PROTOCOL FOR HUMAN EXPOSURE TO OPIOIDS AND CONCENTRATED MEDETOMIDINE USED IN FIELD APPLICATIONS.

Wildlife professionals routinely use potent sedatives and anesthetics when chemically immobilizing wildlife and zoo species in remote environments. Accidental exposure to these prescription veterinary drugs is rare but could be rapidly fatal. Commonly used agents include opioids and α2 adrenoreceptor agonists. These drugs can be reversed with specific antagonists; however, they are often not approved for human use. The protocol created here can be used by wildlife health professionals in a field setting with basic human emergency medical response training in coordination with local Emergency Medical Services (EMS). Key components include, building local relationships between EMS and wildlife professionals, focused EMS training, administering opioid and α2 adrenergic antagonists off label, and local evacuation procedures. This framework could allow wildlife management agencies or zoos to mitigate the risk of human exposures to these commonly used drugs, significantly improving occupational safety in an otherwise high-risk environment.

A different challenge with Benadryl: adolescent diphenhydramine ingestions reported to National Poison Database System, 2007-2020.

BACKGROUND: The US Food and Drug Administration released a warning related to potential adverse effects related to intentional misuse or abuse ingestions of diphenhydramine in September 2020. We sought to evaluate adolescent-aged (13-19 y) diphenhydramine ingestions reported to US poison control centers to characterize these exposures, adverse effects, outcomes, and trends in outcomes and reasons for ingestion. METHODS: The US National Poison Database System was queried for all exposures to diphenhydramine between January 1, 2007 and December 31, 2020. RESULTS: 47,644 ingestions were included for analysis. An increase in the number of ingestions, percentage of cases due to an intentional reason for ingestion and suspected suicide was observed. More serious outcomes, cardiac complications, seizures, and deaths were more common following intentional ingestions and specifically suspected suicide over misuse or abuse. CONCLUSIONS: Adolescent ingestions of diphenhydramine increased between 2007 and 2020. More serious outcomes, intentional reasons, and suspected suicide also increased over the study interval. Suspected suicide was associated with cardiac complications, seizures, coma, and death at higher rates than misuse or abuse. While misuse and abuse remain a concern, public health interventions focusing on the risk that diphenhydramine pose as an agent of suicide attempt may be of higher impact.

Comparing Physician Assistant and Nurse Practitioner Practice in U.S. Emergency Departments, 2010-2017.

INTRODUCTION: We sought to compare physician assistant (PA) and nurse practitioner (NP) practice in United States emergency departments (ED) based on ED visits as reported by the National Hospital Ambulatory Medical Care Survey (NHAMCS). METHODS: We performed a retrospective, secondary analysis of the 2010 to 2017 NHAMCS with analysis of ED visits, patient demographics, and hospital characteristics. RESULTS: Between 2010 to 2017, 21.0% (95% confidence interval, [CI] +/-3.1%) of ED visits were seen by either a PA/NP (with and without physician involvement) and 8.6% (+/-2.9%) were seen by PA/NP alone. We identified an increase for NP visits between 2014-2016 and found that PA/NP visits share many of the same characteristics. CONCLUSION: While emergency medicine has predominately been a specialty for PAs, the number of ED visits with NPs has been increasing over the past several years. While there are some differences, PAs/NPs share many similar practice characteristics in the ED.

Physician assistant utilization in U.S. emergency departments; 2010 to 2017.

