Comparing cost of F(.ab')2AV vs FabAV in the treatment of copperhead envenomation-One center's experience.

The definitive treatment of North American crotalid snakebites is antivenin. In 2000, an FabAV antivenom (CroFab®) was introduced and in 2022, F(ab')2AV (Anavip®) was approved for treatment of copperhead bites. Our center that sees primarily copperhead snake bites added the recently approved treatment as a second option for the 2022 snake bite season. This brief report we describe our initial experience with the two antivenins via retrospective chart review: the cost, charge, laboratory differences, response to therapy, complications and duration of hospitalization of admitted patients with copperhead envenomation. Using three independent reviewers in this IRB exempt report we found 31 patients with copperhead bites (7 exclusions) leaving 19 adults and 7 children for analysis. We found there was no difference in age, sex, presence of lab abnormalities, total vials administered, or length of stay. There was significant differences in hospital costs and charges to the patient. Future research should include multi-center experiences comparing the two antivenins.

A Pilot Study Testing the Novel Use of a Snake Bite Compression Device for Field Hemostasis and Wound Repair in an Animal Model.

INTRODUCTION: A commercially available snake bite device was pilot tested for novel use as a method of hemostasis and wound repair at a noncompressible site in a live swine model. The device is light, is plastic, uses a hook-and-loop strap attachment, and is easily deployed. The device could offer a method for the field repair of an actively bleeding laceration at a noncompressible site in an austere environment. MATERIALS AND METHODS: This was an interventional, prospective, controlled study in a large animal model. The study was approved by the Rhode Island Hospital Institutional Review Board (IRB) and the Animal Welfare Committee/Institutional Animal Care and Use Committee and the Lifespan Research Conflict of Interest Committee. Each animal acted as its own control. Blood loss was measured and compared between repairs of standardized incisions with and without the device's application. The lacerations were sutured closed. Two proceduralists alternated tasks of wound repair versus blood collection. Blood loss was measured by using gauze sponges to capture the blood during a 30-second free-bleeding period and during the repair itself. Using a one sample t-test (the expected difference in blood loss between the two incision repair methods = 0 if the null hypothesis were true), we calculated the mean difference in the deltas between the repair methods. RESULTS: The mean delta difference was 3.1 g (SE ± 0.97). The t-test demonstrated that there was a significantly greater blood loss during the standard repair method, t(9) = 3.11, P < 0.01 than during the repair with the device in place (see Fig. 2). A statistical power analysis conducted showed that with a sample size of 10 animals, there was sufficient statistical power to detect this significant effect (ß = 0.82, α < 0.05, one-tailed). CONCLUSIONS: There was statistically significantly less blood loss during the repairs with the device's application. This feasibility experiment demonstrates that a commercially available snakebite device may be useful for hemostasis during laceration repair at anatomic sites not amenable to application of tourniquets or compressive dressings. Strengths of the study include the prospective controlled design, including the use of each animal as its own control; alternating proceduralists to account for any variability in suturing efficiency; and the statistical significance of the results despite the small number of subjects. One weakness is that the time required for each repair was not measured. The device's portability and reusability suggest applicability in austere medical environments. Future studies could include timing the repairs, using a skin stapler or wound adhesive instead of sutures, applying a hemostatic agent before the repair, and sequentially applying the device to wounds longer than the device.

Introduction of an Electronic Mobile Device Version of an Alcohol Impairment Scale (the Hack's Impairment Index Score) Does Not Impair Nursing Assessment of Patients in Emergency Departments.

BACKGROUND: There is no formal assessment to determine level of disability in the millions of patients with alcohol-induced impairment who present to emergency departments annually. Hack's Impairment Index (HII) is a standardized, serializable clinical tool designed to quantify ability. Nursing staff members at this center perform the HII and determine a score using paper prompts. OBJECTIVE: We developed an HII electronic application and investigated whether or not an electronic version on a mobile device would affect nursing performance. METHODS: A chart review-based quality improvement project compared the number, repetitions, and completeness of HII score documentation performed by nurses over 6.5 months. Group 1: paper-based HII scores for the 90-day period before intervention; group 2: iPad-based HII scores for the 90 days after intervention. There was a 2-week period for staff training and electronic version feedback between groups. Informal, ad hoc interviews were performed with nurses at investigation termination. RESULTS: Group 1: 476 emergency department patients with alcohol-induced impairment had HII scores ordered; 339 (71.2%; 95% CI, 67.1, 75.3%) had HII assessments with a total of 539 HII scores documented. An average (SD) 1.60 (0.01) serial assessments occurred per patient, 5 (1.1%; 95% CI, (0, 2.2%) scores were incomplete. Group 2: 569 alcohol-induced impairment emergency department patients were seen and had HII scores ordered; 420 (73.8%; 95% CI, (70.2, 77.4%) had HII assessments with a total of 639 HII scores documented. An average (SD) 1.52 (0.03) serial assessments occurred per patient, 4 (0.9%; 95% CI, (0.81, 0.99%) had incomplete HII scores. CONCLUSIONS: Although our study took place at 1 center, was a chart review, and not directly observed, we found that the mobile device-based HII application to determine a score did not interfere with nursing performance. Specifically, the repetition and completeness of nursing assessments of emergency department patients with impairment from alcohol use was not altered when comparing paper chart documentation with electronic format documentation. (Curr Ther Res Clin Exp. 2021; 82:XXX-XXX).

