Circumstances Involved in Unsupervised Solid Dose Medication Exposures among Young Children.

OBJECTIVE: To identify types of containers from which young children accessed solid dose medications (SDMs) during unsupervised medication exposures and the intended recipients of the medications to advance prevention. STUDY DESIGN: From February to September 2017, 5 US poison centers enrolled individuals calling about unsupervised solid dose medication exposures by children ≤5 years. Study participants answered contextually directed questions about exposure circumstances. RESULTS: Sixty-two percent of eligible callers participated. Among 4496 participants, 71.6% of SDM exposures involved children aged ≤2 years; 33.8% involved only prescription medications, 32.8% involved only over-the-counter (OTC) products that require child-resistant packaging, and 29.9% involved ≥1 OTC product that does not require child-resistant packaging. More than one-half of exposures (51.5%) involving prescription medications involved children accessing medications that had previously been removed from original packaging, compared with 20.8% of exposures involving OTC products (aOR, 3.39; 95% CI, 2.87-4.00). Attention deficit hyperactivity disorder medications (49.3%) and opioids (42.6%) were often not in any container when accessed; anticonvulsants (41.1%), hypoglycemic agents (33.8%), and cardiovascular/antithrombotic agents (30.8%) were often transferred to alternate containers. Grandparents' medications were involved in 30.7% of prescription medication exposures, but only 7.8% of OTC product exposures (aOR, 3.99; 95% CI, 3.26-4.87). CONCLUSIONS: Efforts to reduce pediatric SDM exposures should also address exposures in which adults, rather than children, remove medications from child-resistant packaging. Packaging/storage innovations designed to encourage adults to keep products within child-resistant packaging and specific educational messages could be targeted based on common exposure circumstances, medication classes, and medication intended recipients.

Elevated Methemoglobin Levels in a Patient Treated with Hydroxocobalamin After Suspected Cyanide Exposure.

BACKGROUND: Cyanide (CN) toxicity commonly occurs during enclosed-space fires. Historically, the first step in treating CN toxicity utilized amyl nitrite and sodium nitrite to induce methemoglobinemia, which can be dangerous in this population. Hydroxocobalamin (OHCob), which binds to CN to form the nontoxic metabolite cyanocobalamin, is now the first-line antidote for CN toxicity, and has the advantage of not inducing methemoglobinemia. CASE REPORT: A 62-year-old man presented to the Emergency Department (ED) after a house fire. He was intubated for respiratory distress and hypoxia with an initial carboxyhemoglobin of 1.3%, methemoglobin 0.3%, and anion gap 19. Eleven hours after presentation, his serum lactic acid was 9 mmol/L. Given his continued deterioration, 14 h after arrival he received OHCob 5 g i.v. for presumed CN toxicity. Methemoglobin concentration 4 min prior to OHCob administration was 0.7%, and 2 h after administration was 4.2%. This subsequently increased to 14.3% (16 h after OHCob administration) and peaked at 16.3% (47 h after OHCob administration), at which time he was administered a dose of methylene blue 50 mg i.v., 60 h after ED arrival. His methemoglobin concentrations fluctuated until a consistent downward trend starting at 92 h from ED arrival. He continued to deteriorate and expired on hospital day 5 with a methemoglobin concentration of approximately 6.0%. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CN toxicity requires immediate recognition and treatment. The antidote, OHCob, is believed to not induce methemoglobinemia. However, this potential side effect must be considered by emergency physicians when treating suspected CN toxicity, especially if the patient does not improve after antidotal therapy.

Retrospective Review of a Novel Approach to Buprenorphine Induction in the Emergency Department.