BACKGROUND: Physician Assistants (PAs) are widely used in United States (US) Emergency Departments (EDs). We sought to characterize ED PA utilization and practice characteristics in US EDs 2010-2017. METHODS: A retrospective, secondary analysis of the 2010 to 2017 Center for Disease Control's National Hospital Ambulatory Medical Care Survey (NHAMCS) was performed. National estimates of ED visits involving PAs alone (PA), PAs with physician involvement (PA+), or physician only (PHYS) were analyzed for patient demographics and hospital characteristics. RESULTS: Between 2010 and 2017, an estimated 1 billion US ED visits occurred. 5.0% (95% confidence interval [CI] ±2.7%) of visits were seen by a PA, and 8.2% (±2.7%) by a PA+; 76.3% (±7.2%) by PHYS. No linear trends by year were identified in PA or PA+ visits. PA acuity was highest for semi-urgent/nonurgent (56.4%, ±10.7%). PA see the minority of ambulance arrival [5.8% (±1.3)] and admit less patients [1.7% (±0.7%)]. Less laboratory [53.3% (±10.2%) vs. 67.0% (±6.2%)] and radiographic [38.8% (±6.6%) vs. 51.6% (±4.6%) studies were performed during PA vs. PHYS visits. PA visits were most common for patients 25-44 years old (yo) (32.9%, ±6.2%) and 15-24 yo (19.2%, ±3.7%). Most PA visits result in a length of stay (LOS) between 1 and 1.9 h (32.9%, ±6.7%) compared to most PHYS visits resulting in a LOS >3 h (40.3%, ±3%). CONCLUSIONS: From 2010 to 2017, no linear trends in US ED PA and PA+ utilization were identified. PHYS continue to see the majority of ED patients.

Sustained stimulation? Characteristics of modified release and immediate release stimulant exposures reported to the national poison data system.

OBJECTIVE: We sought to examine ADHD modified release (MR) and immediate release (IR) stimulant ingestion exposures reported to the National Poison Data System (NPDS) to characterize the nature of the exposures and the outcomes associated with them. METHODS: The NPDS was queried for all single-substance exposures to MR and IR ADHD preparations between January 1, 2007 and December 31, 2017. MR and IR preparations were identified by a generic code of "amphetamine and related compounds" or "methylphenidate" and specific product name containing XR, CD, ER, LA, and SR. RESULTS: A total of 15,796 MR ingestions and 23,418 IR ingestions were identified and followed to known outcome. The majority of ingestions occurred in male patients and in own residence. More serious outcomes (moderate, major, or death) were more common in adult IR and MR ingestions as compared to pediatric; rates of serious outcome increased with age amongst pediatric ingestions. Unintentional ingestions were more common in both MR and IR pediatric cases while intentional ingestions occurred more frequently in adult cases. Symptoms consistent with a hyperadrenergic state were experienced in adult and pediatric patients for both MR and IR ingestions. Supportive care including benzodiazepine administration was more common in IR than MR ingestions. Decontamination with whole bowel irrigation was infrequent. CONCLUSION: Rates of more serious outcome were similar between IR and MR ADHD stimulant ingestions. More serious outcomes were associated with advancing age and intentional ingestions. Similar rates of agitation, tachycardia, and hypertension were experienced by pediatric IR and MR ingestions while more common in adult IR as compared to MR ingestions. Rates of decontamination with whole bowel irrigation were overall low.

Respiratory depression following medications for opioid use disorder (MOUD)-approved buprenorphine product oral exposures; National Poison Database System 2003-2019.

BACKGROUND: Medications for opioid use disorder (MOUD) including buprenorphine is recommended for patients with opioid use disorders. We sought to evaluate the frequencies of respiratory depression, intubation, and naloxone administration, and clinical outcomes among patients reported to the National Poison Database System (NPDS) following single-substance and multiple-substance buprenorphine oral exposures. METHODS: NPDS was queried for all MOUD-approved buprenorphine product exposures between 1 January 2003 and 31 December 2019. Data abstracted included year, route, gender, age, site of exposure, management site, medical outcome, recorded "related" respiratory depression ("respiratory rate <10 breaths/min and/or a SpO2 (pulse oximetry)≤90%), reported administration of naloxone and intubation in oral exposure cases followed to known outcome. Concomitant products were also recorded in multiple-substance buprenorphine cases. RESULTS: 27,275 (11,010 multiple and 16,265 single) buprenorphine oral exposures were identified and followed to known outcome. A 65-fold increase in reported cases was reported over the study interval. A steady increase in the frequency of more serious outcomes by year was also observed. Respiratory depression occurred at a frequency of 11.8% (pediatric single-substance), 11.2% (pediatric multiple-substance), 11.3% (adult single-substance), and 11.9% (adult multiple-substance). Among oral exposures of buprenorphine and only one other product, benzodiazepines, opioids, ethanol, and amphetamines were most common. CONCLUSIONS: Oral exposures have increased substantially between 2003 and 2019. More serious outcomes including deaths following oral exposures to buprenorphine have also increased over the same interval for both adult and pediatric patients. Clinically significant rates of respiratory depression in both adult and pediatric patients when taken alone and with additional substances were observed.

