Leaving Before Completion of Treatment Among Alcohol-Intoxicated, College-Aged Emergency Department Patients.

Background Heavy alcohol use among college-aged students is common and may lead to Emergency Department (ED) visits. A review of alcohol-intoxicated presentations to a single ED was performed to characterize these encounters and identify factors associated with leaving before treatment completion. Methodology Electronic medical records were reviewed for patients aged 18 to 25 years over a nine-month study period who presented to a university-affiliated ED with isolated alcohol intoxication and were subsequently discharged or left before completion of treatment. The frequency and characteristics of these individuals were compared using chi-square analysis. A series of controlled logistic and multinomial regression models were conducted to examine the predictive significance of potentially confounding variables (age, gender, time and day of presentation, method of hospital arrival, and triage level) associated with premature ED departure and length of stay. Measured ethanol levels and vital sign abnormalities at the time of leaving the ED were identified. Results Four hundred sixty-four patients aged 18 to 25 years presented with isolated alcohol intoxication over the study period. A higher frequency of leaving without completion of treatment was noted in college-aged alcohol-intoxicated individuals compared to the general adult ED population (17.9% versus 3.5%; P < 0.01). Abnormal vital signs (10.5%) and elevated ethanol levels before ED departure when measured (85.2%) were not uncommon. Variables significantly associated with leaving before completion of treatment included arrival by means other than emergency medical service (EMS)/police, lower triage levels, and 11 p.m. to 7 a.m. hospital departure.  Conclusions Based on these results, intoxicated college-aged individuals are at high risk for leaving EDs before care completion. The development of targeted protocols to minimize this occurrence and utilizing these ED encounters to consider addressing unhealthy drinking behaviors may be helpful.

Bilateral Scapular Fractures Occurring as a Result of a First-Time Seizure.

The violent nature of generalized tonic-clonic seizures puts individuals at risk of a large number of potential injuries. These can occur due both to the profound muscular contractions that accompany these episodes as well as falls and other traumatic events that occur due to the period of loss of consciousness that occurs during generalized seizures. While injuries such as soft tissue contusions, tongue biting, dental injuries, and facial lacerations resulting from falls from standing predominate, bony injuries are not uncommon. We present a case of bilateral scapular fractures that occurred in an otherwise healthy 32-year male who presented with shoulder and back pain and inability to perform any significant movement of his upper arms secondary to pain after experiencing an apparent first-time generalized tonic-clonic seizure. The presence of unilateral and bilateral scapular fractures, while uncommonly described, should be considered as an additional potential orthopedic injury that may occur secondary to a generalized tonic-clonic seizure. In the absence of observed significant forceful traumatic injury, this injury is unusual, and its presence noted in a patient experiencing sudden loss of consciousness should raise heightened concern of seizures as the potential etiology.

Burst Suppression Electroencephalography (EEG) Pattern with Coma and Loss of Brain Stem Reflexes Following a Baclofen Overdose with Subsequent Full Recovery.

BACKGROUND When taken in overdose, baclofen can produce a unique pattern of clinical findings and EEG abnormalities that contrasts to that seen with other sedative hypnotic medications. This includes profound lethargy and coma, loss of basic brainstem reflexes and pupil reactivity, myoclonic jerks and seizures, and a burst suppression pattern on EEG. In the absence of a clear history of ingestion, clinicians may presume the presence of anoxic brain injury and that a progression towards brain death may be imminent. CASE REPORT We report a case of a middle-aged woman found unresponsive who presented with apnea, loss of rudimentary neurologic findings on physical exam, burst suppression EEG findings, and a prolonged comatose state for nearly 48 h, followed by rapid resolution of symptoms secondary to a supratherapeutic baclofen ingestion. CONCLUSIONS Baclofen toxicity can present both clinically and with EEG abnormalities consistent with anoxic brain injury, suggesting an inevitable progression to brain death. When provided with appropriate supportive care and prolonged observation, improvement with full neurologic recovery is often seen despite the initial grim clinical picture.

Traumatic Retropharyngeal Hematoma in a Patient Taking Clopidogrel.

