Rare Multidrug-resistant Pseudomonas aeruginosa Identified in a U.S. Deployed Service Member Following Host-nation Medical Treatment.

Decision-making related to the utilization of host-nation medical resources in austere forward-deployed environments is complex. Clinical circumstances, local medical intelligence availability, transportation assets, uncertainty regarding standard-of-care variations, military/host-nation funding complications, and regional security concerns all factor into consideration. A case of a U.S. active duty military service member who suffered a cardiac arrest on a military base in Southwest Asia is described in this report. After return of circulation following defibrillation, he was administered thrombolytic therapy for an electrocardiogram-identified ST-elevation myocardial infarction and transported to a local host-nation cardiac hospital for emergent percutaneous coronary intervention. During his subsequent transportation back to the USA, surveillance testing identified that he was colonized with a rare strain of Pseudomonas aeruginosa, demonstrating New Delhi metallo-beta-lactamase-1 and 16S RNA methyltransferase-2 enzymes, which confer significant resistance to carbapenem and aminoglycoside antibiotics, respectively.1-3 This combination of antibiotic resistance has been reported very rarely in the medical literature and has never been reported within the deployed military health system until now. The risk of exposure to multidrug-resistant organisms was not a factor initially considered in the decision to utilize host-nation medical resources in this case, which provided lesson learned and raised new questions, for future operational medical planning.

Methemoglobinemia Secondary to Topical Benzocaine Application to Gastrostomy Site.

Benzocaine is a common topical anesthetic that has the ability to induce methemoglobinemia (MetHgb) in large doses. We describe a 4-year-old girl who received a standard dose of topical benzocaine to her gastrostomy mucosa that resulted in rapid, severe MetHgb. She required intubation, mechanical ventilation, and multiple doses of methylene blue for treatment. The resultant tissue hypoxia from MetHgb caused profound confusion, cyanosis, and myocardial infarction. Although the patient did not sustain any permanent disability, this case demonstrates the need for emergency providers to rapidly identify and treat MetHgb to reverse tissue hypoxia and prevent long-term sequelae.

Medical screening after a coal fly ash spill in Roane County, Tennessee.

OBJECTIVE: To assess the health of community residents following a coal fly ash spill at the Tennessee Valley Authority Kingston Fossil Plant in Harriman, Tennessee, on December 22, 2008. METHODS: A uniform health assessment was developed by epidemiologists at Oak Ridge Associated Universities and medical toxicologists at Vanderbilt University Medical Center. Residents who believed that their health may have been affected by the coal fly ash spill were invited to participate in the medical screening program. RESULTS: Among the 214 individuals who participated in the screening program, the most commonly reported symptoms were related to upper airway irritation. No evidence of heavy metal toxicity was found. CONCLUSIONS: This is the first report, to our knowledge, regarding the comprehensive health evaluation of a community after a coal fly ash spill. Because this evaluation was voluntary, the majority of residents screened represented those with a high percentage of symptoms and concerns about the potential for toxic exposure. Based on known toxicity of the constituents present in the coal fly ash, health complaints did not appear to be related to the fly ash. This screening model could be used to assess immediate or baseline toxicity concerns after other disasters.

Hemodynamically unstable: accidental atenolol toxicity?

BACKGROUND: Antihypertensive medications, including ß-blockers, are widely used in patients with chronic kidney disease. Unlike most ß-blockers, atenolol is excreted primarily by the kidney, and its clearance by peritoneal dialysis is poor. These pharmacokinetic factors may predispose patients to gradual accumulation of the drug over time. OBJECTIVES: To review the management of a diagnostic dilemma, the role of glucagon therapy, and the clinical implications of atenolol clearance. CASE REPORT: A young woman with end-stage renal disease requiring peritoneal dialysis presented with sudden onset of abdominal pain and hemodynamic instability with hypotension and relative bradycardia. The patient reported that she took her regular four antihypertensive agents, including atenolol, with no excess ingestion or recent dose changes. After resuscitation and consideration of a broad differential diagnosis, the most likely cause of the patient's illness was determined to be unintentional atenolol toxicity, with secondary mesenteric ischemia due to a low-flow state that caused her abdominal pain. Glucagon therapy led to rapid correction of the patient's hemodynamic instability and pain. CONCLUSION: The unique pharmacokinetics of long-term medications must be considered in patients with impaired clearance, such as this patient with end-stage renal disease treated by peritoneal dialysis. Medications may gradually accumulate to supratherapeutic levels, which over time may lead to symptoms of significant toxicity.

Pandemic influenza: antiviral preparedness and health care workers.

OBJECTIVES: The primary objective of this study was to determine the preparedness for pandemic influenza of hospitals, in terms of amount of antiviral drugs on hand and employee vaccination rates, in the Finger Lakes region (FLR) of western New York. METHODS: A survey of the 17 FLR hospitals was conducted via e-mail during the period of June 2007 to August 2007. RESULTS: A total of 13 of 17 hospitals responded for a response rate of 76.5%. Only 23.1% of responding hospitals stockpile antiviral drugs. Vaccination rates for personnel with patient contact ranged from 36.8% to 76.1%. CONCLUSIONS: Hospitals in the FLR have insufficient quantities of antiviral agents stockpiled to provide for the protection of health care workers, and influenza vaccination rates for health care workers are low. To ensure that a high level of care is maintained during a pandemic, health care workers need to be provided with appropriate protection. This can be accomplished if hospitals stockpile antiviral agents designated for the treatment and prophylaxis of health care workers with patient contact and their families.