BACKGROUND: The Emergency Department (ED) frequently treats patients with drug overdoses and is an important resource for individuals with opioid use disorder who are seeking treatment. Initiating medication-assisted treatment (MAT) in the ED seems to be an effective way to link patients with opioid use disorder (OUD) to treatment programs. There is ongoing discussion on the best approach to MAT in the ED setting. OBJECTIVE: Describe a new model for managing OUD in the ED. METHOD: Information was obtained retrospectively from the electronic medical records of patients seen in a large county tertiary care center's Clinical Decision Unit (CDU) for OUD between September 1, 2017 and February 6, 2018. Data were summarized descriptively. RESULTS: There were 18 different patients placed in the CDU during the study period. Ninety-five percent were induced with buprenorphine-naloxone in the CDU. The median initial Clinical Opioid Withdrawal Scale score at the time of induction was 10. The median total dose of buprenorphine-naloxone that was administered was 8/2 mg. The median amount of time spent in the CDU and ED combined was 23 h. Approximately (12/19) 63% of subjects went to their initial follow-up appointment in clinic. Nine were still active in clinic at 30 days and 4 were active at 6 months. CONCLUSIONS: This retrospective chart review shows promising preliminary data for managing OUD in an ED CDU. Such strategies have the potential to increase access to care in a vulnerable patient population.

The successful treatment of 5-fluorouracil (5-FU) overdose in a patient with malignancy and HIV/AIDS with uridine triacetate.

According to the NIH, about 275000 patients receive treatment with 5-Fluorouracil (5-FU) and more than 1300 die from 5-FU toxicity every year from life-threatening myelosuppression, gastrointestinal complications, and neurotoxicity. Immunocompromised persons are at higher risk of developing toxicity. Recently uridine triacetate (Vistagard®) has been approved by the Food and Drug Administration (FDA) as the only specific antidote available for 5-FU poisoning. In a clinical trial (n=135), 96% of patients with 5-FU toxicity recovered after treatment, where as in a historical control group only 10% survived. This is the first published case report of survival after 5-FU overdose who also was immunocompromised from HIV/AIDs. A 52year old male with history of HIV/AIDS (CD4 70), CNS toxoplasmosis and anal cancer presented to the emergency department after realizing he had received an entire course of 5-FU in 24 instead of 96h. Treatment with uridine triacetate was arranged in the emergency department. After receiving treatment the patient was asymptomatic and had an uncomplicated hospital course. 5-FU poisoning must be recognized early as uridine triacetate is approved by the FDA for use within 96h following the end of 5-FU administration. Emergency medicine physicians should promptly recognize and treat 5-FU poisoning. However, this may be challenging as patients may not seek medical attention until many hours or several days after last administration since symptoms are often delayed with 5-FU poisoning.

Oral potassium poisoning: a retrospective review of the National Poison Data System 2010-2021.

INTRODUCTION: Oral potassium poisoning can be life-threatening. The study aimed to describe patterns of oral potassium poisoning in adult and pediatric populations and characterize its clinical presentation and management as reported by United States poison centers. METHODS: This is a retrospective review of the National Poison Data System from 1 January 2010 through 30 June 2021. We descriptively analyzed cases involving single substance, oral potassium salts. In a second step, we requested a subset of case-specific narratives for cases that resulted in major outcome or death, as well as cases where patients received any of the following therapies: whole bowel irrigation, sodium bicarbonate, calcium, insulin or hemodialysis. We classified hyperkalemia by expected toxicity: mild (peak potassium concentration <6.5 mEq/L), moderate (peak potassium concentration 6.5 to <8 mEq/L) or severe (peak potassium concentration ≥ 8mEq/L). RESULTS: The National Poison Data System included 1,820 cases, 52.3 percent being adults. Among adult cases, 20% (n = 189) resulted in a moderate effect, major effect or death. Among pediatric cases aged <10 years, all exposures were unintentional. Analysis of 49 case narratives showed a median peak potassium concentration of 7.1 mEq/L (interquartile range 5.4-8.6) and a moderate correlation with the dose ingested (r = 0.66). Severe hyperkalemia was associated with QRS complex widening (P < 0.001), peaked T-waves (P = 0.001), and neurological symptoms (P = 0.04). Whole bowel irrigation was associated with mild hyperkalemia (P = 0.011), and hemodialysis was associated with severe hyperkalemia (P < 0.001). DISCUSSION: Analysis of data showed that therapy to promote intracellular shift of potassium is the mainstay of management of oral potassium poisoning, followed by hemodialysis. LIMITATIONS: Poison center data are susceptible to reporting bias. National Poison Data System data are affected by completeness and accuracy of reporting from health care providers and the lay public. CONCLUSIONS: Single substance, oral potassium poisoning, reported to United States poison centers, is mostly unintentional and rarely results in hyperkalemia.

