Poisonings Associated with Intubation: US National Poison Data System Exposures 2000-2013.

Patients may be intubated after exposure to a variety of substances because of respiratory failure, CNS sedation, pulmonary pathology, or cardiovascular instability. However, there is little data describing the types of substances that are associated with endotracheal intubation or the rates of intubation after these exposures. Evaluation of this association may inform future research on intubation after exposures to specific substances and guide poison prevention education. Our objective was to determine which exposures were commonly associated with intubation using the data from National Poison Data System (NPDS). The NPDS tracks data from potential exposures to substances reported to all American Association of Poison Control Centers. We performed a retrospective analysis of NPDS data from January 1st, 2000 to December 31st, 2013 to identify human exposures to substances that were associated with endotracheal intubation. Descriptive statistics were used to analyze the data. There were 93,474 single substance exposures and 228,507 multiple substance exposures that were associated with intubation. The most common exposures to substances that were associated with intubation were atypical antipsychotics (7.4 %) for single exposures and benzodiazepines (27.4 %) for multiple exposures. Within each age group, the most common known exposures to substances were for patients under 6 years, clonidine for single and multiple exposures; for patients aged 6-12 years, clonidine for single exposures and atypical antipsychotics for multiple exposures; for patients aged 13-19 years, atypical antipsychotics for single and multiple exposures; and for patients over 19 years, atypical antipsychotics for single exposures and benzodiazepines for multiple exposures. From 2000-2013, the exposures to substances most commonly associated with intubation varied by single versus multiple exposures and by age. This study helps clarify the exposures to substances that are associated with intubation reported to poison centers in the USA.

Painful and petechial rash after injecting black tar heroin.

A painful petechial rash developed in a patient after the subcutaneous or intravenous injection of reported black tar heroin. Additional history and the appearance of the skin lesion suggested otherwise.

Acute kidney injury associated with smoking synthetic cannabinoid.

CONTEXT AND OBJECTIVES: Synthetic cannabinoids are illegal drugs of abuse known to cause adverse neurologic and sympathomimetic effects. They are an emerging health risk: 11% of high school seniors reported smoking them during the previous 12 months. We describe the epidemiology of a toxicologic syndrome of acute kidney injury associated with synthetic cannabinoids, review the toxicologic and public health investigation of the cluster, and describe clinical implications of the cluster investigation. MATERIALS AND METHODS: Case series of nine patients affected by the toxicologic syndrome in Oregon and southwestern Washington during May-October 2012. Cases were defined as acute kidney injury (creatinine > 1.3 mg/dL) among persons aged 13-40 years without known renal disease who reported smoking synthetic cannabinoids. Toxicology laboratories used liquid chromatography and time-of-flight mass spectrometry to test clinical and product specimens for synthetic cannabinoids, their metabolites, and known nephrotoxins. Public health alerts informed clinicians, law enforcement, and the community about the cluster and the need to be alert for toxidromes associated with emerging drugs of abuse. RESULTS: Patients were males aged 15-27 years (median, 18 years), with intense nausea and flank or abdominal pain, and included two sets of siblings. Peak creatinine levels were 2.6-17.7 mg/dL (median, 6.6 mg/dL). All patients were hospitalized; one required dialysis; none died. No alternate causes of acute kidney injury or nephrotoxins were identified. Patients reported easily purchasing synthetic cannabinoids at convenience, tobacco, and adult bookstores. One clinical and 2 product samples contained evidence of a novel synthetic cannabinoid, XLR-11 ([1-(5-fluoropentyl)-1H-indol-3-yl](2,2,3,3-tetramethylcyclopropyl)methanone). DISCUSSION AND CONCLUSION: Whether caused by direct toxicity, genetic predisposition, or an as-yet unidentified nephrotoxin, this association between synthetic cannabinoid exposure and acute kidney injury reinforces the need for vigilance to detect new toxicologic syndromes associated with emerging drugs of abuse. Liquid chromatography and time-of-flight mass spectrometry are useful tools in determining the active ingredients in these evolving products and evaluating them for toxic contaminants.

Lead toxicity and endoscopic removal of ingested firearm cartridges.

CONTEXT: Lead toxicity from the ingestion of a lead foreign body has been described in several case reports. Management of ingested live ammunition presents its own challenges due to the risk of accidental discharge. A safe and effective method of retrieving a live cartridge must be considered. CASE DETAILS: We present two cases of lead toxicity due to intact firearm cartridge ingestion with the removal of the cartridges via endoscopy. The first case is of severe pediatric lead toxicity due to the ingestion of 30-mm rifle cartridges. The second case is an adult ingestion of .22 caliber cartridges resulting in mild lead toxicity. DISCUSSION: These cases illustrate a diagnostic dilemma in both the diagnosis of lead toxicity and the removal of live ammunition from the stomach.

Reflections on the 2011 report of the US National Poison Data System.

Clinical toxicologists at US poison control centers (PCCs) are an important component of the public health safety net with roles in the provision of poison information, public poisoning prevention education, medical toxicology supervision, professional education, and advocacy. Data is collected during their routine service to the community, and this data is a window to the toxicological well-being of the nation. The December, 2012, issue of Clinical Toxicology contains the cumulative data report culled from 57 U.S. PCCs in 2011 including 2,334,004 individual human exposures to pharmaceuticals, toxins, and chemicals among 3,624,063 total calls. In this commentary, we reflect on the broad scope of the US National Poisoning Data System (NPDS) report, and the changing landscape of medication and drug usage in the US.

A novel use of ultrasound in pulseless electrical activity: the diagnosis of an acute abdominal aortic aneurysm rupture.

We report a case of a patient who presented to the Emergency Department with pulseless electrical activity. A rapid diagnosis of ruptured abdominal aortic aneurysm was made by Emergency Medicine bedside ultrasonography. On arrival, the patient was without palpable pulses and bradycardic. Therapy with epinephrine, fluids, and atropine was initiated. A bedside ultrasound was immediately performed and revealed coordinated cardiac motion with empty ventricles. A rapid search for signs of blood loss in the abdomen revealed a large abdominal aortic aneurysm. Pulses were restored with fluid, blood, and epinephrine and surgical intervention was begun within 30 min of patient arrival.

Rhinocerebral mucormycosis: a case of a rare, but deadly disease.

Rhinocerebral mucormycosis is a rare fungal infection of the nasal cavity and sinuses that can spread to the orbits and cranium within days. Its presentation can be confused with those of sinusitis, viral infections, diabetic ketoacidosis, or carotid sinus thrombosis, and it is often missed at early presentation. Survival is directly linked to early detection and treatment. We present a case of rhinocerebral mucormycosis and discuss the literature on its early signs and symptoms, pathophysiology, and treatment options.