Methamphetamine Poisoning After "Plugging" Intentional Recreational Rectal Use.

BACKGROUND: Methamphetamine is a commonly used illicit substance. The route of administration is usually parenteral, oral ingestion, or snorting. A less common route of administration is placing in the rectum. CASE REPORT: A 28-year-old man presented to the emergency department with acute methamphetamine toxicity within 30 min after intentional rectal administration of methamphetamine for recreational purposes. The patient had hypertension, tachycardia, drug-induced psychosis, elevated creatine kinase, and required rapid sequence intubation and admission to the intensive care unit. Our patient had no clinical evidence of bowel ischemia or injury at the time of discharge. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Rectal administration of methamphetamine is known as "plugging," "booty bumping," "keestering," and "butt whacking." The rectal administration of methamphetamine has the increased risk of severe acute methamphetamine toxicity, as rectal administration bypasses first-pass metabolism, allowing for a more acute onset and higher bioavailability of methamphetamine compared with oral administration. There is the potential for mesenteric ischemia and bowel injury after rectal methamphetamine. Close clinical monitoring for bowel and rectal ischemia or injury are recommended, in addition to management of the sympathomimetic toxidrome.

Palliative care patient emergency department visits at tertiary university-based emergency department in Ireland.

INTRODUCTION: Palliative care patients often present to the emergency department (ED) for various reasons e.g., acute illness, pain, altered mental status, and complications of therapy. Many visits involve less severe etiologies e.g., dyspnea, constipation, fear as patients approach the end of life, which may be more effectively and efficiently managed outside of the ED. The objective of this study is to identify and assess the frequency of presenting complaints, primary diagnosis, triage acuity, need for admission, in an Irish setting. METHODS: A single-center retrospective, observational study of palliative care patients presenting to a tertiary-care university hospital emergency department in Dublin, Ireland. Study subjects were identified using the palliative care database and cross-referencing with the ED electronic patient record system database. The primary objective to identify potential areas to minimize ED visits and improve patient care and quality of life by elucidating reasons for visits. Outcome measures include presenting complaint, primary diagnosis, triage severity score, admission, discharge, death in hospital. Statistical analysis presented as descriptive statistics. RESULTS: Four-hundred-ninety-nine ED visits, 245 (49%) were male, and 254 (51%) were female with a mean age of 69.3 years-of-age. Most patients, 285 (57.1%) self-referred to the emergency department, with general practitioners and skilled nursing facility referrals 72 (14.4%) and 39 (7.8%), respectively. Primary diagnoses were various cancers, chronic obstructive pulmonary disease, congestive heart failure, and dementia. Major reasons for visits were dyspnea, pain, falls, trauma, fever, and altered mental status. Two-hundred-eighty-nine patients (58%) had an emergency severity index (ESI) score of 1 or 2 demonstrating a higher level of acuity. Three-hundred-fifty-eight (71.7%) were admitted, 141 (28.3%) discharged to home, 64 (12.8%) admitted patients died during their hospital admission. CONCLUSIONS: Palliative care patients utilize ED services not uncommonly. Though many of these patients presented with higher acuity triage scores, 42% had lower ESI scores and may be effectively managed outside of the ED. These data suggest developing mechanisms for these patients to be urgently evaluated in their homes or facilities obviating the need for an ED evaluation.

Death from cardiac glycoside "pong-pong" following use as weight-loss supplement purchased on Internet.

Cerbera odollam or "pong-pong" tree contains cardiac glycosides similar to digoxin, oleander and yellow oleander. Cerbera odollam is a common method of suicide in South East Asia and has also been used as a weight loss supplement. We present a case of a 33-year-old female presenting with lethargy, vomiting, bradycardia, severe hyperkalemia of 8.9 mEq/L, slow atrial fibrillation followed by cardiovascular collapse following the ingestion of "pong-pong", the kernel of Cerbera odollam, as a weight loss supplement. Despite the administration of a total of nine vials of digoxin-specific Fab the patient could not be resuscitated. Clinicians should be aware of natural cardiac glycosides being uses as weight-loss agents and consider acute cardiac glycoside poisoning in patients with hyperkalemia, abnormal cardiovascular signs, symptoms and abnormal ECG findings.