Elevated methemoglobin levels in patients treated with hydroxocobalamin: a case series and in-vitro analysis.

BACKGROUND: Historically, the first step in treating cyanide (CN-) toxicity utilized antidotes to induce methemoglobinemia. This is concerning in patients who are already hypoxemic or have elevated carboxyhemoglobin. Hydroxocobalamin (OHCbl) is now the first-line antidote for CN- toxicity and is not known to induce methemoglobinemia. We observed elevated methemoglobin (MetHb) levels in several patients treated with OHCbl and sought to investigate the incidence of MetHb formation following administration of OHCbl. METHODS: Chart review: A single-center, retrospective case series of patients who received 5 or 10 g of hydroxocobalamin from 01/01/2011 through 04/30/2019. Data was analyzed using descriptive statistics. In-vitro study: Discarded blood was separated into whole blood and plasma samples. OHCbl and normal saline was added to reach 0×, 1×, 2×, and 4× peak therapeutic concentrations and analyzed at times 0, 2, and 4 h after administration. RESULTS: Chart review: Twenty-seven cases of OHCbl administration were identified. The median age was 53 years (IQR 38 - 64) and 20 (74.1%) were male. Exposure to a house fire or smoke inhalation was the reason for OHCbl administration in 21 (77.8%) patients. Five (18.5%) patients received 10 g of OHCbl while the rest received 5 g. Six (22.2%) patients developed methemoglobinemia, all after 5 g OHCbl administration; four had been exposed to fire and smoke, two received the medication for severe acidosis of unknown etiology not related to fire or smoke. The median peak level was 7.1% (IQR 2.2 - 16.4%) at a median time of 11.4 h post-administration. Two patients received methylene blue (MB), neither responded. Death occurred in 17 (63%) cases. In-vitro study: We observed a dose dependent elevation in total hemoglobin but did not detect any increase in MetHb. CONCLUSION: We observed a noteworthy temporal association between the formation of methemoglobinemia and the administration of hydroxocobalamin. This does not appear to be an artifact of the CO-oximeters. This could have profound implications for patients who are already hypoxemic or have impaired oxygen carrying capacity from carboxyhemoglobin.

Veratrum parviflorum poisoning: identification of steroidal alkaloids in patient blood and breast milk.

INTRODUCTION: The Veratrum genus is composed of plants containing a diverse set of steroidal alkaloids. Veratrum plant material has been utilized for centuries as herbal medicines, however the alkaloids have such a low therapeutic index that they are not used in modern medicine. Here we report an incident of inadvertent ingestion of V. parviflorum by hikers in Georgia that allowed detection, and in several instances identification of alkaloids from the plant, and correlated their presence within patient blood and breast milk specimens. CASE HISTORY: Eight patients, three male and five female, presented in the spring of 2020 and 2021 with symptoms requiring emergent medical attention after ingestion of Veratrum parviflorum. All patients believed the plants to be a local native species of wild leek, Allium tricoccum, locally known as ramps. Plants were identified using photographs as well as fresh and cooked plant material provided by patients, in consultation with botanists at the University of Georgia Herbarium. Written consent was obtained from all patients for collection of blood and breast milk specimens for laboratory identification of Veratrum alkaloids. METHODS: V. parviflorum plant material, and patient serum and breast milk were analyzed by high performance liquid chromatography-quadrupole time-of-flight mass spectrometry (HPLC-QTOF) to identify steroidal alkaloids. RESULTS: The V. parviflorum extract was confirmed to contain cyclopamine, veratramine, jervine, and muldamine. Two out of the eight patients had detectable concentrations of Veratrum alkaloids. Of the alkaloids identified in the plant, cyclopamine and jervine were detected within patient serum, and cyclopamine and veratramine were observed to be present in breast milk. DISCUSSION: Toxicity resulting from Veratrum steroidal alkaloids has primarily been reported from V. album and V. viride. This is the second report of V. parviflorum poisoning. The present work reports for the first time the presence of muldamine and jervine within V. parviflorum. This work provides the first instance of identification of Veratrum alkaloids in breast milk. Thus, the findings presented herein add to literature record causative agents contributing to the toxicity of V. parviflorum when ingested and potential for secondary poisoning through breastfeeding. CONCLUSION: V. parviflorum toxicity was observed to cause nausea, vomiting, hypotension, bradycardia, abdominal pain, light-headedness, blurred vision, and tingling in the arms. Patients experiencing mild symptoms improved with supportive care, IV fluids, and antiemetics, but hemodynamically unstable patients required atropine and vasopressors. This study demonstrated that more lipophilic Veratrum alkaloids can be passed along in breast milk, which suggests additional precautions may be critical to limit further poisonings.