The development of a retropharyngeal hematoma may lead to acute airway compromise requiring emergent airway stabilization. We describe the development of a retropharyngeal hematoma in an elderly woman who sustained a fall from standing approximately 10 hours prior to symptom onset who was taking the antiplatelet agents clopidogrel and aspirin. This delayed onset of rapid airway compromise secondary to a retropharyngeal hematoma following a fall in a patient taking clopidogrel is an unusual and potentially life threatening event.

Frequency of return visits to the emergency department in patients discharged following hypoglycemia episodes.

BACKGROUND: In-hospital observation is typically recommended for patients who present to the emergency department with symptomatic hypoglycemia who are taking oral diabetes medications or long acting insulin. Individuals considered to be at low risk of further hypoglycemic episodes by treating providers are however on occasion discharged to home when a low suspicion of recurrence and close observation is available. We describe the frequency of hypoglycemia recurrence requiring further emergency department evaluation who have been recently discharged from the emergency department and are taking oral diabetes medications or long-acting insulin. METHODS: A retrospective chart review was performed over a 2-year period of time at a large community-based academic emergency department for patients with an ICD-9 diagnosis of hypoglycemia who were taking oral or injectable diabetes medications. Patients were included with symptomatic blood sugar readings less than 55 mg/dL measured by prehospital or hospital providers. For those discharged from the emergency department, medical records from the study hospital and nearby health care facilities, Emergency Medical Service reports, and county death records were reviewed to determine recurrence of symptoms requiring care. RESULTS: There were 196 patients discharged over the study period with 10 (5.1%) patients returning to the emergency department within 48 h with recurrent hypoglycemia. Return visits occurred in 4 of 144 taking insulin alone; 2.8% (CI 1.1-6.9%), in 3 of 19 patients taking oral agents alone; 15.8% (CI 5.5-37.5%), and in 3 of 33 patients taking both insulin and oral medications; 9.1% (CI 3.1-23.6%). Frequency of hypoglycemia recurrence requiring repeat ED visits was more common in those taking oral agents compared to individuals taking insulin alone (p = 0.04). All 7 individuals with recurrent hypoglycemia who were taking insulin were taking long-acting insulin preparations. No discharged patients were identified on Emergency Medical Service refusal of care reports or county death records. CONCLUSION: Individuals discharged from the emergency department following hypoglycemic episodes who were taking oral diabetes medications are at a greater risk than individuals taking insulin alone of a return emergency department visit within 48 h for recurrent hypoglycemia.

Agranulocytosis occurrence following recent acute infectious mononucleosis.

Infectious mononucleosis secondary to Epstein-Barr virus typically follows a relatively benign and self-limited course. A small subset of individuals may develop further progression of disease including hematologic, neurologic, and cardiac abnormalities. A mild transient neutropenia occurring during the first weeks of acute infection is a common finding however in rare cases a more profound neutropenia and agranulocytosis may occur up to 6weeks following the onset of initial symptoms. We describe the case of an 18-year-old woman who presented 26days following an acute infectious mononucleosis diagnosis with agranulocytosis and fever. No source of infection was identified and the patient had rapid improvement in her symptoms and resolution of her neutropenia. The presence of fever recurrence and other non-specific symptoms in individuals 2-6weeks following acute infectious mononucleosis symptom onset may warrant further assessment for this uncommon event.

Effect of fuel type on carbon monoxide accumulation in tents of varied design.

OBJECTIVE: The use of backpacking stoves in tents has been recognized to result in elevated carboxyhemoglobin levels and even death among tent inhabitants. A study was performed to evaluate carbon monoxide production occurring in varying tents with variable fuel types. METHODS: Using a popular backpacking stove, both white gas and regular unleaded gasoline were used to heat a pot of water inside 2 tents of differing levels of weather resistance ("3-season tent" and "4-season tent") under controlled settings. A remote carbon monoxide sensor measured levels over a 20-minute period. Multiple 20-minute runs were performed with varying fuel and tent combinations to assess peak levels and rates of carbon monoxide production. RESULTS: Mean peak carbon monoxide levels were obtained in the 3-season tent and 4-season tent when white gas was burned measuring 60.5 ppm (95% CI: 31.2 to 89.8) and 154.5 ppm (95% CI: 112.8 to 195.7; P = .002), respectively. The use of regular unleaded gasoline in the 3-season and 4-season tents resulted in mean peak carbon monoxide levels of 102.9 ppm (95% CI: 77.8 to 128.0) and 210.6 ppm (95% CI: 37.4 to 383.1; P = .06), respectively. Using regular unleaded gasoline resulted in significantly increased mean peak carbon monoxide levels compared with white gas in the 3-season tent (P = .006); however, the difference was not significant in the 4-season tent (P = .23). CONCLUSIONS: The use of backpacking stoves in tents produces varying levels of carbon monoxide related to fuel type and tent styles. Efforts should continue to educate persons of the risk of carbon monoxide poisoning with the use of any stove while inside tents.