Polyethylene glycol electrolyte lavage solution increases tablet dissolution of acetaminophen in an in vitro model mimicking acute poisoning.

INTRODUCTION: Polyethylene glycol electrolyte lavage solution (PEG-ELS) is similar to pharmaceutical solvent propylene glycol and used following acute poisonings for whole bowel irrigation (e.g., "body stuffing"). This raises concern of PEG-ELS increasing solubility following acute ingestions of non-sustained release xenobiotics in the stomach. We theorized PEG-ELS increases solubility of acetaminophen in an in vitro stomach model. MATERIAL AND METHODS: An in vitro artificial stomach with 500 mL simulated gastric fluid and either 500 mL of sodium chloride 0.9% (group A) or 500 mL of PEG-ELS (group B). Ten non-sustained release acetaminophen tablets added with concentrations 0, 15, 45 and 90 min in triplicate. Mean concentrations and mean area under the curve (AUC) (mg-min/L to 90 min). RESULTS: In control group A (normal saline + simulated gastric fluid) mean acetaminophen concentrations 0, 3, 13 and 36 mg/L at 0, 15, 45 and 90 min, respectively. In group B (PEG-ELS + simulated gastric fluid) mean acetaminophen concentrations 0, 34, 109 and 136 mg/L at 0, 15, 45 and 90 min, respectively (p < 0.05). Mean AUC 0-90 1385 [95% C.I. 990.5-1779] mg-min/L in control group A compared to mean AUC 0-90 in group B (PEG-ELS) 7673 mg-min/L [95% C.I. 4832-10513] (p < 0.05). DISCUSSION: Group B (PEG-ELS) with significantly higher mean acetaminophen concentrations and greater mean AUC compared to control group A (normal saline). CONCLUSION: We demonstrated increased mean acetaminophen concentrations and increased mean AUC of following exposure of PEG-ELS in an artificial stomach model.

Pyelonephritis following phenazopyridine use.

We present a case of pyelonephritis following the extended andsolitary use of over-the-counter phenazopyridine in a forty-year-oldfemale. The patient initially had uncomplicated cystitis signs andsymptoms which partially resolved with phenazopyridine and therefore she continued use. She presented to the emergency department with systemicsigns and symptoms of acute pyelonephritis. As phenazopyridine is devoidof antibacterial properties this allowed the lower urinary tractinfection to progress to acute pyelonephritis requiring intravenousantibiotics. Better patient education may preclude this complication.

Reasons for Energy Drink Use and Reported Adverse Effects Among Adolescent Emergency Department Patients.

OBJECTIVES: There is concern of energy drink use by adolescents. The objective of this study was to evaluate the energy drink consumption use, frequency, age of first use, reasons for use, influences of choice of brand, and adverse events recorded in a predominant Latino adolescent population. METHODS: Subjects between the ages of 13 and 19 years utilizing emergency department services for any reason at a large county hospital answered a questionnaire about energy drink usage. RESULTS: There were 192 subjects, of which 49% were male and 51% were female. Latino adolescents were 85% of the participants, although other ethnic groups participated including African American, white, and Asian. Reasons for use include 61% to increase energy, 32% as study aide, 29% to improve sports performance, and 9% to lose weight. Twenty-four percent reported using energy drinks with ethanol or illicit drugs including marijuana, cocaine, and methamphetamine. Adverse reactions were reported in 40% of the subjects including insomnia (19%), feeling "jittery" (19%), palpitations (16%), gastrointestinal upset (11%), headache (8%), chest pain (5%), shortness of breath (4%), and seizures (1%). CONCLUSIONS: Both brand name and packaging influenced the choice of energy drink in most subjects. Forty percent reported at least 1 adverse effect. While most adverse effects were not severe, a small number are serious. In addition, we showed intentional ingestion with ethanol and illicit drugs. Of additional concern is that both brand and packaging seem to directly affect choice of energy drink consumed.

Not Just a Drop in the Bucket-Inversion of Oxymetazoline Nasal Decongestant Container Increases Potential for Severe Pediatric Poisoning.