Toxicological exposures among the pediatric patients at a tertiary care center in Lebanon: the case for establishing a national poison center.

BACKGROUND: Despite its preventable nature, poisoning remains one of the leading causes of morbidity and mortality in the pediatric population. In Lebanon, this population is poorly studied and there is no poison center to which healthcare providers and the public can refer in case of toxicological exposure, leading to unnecessary Emergency Department (ED) visits. This study describes the pediatric toxicological exposures seen at the largest tertiary care center in Lebanon. It also evaluates the appropriateness of ED visits among confirmed or suspected toxicological exposures in children, in order to assess the role of a national poison center in reducing unnecessary ED visits. METHODS: This is a secondary analysis of a database for a telephonic medical toxicology service at the American University of Beirut Medical Center, the largest tertiary care center in Lebanon. Data relating to all pediatric patients aged 0-19 years of age were entered into the database by the medical toxicology team. The cases were independently reviewed by 2 medical toxicologists for the adequacy of referral to the ED and performance of invasive procedures. RESULTS: Two hundred and nine exposures were recorded between 15 April 2015 and 31 December 2019, of which 53.1% were females. Children aged less than 5 years were involved in 67.0% of cases while adolescents aged 13-19 years were involved in 21.1%. The most commonly involved substances were analgesics (14.8%) and cardiovascular drugs (10.0%). The majority had no (59.3%) or minor (26.3%) effects and were treated and discharged home (67.5%). More than a third of ED visits were deemed unnecessary by the toxicologists (Kappa = 0.705), and when including only unintentional cases, around 45% of the ED visits were deemed unnecessary (Kappa = 0.677). CONCLUSION: Our data show that 37% of all pediatric poisoning ED visits and 45% of ED visits due to unintentional pediatric poisonings were unnecessary. Additionally, more often than not lavage suctions were done unnecessarily. Future research investigating the possibility of preventing unnecessary visits by establishing a national poison center is needed.

Telephonic Medical Toxicology Service in a Low-Resource Setting: Setup, Challenges, and Opportunities.

Poisoning and envenomation are a global health problem for which the mortality burden is shouldered heavily by middle- and low-income countries that often lack poison prevention programs and medical toxicology expertise. Although telehealth or teleconsult services have been used to bridge the expertise gap between countries for multiple specialties, the use of medical toxicology teleconsult services across borders has been limited. We aim to describe the use of a United States-based medical toxicology teleconsult service to support patient care at a hospital in a middle-income country that lacks this expertise. This report outlines the logistics involved in setting up such a service, including the challenges and opportunities that emerged from establishing medical toxicology teleconsult service in a low-resource setting.

Metformin overdose with a resultant serum pH of 6.59: survival without sequalae.

Metformin, widely used in the treatment of diabetes mellitus, is known to cause lactic acidosis in both therapeutic use and after an overdose. We report the case of a 40-year-old woman who claimed to have ingested between 75 and 100 grams of metformin and subsequently developed severe lactic acidosis. She eventually developed a peak serum lactate level of 40.0 mmol/L and a serum pH nadir of 6.59 and became obtunded, hypotensive, and hypothermic. After aggressive supportive therapy with mechanical ventilation, vasopressor agents, sodium bicarbonate, and hemodialysis, her metabolic derangements steadily improved and she made a complete recovery without any residual sequelae. Her admission serum metformin concentration was later determined to be 160 microg/mL (therapeutic range is 1-2 microg/mL). There are several case reports and case series describing lactic acidosis secondary to metformin ingestion, although the exact mechanism remains unclear. The overall management of metformin overdose is reviewed. This case represents the largest reported amount of ingested metformin, the lowest serum pH, and the highest serum lactate concentration in any intentional metformin overdose survivor in the literature. Despite potentially lethal metabolic derangements, such patients can survive with aggressive supportive care.