Environmental Toxic Exposures Using Companion Animals as an Indicator of Human Toxicity: A Case Report and Discussion.

BACKGROUND: Hundreds of years ago, humans realized that animals could be used as surrogate indicators of toxic environmental exposures, as a tool to measure risk to human health. The classic example is coal miners bringing canaries into coal mines. The respiratory rate and metabolism of the animal resulted in toxic signs of injurious gases in the environment before humans were injured. Occasionally, modern diagnosis of cryptic toxic exposures can be aided by the discovery of such features in the history. OBJECTIVES: We introduce this review using a case of inhalational mercury toxicity involving humans and companion animals-household dogs and cats. The death of exposed pets prior to the mounting of symptoms in the exposed humans was advance warning of the near-fatal presentation to come. Our objective was to review and characterize the state of the literature on companion animals as sentinel species. DISCUSSION: We reviewed 748 articles, which resulted in 25 selected for inclusion in this narrative review. We detail examples of companion animals (household dogs, cats, and birds) affected by toxic exposures in acute and chronic ways-acting as harbingers of impending human toxicity in acute or chronic settings. Mercury, lead, Teflon, herbicide, and asbestos exposures present with predictable signs and symptoms in companion animals prior to presenting in humans. Identifying the toxidrome in a companion animal allows for subclinical identification of exposure and consequences in the human that permits early treatment and intervention. CONCLUSIONS: Companion animals, when similarly exposed to toxic substances as humans regarding route, dose, and chronicity often mount symptoms and signs in advance of humans. This phenomenon allows the clinician to identify occult exposure, test, and treat while human disease is mild or still subclinical.

A Novel Tool to Facilitate Communication of Pain Quality: "Pain Blocks".

PURPOSE: Assessment of pain is difficult for many reasons, including the inability of patients to translate a subjective experience into words, and it is challenging for health care providers to create a shared understanding of what is being described. Physical representations exist to facilitate the objective scaling of "severity" or "intensity" of pain, but none exist to enable communication of pain quality. The objective of this proof-of-concept study was to develop, introduce, and evaluate consistency of participant interpretation of a novel kinesthetic tool set (Pain Blocks) that was designed to represent qualities of pain. METHODS: A prospective convenience sampling of participants approached in nonmedical settings over 9 months was queried to assess 6 randomly ordered Pain Blocks during structured interviews. The subjects were directed to associate each Pain Block with a pain quality from a list of 12 suggestions or use a free-text area for "other" descriptors. During the study, Pain Blocks were removed and replaced based on consistency of response at interval assessments. In part 2, participants were asked if any of the Pain Blocks accurately characterized the quality of their last severe pain. FINDINGS: A convenience sample of 220 participants was enrolled in the study and assessed 6 Pain Blocks. They interpreted and applied a pain quality to each of the blocks. Using interval assessments, a final selection of 6 Pain Blocks was derived that had consistent high association with specific pain qualities, either individually or with synonyms: Block 1 (stretching and tearing), 81.8%; Block 3 (crampy and throbbing), 90.4%; Block 4 (sharp and stabbing), 99.1%; Block 6 (crushing and dull), 94.1%; Block 7 (twisting), 95.8%; and Block 8b (burning), 100%. There were no differences in consistency of block interpretation between sexes or in terms of past experience of pain. IMPLICATIONS: We were able to create a group of physical objects (Pain Blocks) that were consistently and persistently interpreted, with a high degree of reliability, to represent specific pain qualities across ages and sexes. Although this proof-of-concept article was limited by the inclusion of English-speaking patients only and voluntary participants not currently in pain, the results support further investigation into tools to create a shared understanding of pain sensations between provider and participant.