Oxymetazoline is an over-the-counter nasal decongestant with potent alpha agonist properties. In overdoses as small as 1-2 mL, toxicity can be seen including bradycardia and respiratory depression. We demonstrated that inverting the container increased the volume delivered 20- to 30-fold compared with holding it upright in an in vitro model.

Assessment of Digoxin-Specific Fab Fragment Dosages in Digoxin Poisoning.

Digoxin poisoning still remains a common cause of morbidity and mortality. Fortunately, digoxin-specific Fab fragments are commercially available as an antidote. However, these Fab fragments are several thousand dollars per vial. There is a standardized formula to calculate appropriate Fab fragment dosage based on the serum digoxin concentration. This can greatly reduce the amount of Fab fragment administered. There is also an empiric dosing guideline recommending 6-10 vials be given; however, this may result in higher amounts of Fab fragments being administered than required. We performed this study to assess the amounts of digoxin-specific Fab fragments administered in the treatment of digoxin poisonings recorded in a poison control system database from January 1, 2000, to December 31, 2009, in which digoxin serum concentrations were available. This was a retrospective study of 278 patients, 107 with acute poisonings (group A) and 171 following chronic poisoning (group B). In group A, the calculated Fab dose was higher than the calculated dose based on available concentrations in 39 (36%) of group A and 15 (9%) of group B patients. The average wholesale price cost of the excessive dosages ranged from $4818 to as high as $50,589 per patient. Our data suggests that clinician education on digoxin poisoning and the use of the standardized formula to calculate the Fab dose may decrease over utilization and decrease costs associated with the administration of digoxin-specific Fab fragments in the treatment of digoxin poisonings.

Pediatric chloral hydrate poisonings and death following outpatient procedural sedation.

INTRODUCTION: Chloral hydrate has been used medicinally since the 1800 s as a sedative hypnotic, most commonly for procedural sedation. As it is administered orally and available in a liquid formulation, it is used almost exclusively in pediatric patients despite many safer and more effective alternative agents being available. CASE SERIES: We present three cases of pediatric chloral hydrate poisoning, all occurring following procedural sedation in outpatient clinic settings and presenting to the emergency department. The ages ranged from 15 months to 4 years of age and all required resuscitation. Unfortunately, the 4-year-old died. CONCLUSION: Choral hydrate is associated with significant adverse effects, including death, and safer alternatives for pediatric procedural sedation should be sought and utilized. There are a number of more effective sedative agents with more predictable pharmacokinetic and safety profiles than chloral hydrate including parenteral and oral agents. The practice of pre-procedure sedation should be performed only in a supervised setting where cardiorespiratory monitoring can occur in all cases.

Inconsistencies in emergency instructions on common household product labels.

Human exposures to non-pharmaceutical products often results in serious injury and death annually in the United States. Studies performed more than 25 years ago described inadequate first aid advice on the majority of household products. The current study evaluates contemporary non-pharmaceutical products with respect to location, uniformity and type of their first aid and emergency contact instructions. A random, convenience sample of commercial product label information was obtained from local retail stores over an 8 month period. Twelve common non-pharmaceutical product categories, with large numbers of annual human exposures, were identified from National Poison Data Systems data. A minimum of 10 unique products for each category utilized. The following information identified: product name and manufacturer, location on container, presence and type of route-specific treatment, medical assistance referral information. A total of 259 product labels were examined. First aid/contact information was located on container: rear 162 (63 %), side 28 (11 %), front 3 (1 %), bottom 2 (0.77 %), behind label 14 (5 %), missing entirely 50 (19 %). Fifty-five products (21 %) lacked any first aid instructions. Suggested contacts for accidental poisoning: none listed 75 (29 %), physician 144 (56 %), poison control centers 102 (39 %), manufacturer 44 (17 %), "Call 911" 10 (4 %). Suggested contacts for unintentional exposure and content of first aid instructions on household products were inconsistent, frequently incomplete and at times absent. Instruction locations similarly lacked uniformity. Household product labels need to provide concise, accurate first aid and emergency contact instructions in easy-to-understand language in a universal format on product labels.

Prescription acetaminophen ingestions associated with hepatic injury and death.

