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In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, ß-adrenergic receptor antagonists (also known as ß-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
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Reanimação Cardiopulmonar , Parada Cardíaca , Humanos , Antagonistas Adrenérgicos beta , American Heart Association , Benzodiazepinas , Digoxina , Parada Cardíaca/induzido quimicamente , Parada Cardíaca/terapia , Estados UnidosRESUMO
BACKGROUND: Aortic dissection is a rare but well-known life-threatening disease that classically presents with tearing chest pain radiating to the back yet can have deceiving clinical presentations. CASE REPORT: A 54-year-old man with a history of hypertension presented to the emergency department with mild shortness of breath without chest pain. Point-of-care ultrasound (POCUS) detected diffuse B-lines, a dilated aortic root, aortic regurgitation, and pericardial effusion. A computed tomography angiogram confirmed a Stanford type A aortic dissection with diffuse alveolar hemorrhage (DAH), a rare complication of type A aortic dissection involving the posterior aortic wall with extension into the main pulmonary artery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute aortic dissection can present with a wide range of clinical manifestations with a high mortality rate for patients with an untimely diagnosis. Although an intimal flap within the aortic lumen is the characteristic finding on ultrasound, additional POCUS findings of a pericardial effusion, aortic regurgitation, and a dilated aortic root may be seen with proximal dissections. Diffuse B-lines on thoracic POCUS, although commonly associated with pulmonary edema in decompensated heart failure, can be seen in patients with DAH which has a multitude of etiologies, including aortic dissection.
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Dissecção Aórtica , Insuficiência da Valva Aórtica , Pneumopatias , Derrame Pericárdico , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/complicações , Dor no Peito/etiologia , Dispneia/etiologia , Hemorragia/complicações , Humanos , Pneumopatias/diagnóstico por imagem , Pneumopatias/etiologia , Masculino , Pessoa de Meia-Idade , Derrame Pericárdico/complicações , Derrame Pericárdico/etiologiaRESUMO
Background: Interest in the Southeast Asian natural remedy kratom has increased in Western countries recently, along with increasing concern over its potential toxic effects.Objective: To describe and compare demographics, common co-exposure substances, clinical effects, treatments, and medical outcomes of kratom "abuse" exposures in the United States (US) and Thailand.Methods: This is a retrospective analysis of kratom "abuse" exposures, defined as use when attempting to gain a psychotropic effect, reported to the National Poison Data System (NPDS) in the US and the Ramathibodi Poison Center (RPC) in Thailand from 2010 to 2017. Multivariate analysis identified risk factors for severe medical outcomes, defined as both ICU admissions and death.Results: Nine-hundred-twenty-eight cases were included (760 from NPDS and 168 from RPC). A greater proportion of cases involved co-exposures in Thailand (64.8% versus 37.4%; odds ratio [OR] = 3.10, 95% confidence interval [CI] = 2.15-4.47, p < .01). Both countries had a similar prevalence of opioid and benzodiazepine co-ingestions, but the US had more co-ingestions with other sedatives (4.6% versus 0%, OR = 0, 95% CI = 0-0.47, p < .01). Common clinical effects included tachycardia (30.4%), agitation/irritability (26.2%), and drowsiness/lethargy (21.1%). Six deaths occurred, including one single-substance exposure in the US, three multiple-substance exposures in the US, and two multiple-substance exposures in Thailand. Severe medical outcomes were reported more frequently in the US (OR = 18.82, 95% CI = 5.85-60.56, p < .01).Conclusions: Despite lower frequencies of co-ingestants overall, US kratom abuse exposures yielded greater clinical severity. This disparity may be attributable to differences in the products labeled "kratom," greater sedative co-exposures in the US, and/or differences in population genetics or use patterns.
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Mitragyna/intoxicação , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Extratos Vegetais/intoxicação , Centros de Controle de Intoxicações/estatística & dados numéricos , Estudos Retrospectivos , Tailândia/epidemiologia , Estados Unidos/epidemiologia , Adulto JovemRESUMO
OBJECTIVES: To report a severe case of e-cigarette or vaping product use-associated lung injury with complex course requiring venovenous extracorporeal membrane oxygenation. DESIGN: Case report. SETTING: PICU in an academic medical center. PATIENTS: A 16-year-old girl presenting with gastrointestinal and respiratory symptoms was admitted to our PICU after having progressive respiratory failure and bilateral pulmonary ground-glass opacities on chest CT. INTERVENTIONS: Venovenous extracorporeal membrane oxygenation MEASUREMENTS AND MAIN RESULTS:: After extensive infectious workup was unrevealing, she reported a history of vaping e-cigarette containing either nicotine or delta-9-tetrahydrocannabinol oil prior to symptom onset. She was given a presumptive diagnosis of e-cigarette or vaping product use-associated lung injury. The PICU team in consultation with pulmonology and medical toxicology started high-dose IV methylprednisolone 1 mg/kg bid. Despite initial improvements, she continued to require positive pressure ventilation and developed pneumomediastinum with progression to tension pneumothoraces and a persistent air leak. Unable to maintain her oxygenation, she was placed on venovenous extracorporeal membrane oxygenation for a prolonged course and had a tracheostomy placement. The clinical course, severity, and range of interventions in affected patients around the country have varied widely. Respiratory symptoms have been the most severe, but the constellation of symptoms in e-cigarette or vaping product use-associated lung injury include constitutional symptoms (fevers, weight-loss) and gastrointestinal symptoms (nausea, vomiting, diarrhea). In many cases, steroid use led to rapid clinical improvements. However, other cases with severe illness, like our patient, necessitated high-dose IV steroids, intubation, and venovenous extracorporeal membrane oxygenation. The underlying etiology and pathophysiology of e-cigarette or vaping product use-associated lung injury remains unknown. The Centers for Disease Control and Prevention in conjunction with state/local health departments and the Food and Drug Administration is actively investigating the outbreak. CONCLUSIONS: Clinicians need to be aware of the current outbreak of e-cigarette or vaping product use-associated lung injury and ask about vaping in patients presenting with gastrointestinal and respiratory symptoms. Treatment options are anecdotal and necessitate a multidisciplinary approach.