Physician assistant and nurse practitioner utilization in U.S. emergency departments, 2010 to 2017.

BACKGROUND: Physician Assistants (PAs) and Nurse Practitioners (NPs) are widely utilized in United States (US) Emergency Departments(EDs). We sought to characterize ED PA and NP utilization and practice characteristics in US EDs 2010-2017. METHODS: A retrospective, secondary analysis of the Center for Disease Control's National Hospital Ambulatory Medical Care Survey was performed. National estimates of ED visits involving PAs/NPs alone (PA/NP), PAs/NPs with physician involvement (PA/NP+), or physician only (PHYS) were analyzed for patient demographics and hospital characteristics. RESULTS: Between 2010 and 2017, 1 billion US ED visits occurred. 8.4% (±4.2%) of visits were seen by a PA/NP, and 11.8% (±4.5%) by a PA/NP+; 76.3% (±7.2%) by PHYS. There was an increase in utilization by PA/NP observed in 2016. PA/NP acuity was highest for semi-urgent/nonurgent (53.2%, ±8.6%). PA/NP see the minority of ambulance arrivals [5.4% (±1.2%)] and admit less patients overall [1.6% (±0.7%)]. Less laboratory [53.6% (±10.0%) vs. 67.0% (±6.2%)] and radiographic [38.0% (±7.0%) vs. 51.6% (±4.6%)] studies were performed during PA/NP only vs. PHYS visits. PA/NP visits were most common for patients 25-44 years old (yo) (31.1%, ±5.5%) and 0-15 yo (23.9%, ±4.7%). Most PA/NP visits result in a length of stay (LOS) between 1 and 1.9 h (33.4%, ±5.7%) compared to most PHYS visits resulting in a LOS greater than 3 h (40.3%, ±3%). CONCLUSIONS: From 2010 to 2015, PA/NP utilization remained stable until an increase in 2016. There was a decrease in 2017. Various PA/NP patient characteristics are significant compared to PHYS. PHYS continue to see most ED patients.

Clinical Utility of Carnett and closed eye sign in emergency department.

BACKGROUND: Carnett's sign (CAR) and Closed Eye sign (CE) have been suggested for use in the emergency department setting in the management of abdominal pain. The present study sought to determine the sensitivity/specificity of CAR and CE for pathological CT findings as a primary outcome and for subsequent hospital admission or surgical intervention as secondary outcomes in a community emergency department setting. METHODS: A convenience sample of adults (≥18 y) presenting with acute (<48 h) nontraumatic and non-postoperative abdominal pain determined by treating provider to warrant CT imaging were eligible for enrollment. Treating providers completed a datasheet describing physical examination findings prior to CT imaging. RESULTS: 320 patients were enrolled. 245/320 (76.5%) of enrolled patients had findings on CT Imaging. CAR+ was recorded in 145 and CAR- in 175 patients. CE+ was in 187 and CAR- in 133 patients. Sensitivity and specificity of CAR- for hospital admission was 42.2% and 38.9% and for surgery-44.8% and 43.1%. Sensitivity and specificity of CE- for hospital admission was 28% and 51.6% and for surgery-25.9% and 55%. CAR+ patients were more likely to be admitted or undergo surgery as compared to CAR-. CE+ patients were more likely to be admitted or undergo surgery as compared to CAR-. There were no differences in frequency of pathological CT findings between CAR+ and CAR- or CE+ and CE- patients. CONCLUSION: CAR and CE are neither sufficiently sensitive nor specific for use in the emergency department setting. CT findings were equally likely in CAR+ and CAR- patients. CT Findings were also equally likely in CE+ and CE- patients.