UNLABELLED: The U.S. Food and Drug Administration has formally requested that pharmaceutical manufacturers limit the amount of acetaminophen (APAP) in prescription products. The goal of this study was to describe a state-wide poison control system's experience with prescription APAP ingestions that resulted in hepatic injury or death. Retrospective analysis of statewide California Poison Control System electronic database for cases from the years 2000 through 2009. INCLUSION CRITERIA: adults ≥18 years of age following therapeutic use of an acetaminophen-containing prescription with laboratory evidence of liver injury. Forty cases met the inclusion criteria. All cases involved at least two concurrent acetaminophen-containing products. Prescription APAP strengths of 500 mg per tablet or greater were involved in 32 of 40 cases (80 %). Thirty patients survived, three died, one underwent liver transplantation and seven cases were lost to follow up. The ingestion of concentrated prescription APAP-containing medications in combination with other sources of APAP can result in severe liver injury and death. Limiting the amount of APAP from prescription medications in conjunction with enhanced prescriber and patient education regarding the hazards of ingesting multiple APAP-containing products may assist in decreasing the overall incidence of unintentional APAP poisonings in the United States. Future prospective studies are required to determine if these measures will have a significant impact on both the morbidity and mortality associated with APAP administration.

Energy drink use and adverse effects among emergency department patients.

Energy drink usage is common and contains caffeine or other stimulants. We evaluated demographics, prevalence, reasons and adverse effects with consuming energy beverages. Cross-sectional study of a convenience sample of patients recruited from two San Diego Emergency Departments from January to December 2009. One-thousand-two-hundred-ninety-eight subjects participated of which 52.6% were male. Ethnicity: Caucasian 48.3%, African American 17%, Hispanic 18%, Other 16.7%. Age ranges: 18-29 years (38.4%), 30-54 years (49.6%) and greater than 55 years (12%). Reasons for use: 57% to "increase energy", 9.5% for studying/work projects, 2.4% while prolonged driving, improve sports performance 2%, with ethanol 6.3%, "other" reasons 22.1%. Adverse reactions reported by 33.5% (429) patients. Two-hundred-eighty report feeling "shaky/jittery", insomnia 136, palpitations 150, gastrointestinal upset 82, headache 68, chest pain 39, and seizures in 6. Eighty-five patients reported co-ingestion with illicit "stimulants" including cocaine and methamphetamine. We identified one-third of patients reported at least one adverse effect. Whilst most were not severe, a small number were serious e.g., seizures. In addition, some report purposely ingesting with illicit drugs.

Left upper quadrant abdominal pain.

We present a case of acute appendicitis from mobile cecum presenting with left upper quadrant abdominal pain.

Examination of adverse events following black widow antivenom use in California.

OBJECTIVES: Following widow spider (Latrodectus sp.) envenomation, local pain, erythema, abdominal pain, rigidity, hypertension, and diaphoresis can be seen. While an effective specific antivenom (AV) is available, its use is limited due to concern of possible severe allergic reaction. We performed the current study to determine rate of adverse effects and the efficacy of AV in patients treated for widow spider envenomation. METHODS: Observational case series of the California Poison Control System electronic database from January 1999 to December 2009. All cases of widow spider envenomation treated with AV were included. Age, gender, signs, and symptoms, adjunctive therapy, number of vials of AV given, and adverse reaction to AV were recorded. Descriptive statistical methods were used. RESULTS: Ninety-six patients received AV, mean age 26 years (0.12-74 years), 76% male. Following widow spider envenomation generalized pain was reported in 91%, erythema at site in 57%, hypertension (≥ 140/90 mmHg) in 43%, muscle rigidity/cramping in 43%, abdominal pain in 41%, tachycardia (≥ 100 bpm) in 23% and diaphoresis in 21%. No patient required more than one vial of AV. One patient developed urticaria to AV halfway through infusion which was immediately discontinued. Another patient developed generalized flushing following completion of infusion but had no other effects. Two other patients reported myalgia and paresthesia. There were no deaths in any patients receiving AV. There was no shortness of breath or respiratory distress, no hypotension or chest pain following AV administration. All patients reported pain relief with AV and did not require additional AV doses. CONCLUSIONS: Our results suggest that Black Widow Spider Antivenin® (Merck) administration is relatively safe with mild to moderate adverse effects seen in only a small percentage of patients. There were no deaths, or severe allergic reactions identified. The retrospective use of poison control system data is a limitation of our study. Further prospective studies are needed to validate our findings and elucidate the full safety profile on this antivenom.

