicity (hypofibrinogenemia, defined as fibrinogen <150 mg/dL, or thrombocytopenia, defined as platelets <150 000/mm3), and the cessation of the advancement of swelling. Safety was also evaluated by monitoring for adverse events. A secondary parameter assessed in these children was recurrent hemotoxicity after initial control of signs and symptoms with follow-up visits and laboratory testing on posttreatment days 5, 8, and 15. RESULTS: Twenty-one children received the F(ab')2 antivenom. Efficacy was achieved in all children receiving the product with initial control of swelling and improvement in those with hemotoxicity. No patients suffered anaphylaxis or any other serious adverse events from the F(ab')2 treatment. There were no cases of recurrent hemotoxicity recorded in the study between time of initial control and postinfusion day 15. CONCLUSIONS: In this series of children, the F(ab')2 antivenom appeared to be both safe and effective in the treatment of hemotoxicity and local tissue toxicity (swelling) from Crotalinae envenomation.

An unusual case of an icteric infant with abdominal distention.

BACKGROUND: Jaundiced infants are uncommon in most emergency departments (EDs). Biliary rupture remains one of the more rare and less described causes of this condition. CASE REPORT: A 5-month-old male presented to our ED with scleral icterus, increasing abdominal distention, and increased irritability. A bedside ultrasound revealed a moderate amount of ascites and further imaging suggested he had a rupture of his common bile duct. Surgical exploration confirmed this and revealed the presence of choledocholithiasis, which was the likely cause of the rupture. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Biliary rupture remains a rare but serious condition in very young patients. Emergency physicians should consider bedside ultrasound as an adjunct in undifferentiated abdominal distention or jaundice in this patient population.

Accidental organophosphate poisoning: A case series of 2 pediatric coumaphos exposures.

Introduction: Pediatric organophosphate insecticide poisonings are rare in the United States, and life-threatening toxicity is rarely seen. We report 2 accidental ingestions of the organophosphate insecticide coumaphos that resulted in life-threatening symptoms. Case Reports: A 7-year-old boy and 10-year-old girl both presented from home after accidental ingestion of 1 "spoonful" of coumaphos 20% liquid (Asuntol; Bayer de Mexico, S.A. de C.V., Mexico D.F., Mexico). There were no other known ingestions. Both became rapidly symptomatic, with the boy developing dyspnea, vomiting, and depressed mental status and the girl developing headache and nausea. Soon afterward, the boy had witnessed cardiopulmonary arrest and the girl developed altered mental status and flaccid paralysis. Both were treated initially with atropine, but required no additional doses. On arrival to the pediatric intensive care unit (ICU), both patients received pralidoxime with subsequent plasma exchange and continuous venovenous hemodiafiltration (CVVHDF). Transient anemia, coagulopathy, transaminitis, and hyperglycemia developed in both patients. The girl was extubated on hospital day 6 and the boy on hospital day 11. The girl's course was complicated by aspiration pneumonia and an isolated seizure. The boy's course was complicated mainly by anoxic brain injury, associated seizures, neuroagitation, spasticity, and autonomic instability. The girl was discharged on hospital day 16 and remains asymptomatic 32 days after ingestion. As of 90 days after ingestion, the boy remains admitted to inpatient rehabilitation. Discussion: The clinical benefit of pralidoxime, plasma exchange, and CVVHDF is uncertain in these cases. The optimal treatment regimen for organophosphate insecticide toxicity remains poorly defined.

Sulfhemoglobinemia and methemoglobinemia following acetaminophen overdose.