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Sistemas Eletrônicos de Liberação de Nicotina , Oxigenação por Membrana Extracorpórea , Lesão Pulmonar , Vaping , Adolescente , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Humanos , Pulmão , Vaping/efeitos adversosRESUMO
BACKGROUND: Intravenous lipid emulsion (ILE) has been broadly attempted in the resuscitation of neurologic and cardiac toxic drug overdoses, however, the role of ILE in the emergency department is poorly defined. OBJECTIVE: This review aims to identify recent literature on the use of ILE in humans as an antidote and to familiarize emergency providers with the indications, availability, dosing recommendations, and adverse reactions associated with ILE use. METHODS: A systemic literature search of MEDLINE, EMBASE, and major toxicology conference abstracts was performed for human cases using ILE as an antidote with documented clinical outcomes through January 2014. RESULTS: Ninety-four published articles and 40 conference abstracts were identified, 85% of which had positive outcomes. The most common indication for ILE was for local anesthetic systemic toxicity (LAST). The most common nonlocal anesthetic xenobiotics were tricyclic-antidepressants and verapamil. DISCUSSION: No standard of care is defined for the use of ILE, although the American Heart Association recommends use in LAST, and the American College of Medical Toxicology recommends consideration for circumstances of hemodynamic instability resultant from lipid-soluble xenobiotics. ILE should be administered per American Society of Regional Anesthesia and Pain Medicine dosing recommendations. Laboratory interference, pancreatitis, respiratory distress syndrome, and interference with vasopressors should be considered as risks but are uncommon. CONCLUSIONS: In the setting of severe hemodynamic compromise by lipid-soluble xenobiotics, ILE may be considered for resuscitation by emergency physicians. As such, ILE may be stocked in emergency departments in close proximity to resuscitation rooms and areas where local nerve blocks are performed.
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Antídotos/uso terapêutico , Emulsões Gordurosas Intravenosas/uso terapêutico , Adulto , Anestésicos Locais/intoxicação , Antiarrítmicos/intoxicação , Antidepressivos Tricíclicos/intoxicação , Serviço Hospitalar de Emergência , Feminino , Humanos , Intoxicação/terapia , Guias de Prática Clínica como Assunto , Verapamil/intoxicaçãoRESUMO
BACKGROUND: Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and Pediatric Advanced Life Support (PALS) are integral parts of emergency resuscitative care. Although this training is usually reserved for residents, introducing the training in the medical student curriculum may enhance acquisition and retention of these skills. OBJECTIVES: We developed a survey to characterize the perceptions and needs of graduating medical students regarding BLS, ACLS, and PALS training. METHODS: This was a study of graduating 4th-year medical students at a U.S. medical school. The students were surveyed prior to participating in an ACLS course in March of their final year. RESULTS: Of 152 students, 109 (71.7%) completed the survey; 48.6% of students entered medical school without any prior training and 47.7% started clinics without training; 83.4% of students reported witnessing an average of 3.0 in-hospital cardiac arrests during training (range of 0-20). Overall, students rated their preparedness 2.0 (SD 1.0) for adult resuscitations and 1.7 (SD 0.9) for pediatric resuscitations on a 1-5 Likert scale, with 1 being unprepared. A total of 36.8% of students avoided participating in resuscitations due to lack of training; 98.2%, 91.7%, and 64.2% of students believe that BLS, ACLS, and PALS, respectively, should be included in the medical student curriculum. CONCLUSIONS: As per previous studies that have examined this topic, students feel unprepared to respond to cardiac arrests and resuscitations. They feel that training is needed in their curriculum and would possibly enhance perceived comfort levels and willingness to participate in resuscitations.