Pharmacist dispensed naloxone: Knowledge, availability, participation and cost in selected California counties.

BACKGROUND: In 2014, California signed into law AB1535 permitting pharmacists to dispense naloxone upon request and without physician or midlevel provider prescription. OBJECTIVE: We sought to determine pharmacist knowledge of AB1535, participation, availability of naloxone, future plans for participation, and out-of-pocket charges to consumers amongst outpatient pharmacies in selected California counties. METHODS: All pharmacies in Plumas, Lake, Lassen, Humboldt, Shasta, Fresno, and San Diego Counties were identified. Between January 30 and March 30, 2017, pharmacies meeting inclusion criteria were contacted and the pharmacist-on-duty were queried regarding knowledge, participation, availability, and cost of naloxone. RESULTS: A total of 2296 pharmacies were identified in the 7 counties. Twenty-six were unwilling or unable to participate and an additional 1648 were excluded because of licensing or special pharmacy status. Six-hundred-twenty-two pharmacies completed the survey. There was variation in knowledge of AB1535, participation in, immediate availability of naloxone, charge, and expressed future interest in participation identified. Charge to consumers was similarly variable amongst surveyed pharmacies within counties. CONCLUSIONS: Despite considerable public health and political support, the passage of CA AB1535 has not resulted in broad current, future planned participation, or availability of naloxone in selected counties. Out-of-pocket costs to the consumer remain highly variable.

Does the U Stand for Useless? The Urine Drug Screen and Emergency Department Psychiatric Patients.

BACKGROUND: Behavioral emergencies account for a significant portion of emergency department (ED) visits in the United States. Substance abuse is common in this population and may precipitate or exacerbate preexisting psychiatric illness. Contrary to ED policy guidelines, many behavior health centers (BH) require a urine drug screen (UDS) in stable patients prior to transfer. OBJECTIVE: We sought to determine the role of the UDS in ED length of stay (LOS), cost, and charges to patients and inpatient psychiatric care. METHODS: We performed a retrospective chart review of all patients transferred to an in-network BH from September 1-30, 2014. Clinical data were extracted and analyzed from our electronic medical record, including records from both the ED visit and the BH stay. RESULTS: There were 205 patient encounters identified; 89 patients had a UDS performed in the ED and 89% were obtained after the ED medical clearance. LOS were similar between the two groups, however, time to ED departure from time of medical clearance was delayed in the UDS group. BH providers mentioned UDS results < 25% of the time and no confirmatory tests were performed. There was no difference in BH LOS or discharge diagnosis of substance-abuse disorder. Patient charges for UDS over the month totaled $21,093. CONCLUSION: The UDS did not seem to have any significant effect on inpatient psychiatric care; whereas ED LOS and cost were both negatively affected. Based on these results, the UDS seems to be of little-to-no benefit in the setting of acute psychiatric illness.

Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department.