Toxicological exposures reported to a telephonic consultation service at a tertiary care hospital in Lebanon.

Introduction: This study aims to describe the epidemiology of toxicological exposures reported to a telephonic medical toxicology service at a tertiary care center in Lebanon during a 46-months period.Methods: This study is a secondary analysis of a database for a telephonic medical toxicology service at a tertiary care center in Lebanon. Clinical information from all pediatric and adult patients, presenting with intentional or unintentional toxicological exposure, was entered into the database by the medical toxicology team.Results: Four hundred and seventy-seven exposures were recorded from 1 March 2015 to 31 December 2018. Female patients were involved in 60.2% of cases. Children less than 5 years old constituted 23.5% of cases and adults aged 20-49 constituted 48.6%. Up to 51.6% of cases were intentional, with 37.7% resulting from suicidal attempts. The majority of patients displayed no effects (33.1%) or minor effects (39.2%). Almost half of patients were treated and discharged from the Emergency Department (ED) without further hospitalization, and another 18.9% of patients left the ED against medical advice. The most common pharmaceutical agents involved were sedative/hypnotics/antipsychotics (14.7%), analgesics (12.6%) and antidepressants (11.3%). The most common non-pharmaceutical agents involved were household cleaning substances (8.0%), pesticides (5.2%) and bites and envenomations (3.8%).Conclusions: The results of this study suggest that sedative/hypnotics/antipsychotics, analgesics, antidepressants and household cleaning substances are the most common agents involved. Adult women and children ≤5 years old constitute a large portion of patients with toxicological exposures. Prevention strategies and policies should be implemented to mitigate these hazards.

Acute metformin overdose: examining serum pH, lactate level, and metformin concentrations in survivors versus nonsurvivors: a systematic review of the literature.

STUDY OBJECTIVE: Metformin is known to cause potentially fatal metabolic acidosis with an increased lactate level in both overdose and therapeutic use. No association between mortality and serum pH, lactate level, or metformin concentrations, though intuitive, has yet been described. This systematic literature review is designed to evaluate the association between mortality and serum pH, lactate level, and metformin concentrations in acute metformin overdose. METHODS: We reviewed the literature by using the MEDLINE, EMBASE, CINAHL, and TOXNET databases for cases of metformin overdose with documented mortality data and values of serum pH, lactate level, and metformin concentrations. When available, patient age, patient sex, and whether patients received intravenous sodium bicarbonate therapy or hemodialysis were also analyzed. Cases meeting inclusion criteria were analyzed to determine whether a difference in distribution of nadir serum pH, peak serum lactate level, or peak serum metformin concentrations existed between overdose survivors and nonsurvivors. RESULTS: We identified 10 articles that had 1 or more cases meeting our inclusion criteria. In total, there were 22 cases of metformin overdose (5/22 died) that met inclusion criteria. No intentional overdose patients died whose serum pH nadir was greater than 6.9, maximum lactate concentration less than 25 mol/L, or maximum metformin concentration less than 50 microg/mL (therapeutic range 1 to 2 microg/mL). Intentional overdose patients with a nadir serum pH less than 6.9 had 83% mortality (5/6), those with lactate concentration greater than 25 mmol/L had 83% mortality (5/6), and those with metformin concentration greater than 50 microg/mL had 38% mortality (5/12). Nadir serum pH and peak serum lactate and metformin concentration distributions in survivors and nonsurvivors revealed that survivors had a median nadir pH of 7.30, interquartile range (IQR) 7.22, 7.36; nonsurvivors, a median nadir pH of 6.71, IQR 6.71, 6.73; survivors, a median peak lactate level of 10.8 mmol/L, IQR 4.2, 12.9; nonsurvivors, a median peak lactate level of 35.0 mmol/L, IQR 33.3, 39.0; survivors, a median peak metformin level of 42 microg/mL, IQR 6.6, 67.6; and nonsurvivors, a median peak metformin level of 110 microg/mL, IQR 110, 110. CONCLUSION: No cases of acute metformin overdose meeting the study's inclusion criteria were found in which patients with a nadir serum pH greater than 6.9, peak serum lactate concentrations less than 25 mmol/L, or peak serum metformin concentrations less than 50 microg/mL died. Patients with acute metformin overdose who died had much lower serum pH nadirs and much higher peak serum lactate and metformin concentrations than those who survived.