Opioid Overdose With Parkinsonian Features.

A 54-year-old man presented to the emergency department with confusion and Parkinsonian features after suspected heroin snorting. He had magnetic resonance imaging of the brain demonstrating isolated symmetric bilateral globus pallidus (GP) restricted diffusion and edema consistent with hypoxic ischemic encephalopathy. In contrast to other anoxic/ischemic insults, where the GP is preferentially spared, autopsy reports on intravenous heroin users have found the GP to be specifically affected, often demonstrating symmetric bilateral lesions. Opioid toxicity should be considered in patients presenting with Parkinsonian features on examination or pallidal lesions on imaging, especially in younger adults where infarction is less common.

Disulfiram and Hypotension in a 53-year-old Woman.

We describe a case of disulfiram-ethanol reaction in a patient presenting with altered mental status. The patient was found to be profoundly hypotensive, requiring multiple vasopressor agents. As the symptoms associated with disulfiram reaction are non-specific, it is important to maintain a high level of suspicion for drug reaction when caring for the undifferentiated altered and hypotensive patient.

Carboxyhemoglobin Levels Induced by Cigarette Smoking Outdoors in Smokers.

INTRODUCTION: Non-invasive screening of carboxyhemoglobin saturation (SpCO) in the emergency department to detect occult exposure is increasingly common. The SpCO threshold to consider exposure in smokers is up to 9%. The literature supporting this cutoff is inadequate, and the impact of active smoking on SpCO saturation remains unclear. The primary objective was to characterize baseline SpCO in a cohort of smokers outdoors. Secondary objectives were to explore the impact of active smoking on SpCO and to compare SpCO between smokers and non-smokers. METHODS: This was a prospective cohort pilot study in two outdoor urban public areas in the USA, in a convenience sample of adult smokers. SpCO saturations were assessed non-invasively before, during, and 2 min after cigarette smoking with pulse CO-oximetry. Analyses included descriptive statistics, correlations, and a generalized estimating equation model. RESULTS: Eighty-five smokers had mean baseline SpCO of 2.7% (SD 2.6) and peak of 3.1% (SD 2.9), while 15 controls had SpCO 1.3% (SD 1.3). This was a significant difference. Time since last cigarette was associated with baseline SpCO, and active smoking increased mean SpCO. There was correlation among individual smokers' SpCO levels before, during, and 2 min after smoking, indicating smokers tended to maintain their baseline SpCO level. CONCLUSIONS: This study is the first to measure SpCO during active smoking in an uncontrolled environment. It suggests 80% of smokers have SpCO ≤ 5%, but potentially lends support for the current 9% as a threshold, depending on clinical context.

Performance of the Hack's Impairment Index Score: A Novel Tool to Assess Impairment from Alcohol in Emergency Department Patients.

BACKGROUND: Over 35 million alcohol-impaired (AI) patients are cared for in emergency departments (EDs) annually. Emergency physicians are charged with ensuring AI patients' safety by identifying resolution of alcohol-induced impairment. The most common standard evaluation is an extemporized clinical examination, as ethanol levels are not reliable or predictive of clinical symptoms. There is no standard assessment of ED AI patients. OBJECTIVE: The objective was to evaluate a novel standardized ED assessment of alcohol impairment, Hack's Impairment Index (HII score), in a busy urban ED. METHODS: A retrospective chart review was performed for all AI patients seen in our busy urban ED over 24 months. Trained nurses evaluated AI patients with both "usual" and HII score every 2 hours. Patients were stratified by frequency of visits for AI during this time: high (≥ 6), medium (2-5), and low (1). Within each category, comparisons were made between HII scores, measured ethanol levels, and usual nursing assessment of AI. Changes in HII scores over time were also evaluated. RESULTS: A total of 8,074 visits from 3,219 unique patients were eligible for study, including 7,973 (98.7%) with ethanol levels, 5,061 (62.7%) with complete HII scores, and 3,646 (45.2%) with health care provider assessments. Correlations between HII scores and ethanol levels were poor (Pearson's R2  = 0.09, 0.09, and 0.17 for high-, medium-, and low-frequency strata). HII scores were excellent at discriminating nursing assessment of AI, while ethanol levels were less effective. Omitting extrema, HII scores fell consistently an average 0.062 points per hour, throughout patients' visits. CONCLUSIONS: The HII score applied a quantitative, objective assessment of alcohol impairment. HII scores were superior to ethanol levels as an objective clinical measure of impairment. The HII declines in a reasonably predictable manner over time, with serial evaluations corresponding well with health care provider evaluations.