BACKGROUND: Gastroparesis associated nausea, vomiting & abdominal pain (GP N/V/AP) are common presentations to the emergency department (ED). Treatment is often limited to antiemetic, prokinetic, opioid, & nonopioid agents. Haloperidol (HP) has been shown to have analgesic & antiemetic properties. We sought to evaluate HP in the ED as an alternative treatment of GP N/V/AP. METHODS: Using an electronic medical record, 52 patients who presented to the ED w/GP N/V/AP secondary to diabetes mellitus and were treated w/HP were identified. Patients who received HP were compared to themselves w/the most recent previous encounter in which HP was not administered. ED length of stay (LOS), additional antiemetics/prokinetics administered, hospital LOS, and morphine equivalent doses of analgesia (ME) from each visit were recorded. Descriptive statistics, categorical (Chi Square Test or Z-Test for proportion) and continuous (Wilcoxon Signed Rank Test) comparisons were calculated. Statistical significance was considered for two tail p-values less than 0.05. RESULTS: A statistically significant reduction in ME (Median 6.75 [IQR 7.93] v 10.75 [IQR12]: p=0.001) and reduced admissions for GP (5/52 v 14/52: p=0.02) when HP was administered was observed. There were no statistically significant differences in ED or hospital LOS, and additional antiemetics administered between encounters in which HP was administered and not administered. No complications were identified in patients who received HP. CONCLUSIONS: The rate of admission and ME was found to be significantly reduced in patients with GP secondary to diabetes mellitus who received HP. HP may represent an appropriate, effective, and safe alternative to traditional analgesia and antiemetic therapy in the ED management of GP associated N/V/AP.

A Double-Blinded, Randomized, Placebo-Controlled Sub-Dissociative Dose Ketamine Pilot Study in the Treatment of Acute Depression and Suicidality in a Military Emergency Department Setting.

BACKGROUND: Rates of completed suicide in the military have increased. Options are limited for acute relief of depression and suicidal ideation. Traditional treatments' effects take weeks to months. A novel, rapid, therapeutic target has emerged with the N-methyl-D-aspartate antagonist ketamine. Previous studies suggest that a single dose of intravenous (IV) ketamine rapidly alleviates depression and suicidality. METHODS: In this proof of concept study, an active duty convenience sample population presenting to the emergency department (ED) meeting criteria for inpatient psychiatric admission as a result of depression and suicidal thinking were randomized to receive either a subdissociative dose (0.2 mg/kg) of IV ketamine or equivalent volume of normal saline (placebo). Subjects were evaluated for symptoms throughout a 4-hour ED course, at hospital discharge, and 2 weeks postdischarge. RESULTS: Methodological problems limited analyzable data to 10 subjects. Two of three who received ketamine experienced dramatic decreases in suicidality and hopelessness within 40 minutes. No such improvements were seen in any of seven controls over the 4-hour observation in the ED. At discharge from the hospital, there was no clinically significant difference. No subjects described adverse symptoms. CONCLUSION: Despite methodology difficulties noted in this pilot study, there was statistical improvement in intervention group versus controls.

A Case of 3,4-Dimethoxyamphetamine (3,4-DMA) and 3,4-Methylenedioxymethamphetamine (MDMA) Toxicity with Possible Metabolic Interaction.

We present a case of "ecstasy" ingestion revealing 3,4-methylenedioxymethamphetamine (MDMA) and 3,4-dimethoxyamphetamine (3,4-DMA) and absence of cytochrome P450 (CYP)-2D6 MDMA metabolites. CASE REPORT: A 19-year-old presented following a seizure. Initial vital signs were normal. Laboratories were normal with the exception of sodium 127 mEq/L and urine drugs of abuse screen positive for amphetamines. Twelve hours later, serum sodium was 114 mEq/L and a second seizure occurred. After receiving hypertonic saline (3%), the patient had improvement in mental status and admitted to taking "ecstasy" at a rave prior to her initial presentation. Liquid chromatography-time-of-flight mass spectrometry (LC-TOF/MS) of serum and urine revealed MDMA, 3,4-DMA, and the CYP-2B6 MDMA metabolites 3,4-methylendioxyamphetamine (MDA) and 4-hydroxy-3-methoxyamphetamine (HMA). The CYP2D6 metabolites of MDMA, 3,4-dihydromethamphetamine (HHMA) and 4-hydroxy-3-methoxymethamphetamine (HMMA), were detected at very low levels. CONCLUSION: This case highlights the polypharmacy which may exist among users of psychoactive illicit substances and demonstrates that concurrent use of MDMA and 3,4-DMA may predispose patients to severe toxicity. Toxicologists and other healthcare providers should be aware of this potential toxicity.