Will emergency health care providers respond to mass casualty incidents?

UNLABELLED: Emergency response plans often call on health care providers to respond to the workplace outside of their normal working pattern. HYPOTHESIS: Providers will report to work during a mass casualty emergency regardless of family duties, type of incident, or availability of treatment. METHODS: Survey of emergency personnel needed to respond to a mass casualty incident. Two scenarios were presented: one involving the release of a non-transmissible biological agent with proven treatment and the other the release of a transmissible biological agent with no treatment. At critical time points, participants were asked whether they would report to work. Additional questions considered the effect of commonly used treatment dissemination methods. RESULTS: A total of 186 surveys were issued and returned. (45 physicians, 29 nurses, 86 EMS personnel, and 20 support staff); 6 were incomplete and excluded. Initial commitment rates were 78%. The highest commitment rate identified was 84% and the lowest was 18%. Any treatment dissemination method excluding providers' family members led to decreases in commitment rate, as did agents identified to be transmissible. CONCLUSIONS: As an event develops, fewer health care providers will report to work and at no time will all providers report when asked. This conclusion may be generalizable to several types of incidents ranging from pandemic influenza to bioterrorism. Identification of the causative agent is a major decision point for providers to return to or stay away from work. Offering on-site treatment of providers' family increases commitment to work. These factors should be considered in emergency planning.

Will emergency health care providers respond to mass casualty incidents?

INTRODUCTION: Emergency response plans often call on health care providers to respond to the workplace outside of their normal working pattern. HYPOTHESIS: Providers will report to work during a mass casualty emergency regardless of family duties, type of incident, or availability of treatment. METHODS: Survey of emergency personnel needed to respond to a mass casualty incident. Two scenarios were presented: one involving the release of a nontransmissible biological agent with proven treatment and the other the release of a transmissible biological agent with no treatment. At critical time points, participants were asked whether they would report to work. Additional questions considered the effect of commonly used treatment dissemination methods. RESULTS: A total of 186 surveys were issued and returned. (45 physicians, 29 nurses, 86 EMS personnel, and 20 support staff); 6 were incomplete and excluded. Initial commitment rates were 78%. The highest commitment rate identified was 84% and the lowest was 18%. Any treatment dissemination method excluding providers' family members led to decreases in commitment rate, as did agents identified to be transmissible. CONCLUSIONS: As an event develops, fewer health care providers will report to work and at no time will all providers report when asked. This conclusion may be generalizable to several types of incidents ranging from pandemic influenza to bioterrorism. Identification of the causative agent is a major decision point for providers to return to or stay away from work. Offering on-site treatment of providers' family increases commitment to work. These factors should be considered in emergency planning.

Acute oxcarbazepine and atomoxetine overdose with quetiapine.

We present a case of acute oxcarbazepine and atomoxetine overdose combined with excess quetiapine in a 19-y-old male. The patient ingested approximately 36 g oxcarbazepine (514 mg/kg), 1.2 g atomoxetine (17 mg/kg), and 9 mg Quetiapine (128 mg/kg). Central nervous system (CNS) depression with initial unresponsiveness developed within 1 h of ingestion, necessitating intubation for airway protection. Despite aggressive therapy with whole bowel irrigation and charcoal administration, the patient's somnolence persisted for 4 d, punctuated by occasional violent outbursts. Prolonged QTc was noted initially, but normalized within 4 d. This case suggests that acute overdose of oxcarbazepine and atomoxetine combined with quetiapine is associated with rapid and prolonged CNS depression.

A community exposure to 2-chloro-6-fluorophenol.

A rural town in western New York was the site of a release of a mixture of 2-chloro-6-fluorophenol (CFP), toluene and water due to a pressure build-up at a nearby chemical facility. The regional poison control center received calls from physician offices and individual patients describing symptoms felt related to this exposure. Symptoms included headache, dry throat, cough, chest discomfort, nausea/vomiting, and diarrhea. Environmental sampling by the state health department confirmed soil and surface contamination; however, despite a noticeable odor during sampling, staff did not detect CFP in air samples. To our knowledge, although many individuals visited their primary care providers, none were hospitalized. This incident suggests that acute exposure to CFP is similar to other phenol exposures with relatively minor symptoms including headache, irritation of mucous membranes, and gastrointestinal symptoms.

Acute quetiapine overdose in an eleven-year-old girl.

We present a case of acute Quetiapine (SeroQuel) overdose in an 11-y-old girl who ingested 1,300 mg (22.2 mg/kg bw). Initial lethargy developed within I h followed by an episode of agitation and combativeness 3 h after ingestion. After treatment with lorazepam the patient experienced extended somnolence followed by return to normal mental status 16 h after ingestion. No cardiotoxic or laboratory abnormalities were found. This is the first report of acute Quetiapine overdose in an adolescent and suggests a relatively benign clinical course.