Intravenous lipid emulsion in the resuscitation of cocaine-induced cardiovascular arrest in a rat model.

CONTEXT: Intravenous lipid emulsion (ILE) is a potential antidote for severe overdose of certain lipophilic drugs. Cocaine overdose is often fatal and has no antidote. The use of ILE after cocaine-induced cardiac arrest has been suggested but is not well characterized. OBJECTIVE: The objective of the study is to determine if ILE would reverse cocaine-induced cardiac arrest in a rat model. MATERIALS AND METHODS: Twelve Sprague-Dawley rats with intra-arterial and intravenous access were sedated with isoflurane and split into 2 cocaine dose groups, then given either ILE or normal saline (NS) intravenously (IV)-group A, 7 animals received cocaine (10 mg/kg IV) with 6 of 7 given ILE (15 mg/kg IV) and 1 of 7 given NS (equal volume); group B, 5 animals received cocaine (5 mg/kg IV) with 3 of 5 given ILE (15 mg/kg IV) and 2 of 5 given NS (equal volume). Closed chest compressions were initiated for asystole and continued for 15 minutes with rhythm checks every minute. RESULTS: All 12 rats experienced cardiac arrest after cocaine bolus. Resuscitation was successful in 1 of 7 rats in group A and 0 of 5 in group B. CONCLUSIONS: Intravenous lipid emulsion administration did not affect outcome of cocaine-induced cardiac arrest compared with control in this model.

Snakebite! Crotalinae Envenomation of a Man in Rhode Island.

The incidence of poisonous snakebites has regional variance. Health care providers' knowledge and comfort in treating these envenomated patients depends on the density of poisonous snakes in their environment, with practitioners in the southern U.S. typically treating more exposed patients than those in colder regions in the North. We present a rare case of a confirmed copperhead snakebite that occurred in Rhode Island. We will review Copperhead bites, clinical management and treatment options.

The H-Impairment Index (HII): a standardized assessment of alcohol-induced impairment in the Emergency Department.

BACKGROUND: Emergency Departments (EDs) care for thousands of alcohol-intoxicated patients annually. No clinically relevant bedside measures currently exist to describe degree of impairment. OBJECTIVES: To assess a group of bedside tests ("Hack's Impairment Index [HII] score") that applies a numerical value to the degree of alcohol-induced impairment in ED patients. METHODS: A six-month retrospective review of HII score data was performed in a convenience sample of 293 intoxicated ED patients. Patients were scored 0-4 on five tasks, divided by the maximum score (20 if all tasks completed), every 2 hours; and classified by the number of visits: Low-frequency (1 visit); Medium-frequency (2 visits); High-frequency (≥3 visits). Correlations were assessed between HII score, healthcare provider judgment of intoxication, and measured alcohol levels. RESULTS: Study patients had 513 visits; 236 were low-frequency, 26 middle-frequency and 31 high-frequency. Clinical assessment and HII score were strongly correlated (Spearman's rho = 0.82, p << 0.001); clinical assessment and alcohol level less strongly so (rho = 0.49, p << 0.001). Among low-frequency patients, HII score and alcohol level were weakly correlated (r = 0.324, p < 0.001), with no such correlation among high-frequency visitors (r = -0.04, p = 0.89). The mean decline between serial HII scores was 0.126 (95% CI: 0.098-0.154). CONCLUSION: This pilot study shows the HII score can be performed at the bedside of alcohol-intoxicated patients. The HII declines in a reasonably predictable manner over time; and applies a quantitative, objective assessment of alcohol impairment.

Pretreatment with intravenous lipid emulsion reduces mortality from cocaine toxicity in a rat model.