A retrospective evaluation of shortened-duration oral N-acetylcysteine for the treatment of acetaminophen poisoning.

INTRODUCTION: The use of less than the traditional 72-hour course of oral N-acetylcysteine has been an alternative treatment option following potentially toxic acute and chronic acetaminophen ingestions felt to be at low risk of developing hepatotoxicity. While clinical experience with shortened treatment duration is extensive, there are few studies evaluating the effectiveness and extent to which these regimens may be used. METHODS: A large statewide poison center database was reviewed for all acetaminophen exposures involving potentially toxic acute and chronic ingestions, in addition to those taking place at unknown times. Patients were identified who met laboratory criteria for early N-acetylcysteine (NAC) discontinuation (APAP>10 micro/mL, INR

Subcutaneous silicone injection leading to multi-system organ failure.

BACKGROUND: Silicone is an inert liquid polymer often chosen for cosmetic procedures due to its durability and thermal stability. Following silicone injection, end organ toxicity can occur. We report two cases of multiorgan dysfunction following silicone injection. CASE REPORT: Two transsexual males presented to the emergency department with altered consciousness after receiving subcutaneous injections of silicone into the hip and buttocks. Each patient had received injections totaling between one and two liters of silicone. Soon after the injections, each reported feeling nauseated and lethargic, and then lost consciousness. On arrival, each was somnolent, with tachycardia and hypotension. Lungs were clear and there were multiple injection sites of induration noted over the hips and gluteal regions. Laboratory screening showed leukocytosis and hemoconcentration in each, with no drugs found on urine toxicology screening. Chemistries were normal. Both became hypoxic on arterial blood gas analysis. Oxygenation worsened in each despite intubation and ventilator manipulation. Chest radiographs were initially clear but progressively showed adult respiratory distress syndrome. One patient gradually improved over several days, was extubated, and recovered neurologically. The second patient continued to be hypoxic, never regained neurologic function, and expired three weeks after presentation. Post-mortem examination revealed clinical respiratory failure with organizing pneumonia, adult respiratory distress syndrome, and foreign body giant cell reactions to silicone. Additionally, multiple small subacute brain white matter infarcts consistent with silicone embolization were found. CONCLUSION: Clandestine application of silicone for body enhancement is common and clinicians should be aware of the potential complications.

Comparative treatment of alpha-amanitin poisoning with N-acetylcysteine, benzylpenicillin, cimetidine, thioctic acid, and silybin in a murine model.

STUDY OBJECTIVE: The foraging of wild mushrooms can be complicated by toxicity from several mushroom types. Amatoxin, a peptide contained in several mushroom species, accounts for the majority of severe mushroom poisonings by binding to RNA polymerase II irreversibly, leading to severe hepatonecrosis. There is no effective antidote for severe amatoxin poisoning. We compare the effectiveness of 5 potential antidotal therapies in limiting the degree of hepatonecrosis in a randomized, controlled, murine model of amatoxin-induced hepatotoxicity. METHODS: One hundred eighty male Institute of Cancer Research mice were randomized into 6 equal groups. Within each group, 21 mice were intraperitoneally injected with 0.6 mg/kg of alpha-amanitin (amatoxin); the remaining 9 were injected with 0.9% normal saline solution. Four hours postinjection, each group of 30 mice was randomized to 1 of 5 intraperitoneal treatments (N-acetylcysteine, benzylpenicillin, cimetidine, thioctic acid, or silybin) or normal saline solution. Repeated dosing was administered intraperitoneally every 4 to 6 hours for 48 hours. After 48 hours of treatment, each subject was killed, cardiac blood was aspirated for hepatic aminotransferase measurements (alanine transaminase and aspartate transaminase), and liver specimens were harvested to evaluate the extent of hepatonecrosis. The degree of hepatonecrosis was determined by a pathologist blinded to the treatment group and divided into 5 categories according to percentage of hepatonecrosis. RESULTS: Amanitin significantly increased aspartate transaminase in treated mice compared with normal saline solution-treated controls (mean [SD] 2,441 [2,818] IU/L versus 310 [252]; P=.03). None of the antidotal therapies were found to significantly decrease the increase in aminotransferases compared with controls. Further, none of the antidotal therapies demonstrated an important decrease in hepatonecrosis compared with controls when a histologic grading scale was used. CONCLUSION: In this murine model, N-acetylcysteine, benzylpenicillin, cimetidine, thioctic acid, and silybin were not effective in limiting hepatic injury after alpha-amanitin poisoning. Increases of aminotransferases and degrees of histologic hepatonecrosis were not attenuated by these antidotal therapies.