Unintentional trazodone overdoses in children ≤6 years of age: data from poison center over a period of 16 years.

CONTEXT: Trazodone is an atypical antidepressant with no established safety in children. Previous case reports showed no complications at doses 50-500 mg in children. Our study objective is to characterize the clinical effects, dose-related toxicity, and establish triage dose for acute trazodone ingestions in children ≤6 years of age. METHODS: Cases with acute trazodone ingestions in children ≤6 years of age between 2000 and 2015 were retrospectively reviewed. Data were analyzed for dose (mg/kg), clinical effects, management site, treatment, and outcome. Cases with coingestions, unknown outcome, or unknown dose were excluded. RESULTS: A total of 84 patients (mean age 26.7 months, 35 females, 49 males) were included. Of those, 52 (61.9%) had no clinical effects; 29 (34.5%) had minor effects (vomiting, dizziness, headache); and three (3.6%) had moderate effects (ataxia, slurred speech, priapism). No major effects or deaths were observed. Moderate effects were manifested at doses ≥6.9 mg/kg. Priapism occurred in a 2-year-old child at a dose of 6.9 mg/kg. Sixteen (19%) patients were managed at home and 68 (81%) patients were referred to a HCF. Among those referred to a HCF, three (4.4%) patients had moderate effects with ingested dose ≥6.9 mg/kg. However, 27 (39.7%) patients of those referred to a HCF had an ingested dose <6 mg/kg and none of them manifested symptoms beyond minor effects. All referred patients had uneventful recovery and no sequela. CONCLUSIONS: Children should be referred for further evaluation in acute unintentional trazodone ingestions with doses ≥6 mg/kg.

Does Lidocaine Cause False Positive Results on Cocaine Urine Drug Screen?

BACKGROUND: Individuals who have tested positive for cocaine have claimed that lidocaine, or its primary metabolite, norlidocaine (monoethylglycinexylidide (MEGX)), have caused false positive results for the cocaine metabolite benzoylecgonine (BE) on urinary immunoassay testing. OBJECTIVE: The goal of the study was to determine if lidocaine exposure from routine medical procedures can result in false positives on a commercially available cocaine immunoassay urine drug screen (UDS). METHODS: We performed a cross-sectional observational study of patients receiving lidocaine as part of their regular care. Standard immunoassay drug screens and confirmatory liquid chromatography-mass spectrometry (LC-MS) were performed on all urine samples to assess for MEGX and BE. RESULTS: In total, 168 subjects were enrolled; 121 samples positive for lidocaine were ultimately included for analysis. One hundred fourteen of the 121 were also positive for MEGX. None of the 121 were positive for cocaine/BE on the UDS (95% CI), 0-3.7% for the full sample and 0-3.9% for the 114 who tested positive for MEGX. CONCLUSION: The present study found no evidence that lidocaine or norlidocaine are capable of producing false positive results on standard cocaine urine immunoassays.

Elevated lead level from a tobacco source requiring chelation in a 12-year-old child.

CONTEXT: Across the world, tobacco is used in a variety of forms, including being smoked or added to a "quid" that is then chewed. We report a case of lead poisoning in a child from tobacco imported from Thailand. CASE DETAILS: A 12-year-old Thai immigrant boy had a blood lead level (BLL) of 6 mcg/dL on routine testing upon arrival to the United States, but which increased to 72 mcg/dL six months after his arrival. He was asymptomatic with unremarkable workup. At this time his father, mother and two siblings were also found to have elevated BLLs of 53, 16, 22, and 11 mcg/dL, respectively. Water, paint, food and cookware sources tested negative for lead, whereas samples of the father's dried tobacco leaves imported from Thailand contained 36.12 ppm (mcg/g) of lead. The mother admitted that both she and the patient used the tobacco as well. The child was chelated with oral succimer and his BLL decreased. DISCUSSION: In our case, the source of the lead exposure was from the tobacco that the patient was chewing. Tobacco is often overlooked as a source of lead exposure, though it has been reported in the literature, both from direct smoking and from chewing, as well as through secondhand smoke. Toxicologists and health care professionals should consider cultural practices when evaluating patients with elevated BLLs.