STUDY OBJECTIVE: We compare the effects of intravenous lipid emulsion and normal saline solution pretreatment on mortality and hemodynamic changes in a rat model of cocaine toxicity. We hypothesize that intravenous lipid emulsion will decrease mortality and hemodynamic changes caused by cocaine administration compared with saline solution. METHODS: Twenty male Sprague-Dawley rats were sedated and randomized to receive intravenous lipid emulsion or normal saline solution, followed by a 10 mg/kg bolus of intravenous cocaine. Continuous monitoring included intra-arterial blood pressure, pulse rate and ECG tracing. Endpoints included a sustained undetectable mean arterial pressure (MAP) or return to baseline MAP for 5 minutes. The log-rank test was used to compare mortality. A mixed-effect repeated-measures ANOVA was used to estimate the effects of group (intravenous lipid emulsion versus saline solution), time, and survival on change in MAP, pulse rate, or pulse pressure. RESULTS: In the normal saline solution group, 7 of 10 animals died compared with 2 of 10 in the intravenous lipid emulsion group. The survival rate of 80% (95% confidence interval 55% to 100%) for the intravenous lipid emulsion rats and 30% (95% confidence interval 0.2% to 58%) for the normal saline solution group was statistically significant (P=.045). CONCLUSION: Intravenous lipid emulsion pretreatment decreased cocaine-induced cardiovascular collapse and blunted hypotensive effects compared with normal saline solution in this rat model of acute lethal cocaine intoxication. Intravenous lipid emulsion should be investigated further as a potential adjunct in the treatment of severe cocaine toxicity.

Intravenous lipid emulsion does not reverse dabigatran-induced anticoagulation in a rat model.

OBJECTIVES: The anticoagulant dabigatran has no reversal agent and may cause life-threatening bleeding in patients with trauma or closed-space hemorrhage. Intravenous lipid emulsion (ILE) is thought to create a lipid compartment in serum that sequesters lipophilic drugs. Dabigatran is lipophilic, and its anticoagulant effects are concentration dependent. The study objective was to determine if ILE therapy reverses dabigatran's anticoagulant effects. METHODS: Twenty rats were selected at random, 10 in the ILE group and 10 in a normal saline (NS) control group. Animals had a baseline tail bleeding time (T0), followed by oral dabigatran administration (15 mg/kg). At 45 minutes (T45), a second tail bleed time measurement was performed, followed by a 7-minute infusion of 15 mL/kg ILE or NS. A final 60-minute (T60) bleed time measurement was obtained. An ILE-only group of five animals had bleeding times assessed prior to (T0) and 15 minutes after (T15) ILE therapy. A mixed-effect repeated-measures analysis of variance modeling the effect of time, group, and the interaction of group and time on bleed times was conducted. RESULTS: There was a significant within-subject change in bleeding time across the assessment points (F(2,36) = 33; p < 0.001), but there were no effect of group (F(1,18) = 1.42, p = 0.25) or an interaction between group and assessment point on mean bleeding time (F(2,36) = 0.59, p = 56). Between T0 and T45, average bleeding times increased from 109.5 seconds (95% confidence interval [CI] = 94 to 125 seconds) to 231.8 seconds (95% CI = 193 to 271 seconds; p < 0.0001) for both the ILE group and the NS control group. Between T45 and T60, bleeding times in the ILE group decreased by 31.5 seconds (95% CI = -77 to 14 seconds) and by 6 seconds (95% CI = -67 to 55 seconds) in the NS group (p = 0.46). In the five ILE-only animals, the average bleeding time at T0 was 114 seconds (95% CI = 62 to 166 seconds), which increased significantly at T15 to 237 seconds (95% CI = 161 to 313 seconds; p = 0.02). CONCLUSIONS: The anticoagulant effects of dabigatran are not reversed with ILE therapy. Although ILE itself significantly prolonged bleeding times, when administered to dabigatran-anticoagulated rats, bleeding times did not change significantly. There may be a complex interaction of ILE with dabigatran that this study was not able to elucidate.

Hyperglycemic crisis.

BACKGROUND: Hyperglycemic crisis is a metabolic emergency associated with uncontrolled diabetes mellitus that may result in significant morbidity or death. Acute interventions are required to manage hypovolemia, acidemia, hyperglycemia, electrolyte abnormalities, and precipitating causes. Despite advances in the prevention and management of diabetes, its prevalence and associated health care costs continue to increase worldwide. Hyperglycemic crisis typically requires critical care management and hospitalization and contributes to global health expenditures. OBJECTIVE: Diagnostic and resolution criteria and management strategies for diabetic ketoacidosis and hyperosmolar hyperglycemic crisis are provided. A discussion of prevalence, mortality, pathophysiology, risk factors, clinical presentation, differential diagnosis, evaluation, and management considerations for hyperglycemic crisis are included. DISCUSSION: Emergency physicians confront the most severe sequelae of uncontrolled diabetes and provide crucial, life-saving management. With ongoing efforts from diabetes societies to incorporate the latest clinical research to refine treatment guidelines, management and outcomes of hyperglycemic crisis in the emergency department continue to improve. CONCLUSION: We provide an overview of the evaluation and treatment of hyperglycemic crisis and offer a concise, targeted management algorithm to aid the practicing emergency physician.