A prospective evaluation of shortened course oral N-acetylcysteine for the treatment of acute acetaminophen poisoning.

STUDY OBJECTIVE: Treatment with a shortened duration of oral N-acetylcysteine (20 to 48 hours) after acute acetaminophen poisoning is effective in the prevention of subsequent hepatic failure and death when administered to individuals meeting appropriate laboratory criteria. METHODS: Individuals with a potentially toxic acetaminophen ingestion according to serum acetaminophen levels were identified prospectively using a large statewide poison control system database throughout a 12-month period. N-acetylcysteine was administered for a minimum of 6 doses (20 hours), after which laboratory studies were obtained. Discontinuation of N-acetylcysteine was recommended by the poison center when 2 criteria were met: serum acetaminophen was undetectable (<10 microg/mL) and liver test results were normal (serum aminotransferase, international normalized ratio). A follow-up questionnaire was administered to individuals treated with N-acetylcysteine for 48 hours or less to ascertain the presence of symptoms consistent with progressive hepatotoxicity. RESULTS: Of 205 acutely poisoned individuals treated with N-acetylcysteine for 48 hours or less, 195 were successfully contacted after discharge, and 187 of 195 (95.9%) reported no symptoms consistent with hepatic failure. Eight individuals (4.1%) reported abdominal pain or vomiting; however, none received further N-acetylcysteine treatment or additional hospitalization. CONCLUSION: A shortened duration of treatment with N-acetylcysteine (20 to 48 hours) may be an effective treatment option in individuals considered to be at no further risk of developing liver toxicity according to the fulfillment of appropriate laboratory criteria before N-acetylcysteine discontinuation.

Antidote use in the critically ill poisoned patient.

The proper use of antidotes in the intensive care setting when combined with appropriate general supportive care may reduce the morbidity and mortality associated with severe poisonings. The more commonly used antidotes that may be encountered in the intensive care unit (N-acetylcysteine, ethanol, fomepizole, physostigmine, naloxone, flumazenil, sodium bicarbonate, octreotide, pyridoxine, cyanide antidote kit, pralidoxime, atropine, digoxin immune Fab, glucagon, calcium gluconate and chloride, deferoxamine, phytonadione, botulism antitoxin, methylene blue, and Crotaline snake antivenom) are reviewed. Proper indications for their use and knowledge of the possible adverse effects accompanying antidotal therapy will allow the physician to appropriately manage the severely poisoned patient.

Massive honey bee envenomation-induced rhabdomyolysis in an adolescent.

Massive envenomations by honey bees are capable of causing multiorgan dysfunction as a result of the direct toxic effects of the large venom load received. Although all varieties of honey bee have the potential for these attacks, the Africanized honey bee (Apis mellifera scutellata) is the most commonly implicated subspecies. In the United States, the Africanized strain is found primarily in the southwestern states and is known for its highly defensive behavior if disturbed. Mechanisms behind the multiorgan dysfunction produced by these mass envenomations are not clearly understood. We present a case of a 13-year-old male who was stung by approximately 700 honey bees and developed progressive upper-body swelling and systemic manifestations of mass envenomation including rhabdomyolysis, renal insufficiency, and a transient transaminase elevation.

North American coral snake antivenin for the neutralization of non-native elapid venoms in a murine model.