Hikers poisoned: Veratrum steroidal alkaloid toxicity following ingestion of foraged Veratrum parviflorum.

INTRODUCTION: Steroidal alkaloids are found in plants of the genus Veratrum. Their toxicity manifests as gastrointestinal symptoms followed by a Bezold-Jarisch reflex: hypopnea, hypotension, and bradycardia. Some Veratrum steroidal alkaloids are also teratogens interfering with the hedgehog-2 signaling pathway, which causes cyclopsia and holoprosencephaly. We present a case of accidental poisoning from Veratrum parviflorum mistaken for the edible Allium tricoccum (ramps, wild leek). CASE HISTORY: A 27-year-old man and his 25-year-old wife presented to the emergency department with nausea, vomiting, hypotension, and bradycardia after foraging and ingesting plants that they believed to be a local native species of wild leek. METHODS: We collected and analyzed the implicated fresh plant material and both patients' serum/plasma. We used liquid chromatography-mass spectroscopy and high-resolution electrospray ionization time of flight tandem mass spectrometry to extract and characterize steroidal alkaloids from the foraged plant and patients' serum. RESULTS: Our V. parviflorum samples contained verazine, veratramine, veratridine, and cyclopamine. DISCUSSION: Steroidal alkaloids have been previously isolated from Veratrum viride and Veratrum album and toxicity has been reported mainly from V. album species. CONCLUSION: V. parviflorum toxicity manifests with gastrointestinal and cardiac symptoms. Treatment is symptomatic and supportive as with previous case reports of toxicity with other Veratrum species.

Pilot Study of the Importance of Factors Affecting Emergency Department Opioid Analgesic Prescribing Decisions.

INTRODUCTION: Little is known about the factors driving decision-making among emergency department (ED) providers when prescribing opioid analgesics (OA). The aim of this pilot study was to identify the importance of factors influencing OA-prescribing decisions and to determine how this varied among different types of providers. METHODS: This was an observational cross-sectional survey study of 203 ED providers. The importance of decisional factors was rated on a 5-point Likert scale. Differences between provider groups were tested using Chi-squared or ANOVA tests where applicable. RESULTS: Overall, 142/203 (69.9 %) potential respondents participated in the study. The five highest-rated factors were (mean ± SD) patient's opioid prescription history (4.4 ± 0.8), patient's history of substance abuse or dependence (4.4 ± 0.7), diagnosis thought to be the cause of patient's pain (4.2 ± 0.8), clinical gestalt (4.2 ± 0.7), and provider's concern about unsafe use of the medication (4.0 ± 0.9). The importance of 6 of 21 decisional factors varied significantly between different groups of providers. CONCLUSION: In this pilot study of ED providers, the self-reported importance of several factors influencing OA-prescribing decisions were significantly different among attending physicians, resident physicians, and advanced practice providers. Further investigation into how ED providers make OA-prescribing decisions is needed to help guide interventions aimed at improving appropriate pain management.

Report of a Bite from a New Species of the Echis Genus--Echis omanensis.

BACKGROUND: Carpet vipers (Echis) are found across the semiarid regions of west, north, and east Africa; west, south, and east Arabia; parts of Iran and Afghanistan north to Uzbekistan; and in Pakistan, India, and Sri Lanka. Recently, a new species belonging to the Echis genus, Echis omanensis has been recognized in Oman. Not much is known about the clinical manifestations of envenomation from its bite. CASE REPORT: A 63-year-old snake keeper presented to the emergency department shortly after being bitten by an Oman carpet viper (E. omanensis). The incident occurred during expression of the venom at a research center. The patient complained of severe pain and swelling of the left index finger, which extended to the mid-forearm within 1 h. His vital signs remained stable, with no evidence of systemic manifestations. He was treated initially with analgesics and tetanus toxoid. Due to rapidly progressive swelling and the potential for a delayed coagulopathy, the Saudi National Guard polyvalent snake antivenom was administered according to the Ministry of Health protocol. The patient was admitted to the intensive care unit, remained hemodynamically stable, and had normal serial coagulation tests, with subsequent resolution of the swelling. CONCLUSION: We report the first case of an E. omanensis bite in which the patient developed rapidly progressive local toxicity, which improved after administration of the Saudi polyvalent antivenom.