A chance to cut is not always a chance to cure- fasciotomy in the treatment of rattlesnake envenomation: A retrospective poison center study.

BACKGROUND: Fasciotomy has been described in the treatment of rattlesnake-envenomation. We sought to compare the characteristics of patients undergoing fasciotomy with those where fasciotomy was discussed but not performed. METHODS: A retrospective case-series constructed from a single-statewide-poison-system electronic database for cases of fasciotomy discussion or completion in rattlesnake-envenomation between January 2001 and May 2012. Age, gender, bite location, antivenom administered, compartment pressure measurements, Snakebite Severity Score (SSS) and length of hospitalization (LOS) were recorded. Comparisons were made between fasciotomy completed and where fasciotomy was only discussed. RESULTS: One-hundred-five cases of fasciotomy discussion or completion were identified. Fasciotomy was performed in 28 cases (27%). There was no statistically significant difference (p > 0.05) between groups in age, gender, bite site, SSS, and total number of vials of antivenom administered. Only 2 of 28 (7%) had compartment pressure measurements. Patients undergoing fasciotomy spent an additional 2 days in the hospital. CONCLUSIONS: Fasciotomies continue to take place, without compartment pressure measurements, and without repeat dosing of antivenom. In the absence of clear objective evidence that limb-threatening compartment syndrome occurs despite adequate antivenom administration, fasciotomy does not favorably impact morbidity and may be associated with increased costs for care following rattlesnake envenomation.

Nebulized fentanyl vs intravenous morphine for ED patients with acute abdominal pain: a randomized double-blinded, placebo-controlled clinical trial.

OBJECTIVES: Patients with acute abdominal pain commonly present to emergency departments. The safe and effective relief of discomfort is a concern to patients and physicians. Intravenous opioids are the traditional method used to provide pain relief in this setting, but intravenous access is time consuming and not always achievable. Alternative methods of pain control may therefore be necessary for the acute management of painful conditions without adding to the overall physical or psychological discomfort. The purpose of this study was to evaluate the feasibility of nebulized fentanyl (NF) in the alleviation of acute and undifferentiated abdominal pain. We also sought to compare NF with intravenous morphine (IVM) and to assess patient and provider satisfaction with NF. Nebulized fentanyl (2 µg/kg) was compared to IVM (0.1 mg/kg) at 10, 20, 30, and 40 minutes; and patient and physician satisfaction was recorded. The NF group experienced more rapid pain relief and more sustained and clinically significant pain relief over the 40-minute study interval. There were no adverse effects noted in the NF group. Both patient and physician satisfaction scores were higher in the NF group. Fentanyl citrate at a dose of 2 µg/kg through a breath-actuated nebulizer appears to be a feasible and safe alternative to IVM (0.1 mg/kg) in the treatment of acute abdominal pain.

Complementary and Alternative Medicine practices in military personnel and families presenting to a military emergency department.

OBJECTIVES: Limited published literature is available on Complementary and Alternative Medicine (CAM) use and attitudes toward CAM in the military community. We sought to evaluate past experiences with CAM, common conditions for which CAM is used, and willingness to use acupuncture for acute conditions in an Emergency Department (ED) setting by patients and family members presenting to a tertiary military treatment facility (MTF). METHODS: After institutional review board approval, an 18-item questionnaire was distributed to a convenience sample of ED patients presenting to a Navy MTF. RESULTS: A response was obtained from 1,005 respondents with 45% describing previous or current CAM use. Massage, chiropractic, herbal, and acupuncture were most frequently employed. The most common reasons for use of CAM therapies are described. The majority (88%) of surveyed participants reported that CAM therapies should be offered by the MTF and 80% reported a willingness to use acupuncture in the ED setting. CONCLUSION: CAM therapies are used by the military community for a wide variety of conditions. The use of acupuncture in the ED for treatment of presenting complaints was met with interest by respondents. Further studies are necessary to determine indications, efficacy, and patient satisfaction with such therapy in an emergent setting.