OBJECTIVES: North American coral snake antivenin (CSAV; Wyeth Antivenin [Micrurus fulvius], equine origin) is approved for the treatment of coral snake envenomations in the United States. The coral snake is the only elapid that is native to North America, but envenomations from non-native elapids are occurring more commonly in this country. This study was designed to evaluate the efficacy of CSAV in the neutralization of two exotic elapid envenomations: Naja naja (Indian cobra) and Dendroaspis polylepsis (black mamba). METHODS: A randomized, blinded, placebo-controlled murine model of intraperitoneal venom injection was employed. Venom potency was determined in preliminary dosing studies. Study animals then were divided into five groups: 1) N. naja venom + CSAV, 2) N. naja venom + 0.9% normal saline (NS), 3) D. polylepsis venom + CSAV, 4) D. polylepsis venom + NS, and 5) CSAV + NS. The venom dose was chosen to be twice the estimated LD50. The amount of CSAV injected was ten times the amount necessary for neutralization of a 2 x LD50 dose of M. f. fulvius venom in a murine model. Statistical analysis included Fisher's exact and log-rank testing to compare survival rates and times. RESULTS: Preliminary studies estimated the venom LD50 to be 2.58 mg/kg and 0.45 mg/kg, respectively, for the N. naja and D. polylepsis. A significant difference was shown in comparison of survival times between CSAV-venom groups and normal saline-venom groups despite all animals in both treatment and control arms dying. Animals receiving CSAV and N. naja venom survived (mean +/- SD) 24.4 +/- 3.0 minutes, versus 17.8 +/- 1.3 minutes in the control group (p < 0.001), whereas those receiving CSAV and D. polylepsis venom survived 203.8 +/- 37.0 minutes versus 130.0 +/- 42.6 minutes in the control group (p < 0.001). All animals in the CSAV + NS group survived to the conclusion of the study. CONCLUSIONS: When premixed with venom, CSAV increased survival time in a murine model of intraperitoneal N. naja and D. polylepsis venom injection. The clinical implications of this are unclear, given unchanged mortality rates.

Crotalidae polyvalent immune Fab (ovine) antivenom is effective in the neutralization of South American viperidae venoms in a murine model.

STUDY OBJECTIVE: Crotalidae polyvalent immune Fab (ovine) (CroFab; FabAV) is used in the treatment of symptomatic crotaline envenomations in North America. Unlike Antivenin (Crotalidae) Polyvalent, which is approved for treatment of crotaline envenomation in North and South America, FabAV is manufactured using only venoms from crotaline snakes native to the United States. This study was designed to evaluate the efficacy of FabAV in the neutralization of venom from 2 South American crotaline snakes: Crotalus durissus terrificus (tropical rattlesnake) and Bothrops atrox (fer-de-lance). METHODS: A randomized, blinded, placebo-controlled murine model of intraperitoneal venom injection was used. Venom potency was determined in preliminary median lethal dose (LD 50) dosing studies. Study animals were then divided into 7 groups: (1) C durissus terrificus venom (Sigma-Aldrich Co.)+FabAV, (2) C durissus terrificus venom (Sigma-Aldrich Co.)+0.9% normal saline solution, (3) C durissus terrificus venom (Biotoxins Inc.)+FabAV, (4) C durissus terrificus venom (Biotoxins Inc.)+normal saline solution, (5) B atrox venom+FabAV, (6) B atrox venom+normal saline solution, and (7) FabAV+normal saline solution. Twice the estimated LD 50 was the chosen venom dose, and the amount of FabAV injected was 10 times the amount needed for venom neutralization. Statistical analysis included Fisher's exact test and log-rank testing to compare survival rates and times. RESULTS: The venom LD 50 was found in preliminary studies to be 0.9 mg/kg and 1.35 mg/kg for the C durissus terrificus venom obtained from Sigma-Aldrich Co. and Biotoxins Inc., respectively. The LD 50 for B atrox venom was 5.0 mg/kg. All animals receiving venom only and saline solution died. Animals receiving FabAV together with either venom survived to the end of the 24-hour observation period ( P <.001). Comparison of survival times between groups demonstrated a significant difference in time to death between venom-only control groups and the FabAV+venom groups (P <.001). All animals in the FabAV+normal saline solution group survived to the conclusion of the study. CONCLUSION: FabAV, when premixed with venom, decreases lethality in a murine model of intraperitoneal venom injection of the South American pit vipers, C durissus terrificus and B atrox .