Mass sociogenic illness initially reported as carbon monoxide poisoning.

BACKGROUND: Mass sociogenic illness (MSI) is a rare occurrence involving a constellation of physical signs and symptoms in a group of individuals that are exhibited subconsciously and have no corresponding organic etiology. OBJECTIVES: To describe an outbreak of MSI initially attributed to carbon monoxide (CO) poisoning. CASE REPORTS: While attending a church service, one child fainted, followed by another. This led to multiple individuals reporting a constellation of symptoms. A total of 22 individuals presented to emergency departments (EDs) with neurologic, gastrointestinal, and respiratory complaints. The onset of symptoms followed evacuation in most of these patients. Prehospital personnel obtained carboxyhemoglobin (COHb) levels with a portable oximeter device, identifying levels up to 19% in 6 patients; 17 were taken to a tertiary hospital with a hyperbaric oxygen chamber, and the other 5 to a local ED. All other attendees were asymptomatic. Within the 15-min transport time, all patients were asymptomatic and had normal physical examinations. The mean age of patients was 13 years; 7 were male and 10 were female. Venous blood gas identified normal COHb levels in all patients. Pulse oximetry in the ED was normal. Another handheld oximeter device in the ED found normal COHb and methemoglobin levels. CONCLUSION: Varying complaints with onset after removal from the church suggest MSI. The hazardous materials team reproduced the scenario and no toxic gases were detected. Escalation of symptoms and an increased number of persons being affected along with increasing ambulance presence are common in MSI. We suspect that field oximeter readings were either aberrant from an inexperienced operator or were false-positive COHb readings. Clinicians should consider MSI after mass outbreaks of illness, particularly with rapid onset, rapid resolution of symptoms, and normal physical examinations and laboratory analyses. However, the diagnosis of MSI should be entertained only after potential toxicologic etiologies have been excluded.

Ultrasound visualization of ingested tablets: a pilot study.

STUDY OBJECTIVE: To evaluate the ability of ultrasonography as a radiographic technique to visualize ingested tablets in the human stomach. DESIGN: Prospective, ultrasonographer-blinded, pilot study. SETTING: Tertiary care medical center. SUBJECTS: Fifteen healthy adults (12 male, 3 female; mean age 35.5 yrs). INTERVENTION: After fasting for at least 12 hours, subjects were randomized to either ingest a total of 10 tablets (four acetaminophen, four ibuprofen, and two multivitamin tablets) with 500 ml of water or to drink 500 ml of water alone (control group). MEASUREMENTS AND MAIN RESULTS: Nine subjects were randomized to the group taking the tablets and six to the control group. Within 30 minutes after ingesting the tablets with water or the water alone, each subject underwent ultrasonography 2 times by two respective blinded ultrasonographers (emergency department physicians who were experienced with the ultrasound technique). Each performed the radiographic technique in isolation of the other ultrasonographer so as not to influence each other's interpretation. They recorded whether or not they thought tablets were visible. One ultrasonographer was correct for 14 (93%) of the 15 subjects, but the other ultrasonographer was correct for only 6 subjects (40%). Interobserver agreement was assessed, with no agreement found between the two ultrasonographers (Cohen κ coefficient -0.25 [95% confidence interval -0.7-0.2]). The ultrasonographers also found six false positives (no drugs present in the stomach but incorrectly identified as present by the ultrasonographer) and four false negatives (tablets present in the stomach but not identified by the ultrasonographer). CONCLUSION: Our results do not support the application of ultrasonography to determine the presence or absence of tablets in an individual's stomach after an acute poisonings. We did show that, similar to other radiologic techniques (e.g., projection radiography), the absence of tablet visualization does not exclude their presence. However, the ultrasonographers also found several false positives. Thus, further studies are needed with larger numbers of both subjects and ultrasonographers to elucidate the potential benefit of ultrasonography in individuals who experience acute poisoning.