Introduction: Though acetaminophen overdoses are common, acetaminophen induced methemoglobinemia is rare and it is thought to be due to oxidative stress from reactive metabolites. However, few prior cases of sulfhemoglobinemia in the setting of acetaminophen overdose have been reported. We report a case of mixed methemoglobinemia and sulfhemoglobinemia in the setting of a large, isolated acetaminophen ingestion. Case report: A 30-year-old African American male presented after intentionally ingesting 50 tablets of 500 mg acetaminophen two days prior. He was cyanotic and tachypneic. Peripheral oxygen saturation was 78 % on room air and minimally improved with high-flow oxygen. He was noted to have leukocytosis, thrombocytopenia, anion gap metabolic acidosis with lactic acidemia, acute kidney injury, transaminitis, hyperbilirubinemia, and coagulopathy. Arterial partial pressure of oxygen was normal. Methemoglobin and sulfhemoglobin concentrations were 8.5 % and 5.2 %, respectively. Along with intravenous N-acetylcysteine, methylene blue was administered without clinical improvement. Hemolytic anemia was subsequently noted. Glucose-6- phosphate dehydrogenase (G6PD) deficiency was then confirmed with a quantitative assay and genetic testing. He also received one dose of intravenous metoclopramide. The patient ultimately required eight units of packed red blood cells and several weeks of hemodialysis before discharge on hospital day 43. Discussion: Acetaminophen is structurally related to compounds known to cause methemoglobinemia and sulfhemoglobinemia. We hypothesize that these dyshemoglobinemias were triggered by acetaminophen-induced oxidative stress. The role of G6PD deficiency in the formation of sulfhemoglobinemia is unclear. Acetaminophen overdoses presenting with methemoglobinemia should prompt concern for underlying G6PD deficiency. Coincidental sulfhemoglobinemia should be considered if the clinical presentation is more severe than the methemoglobin concentration alone would suggest. Use of methylene blue in this case, despite the low measured methemoglobin percentage, which likely triggered hemolytic anemia; methylene blue use in a similar circumstance should be weighed carefully against the risk of harm.

Interobserver agreement between emergency clinicians and nurses for Clinical Opiate Withdrawal Scale.

OBJECTIVES: The Clinical Opiate Withdrawal Scale (COWS) is a validated, commonly used tool to objectively quantify withdrawal symptoms, often in anticipation of treatment with buprenorphine. Our primary aim was to determine the agreement between emergency department (ED) nurses compared with emergency physicians in determining this score in ED patients who presented for opioid withdrawal treatment. Secondarily, we wanted to investigate the safety of buprenorphine induction in the ED setting. METHODS: Scoring for opioid withdrawal using the COWS was performed by ED clinicians and ED nurses independently on 120 patients. In addition to overall concordance, agreement (weighted kappa) was calculated between the 2 scores by various cutoffs: overall severity, COWS ≥ 5, and the 11 different individual measures. Patient documents also were reviewed for complications that could be possibly linked to buprenorphine induction. RESULTS: Our study sample of 120 subjects was 77% Hispanic and 78.3% male. The clinicians assigned a median interquartile range overall COWS score of 6 (2-12), which categorizes as mild withdrawal. Seventy-eight (65%) subjects met the criteria of withdrawal (≥ 5 COWS) and 69 (58%) received an induction dose of buprenorphine (range 2 mg-24 mg) during the ED visit. No adverse effects or worsening withdrawal were reported. The overall observed concordance, based on severity withdrawal categorization, for all clinician pairs, was 67.5% (81/120) (95% confidence interval [CI], 58.7-75.2%). The weighted kappa for that concordance was 0.55 (95% CI, 0.43-0.67), giving a moderate strength of agreement. When data are dichotomized by COWS score ≥5, concordance was 82.5% (99/120) (95% CI, 74.7%-88.3%) and the weighted kappa was 0.65 (95% CI, 0.51-0.78), indicating substantial agreement. The breakdown by the 11 factors that constitute COWS showed only substantial agreement for pulse measurement. CONCLUSION: The agreement between ED clinicians and nurses for the overall COWS scoring in patients presenting for opioid withdrawal treatment was substantial. COWS scoring by ED nurses may help expedite treatment with buprenorphine on presentation.