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Atitude do Pessoal de Saúde , Educação de Graduação em Medicina , Medicina de Emergência/educação , Cuidados para Prolongar a Vida , Parada Cardíaca/terapia , Humanos , Estados UnidosRESUMO
BACKGROUND: Caustic ingestions are relatively uncommon, but remain a significant source of morbidity. Patients with caustic injury often undergo an urgent EGD, although it is not clear if an EGD is routinely needed in an asymptomatic patient. The study has two primary objectives; 1) to determine the utility of routine EGD in asymptomatic suicidal caustic ingestions; 2) to determine if asymptomatic unintentional acidic ingestions can be managed with observation alone, similar to basic ingestions. METHODS: This retrospective study, which took place at 14 hospitals in three countries evaluated all patients who presented with a caustic ingestion between 2014-2020. The presence of symptoms and esophageal injury, demographic information, pH of ingested substance, reason for the ingestion, and outcome were recorded. RESULTS: 409 patients were identified; 203 (46.9%) were male. The median (IQR) age was 18 (4-31) years; overall range 10 months to 78 years. Suicidal ingestions accounted for 155 (37.9%) of cases. Dysphagia or dysphonia were more likely in those with significant esophageal injury compared to those without (59.3% vs. 12.6% respectively; OR 10.1; 95% CI 4.43-23.1). Among 27 patients with significant esophageal injury, 48% were found in suicidal patients, compared with 51.9% in non-suicidal patients (p = NS). On multivariate regression, there was no difference in the rate of significant esophageal injury among suicidal vs. non suicidal patients (aOR 1.55; p = 0.45, 95% CI 0.45-5.33). Most ingestions involved basic substances (332/409; 81.2%). Unknown or mixed ingestions accounted for 25 (6.11%) of the ingestions. Significant esophageal burns were found in 6/52 (11.5%) of acid ingestions, compared with 21/332 (6.3%) of basic ingestions. Of the 42 cases of acidic ingestions without dysphagia or odynophagia, 2 (4.8%; 0.58-16.1%) had significant esophageal burns, compared with 9 (3.2%; 95% CI 1.4-5.9%) of the 284 basic ingestions; p = 0.64). On multivariate logistic regression, patients with acidic ingestions were not more likely to experience a significant burn (aOR 1.7; p = 0.11, 95% CI 0.9-3.1) compared to those with basic ingestions. No patient with significant esophageal burns was asymptomatic. CONCLUSION: In this study, there was no statistical differences in the rates of significant burns between acidic and basic caustic ingestions. There were no significant esophageal injuries noted among asymptomatic patients.
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Queimaduras Químicas , Cáusticos , Humanos , Masculino , Feminino , Cáusticos/intoxicação , Cáusticos/toxicidade , Estudos Retrospectivos , Adulto , Queimaduras Químicas/terapia , Pessoa de Meia-Idade , Adulto Jovem , Adolescente , Idoso , Criança , Pré-Escolar , Lactente , Endoscopia do Sistema Digestório , Esôfago/lesões , Esôfago/fisiopatologia , Tentativa de Suicídio/estatística & dados numéricosRESUMO
BACKGROUND: During the opioid epidemic, misuse of acetaminophen-opioid products resulted in supratherapeutic acetaminophen ingestions and cases of hepatotoxicity. In 2014, the US Food and Drug Administration (FDA) limited the amount of acetaminophen in combination products to 325 mg, and the US Drug Enforcement Administration (DEA) changed hydrocodone/acetaminophen from schedule III to schedule II. This study assessed whether these federal mandates were associated with changes in acetaminophen-opioid supratherapeutic ingestions. METHODS: We identified emergency department encounters at our institution of patients with a detectable acetaminophen concentration and manually reviewed these charts. RESULTS: We found a decline in acetaminophen-opioid supratherapeutic ingestions after 2014. A downtrend in hydrocodone/acetaminophen ingestions accompanied a relative increase in codeine/acetaminophen ingestions from 2015 onwards. CONCLUSION: This experience at one large safety net hospital suggests a beneficial impact of the FDA ruling in reducing likely unintentional acetaminophen supratherapeutic ingestions, carrying a risk of hepatotoxicity, in the setting of intentional opioid ingestions.
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Acetaminofen , Doença Hepática Induzida por Substâncias e Drogas , Humanos , Analgésicos Opioides/uso terapêutico , Hidrocodona/uso terapêutico , Doença Hepática Induzida por Substâncias e Drogas/epidemiologia , Doença Hepática Induzida por Substâncias e Drogas/etiologia , Doença Hepática Induzida por Substâncias e Drogas/tratamento farmacológicoRESUMO
BACKGROUND: Despite conflicting data, intravenous lipid emulsion has emerged as a potential antidote. The "lipid sink" theory suggests that following intravenous administration of lipid, lipophilic drugs are sequestered in the vascular compartment, thereby reducing their tissue concentrations. This study sought to determine if survival is associated with the intoxicant's degree of lipophilicity. METHODS: We reviewed all cases in the Toxicology Investigators Consortium's lipid sub-registry between May 2012 through December 2018. Information collected included demographics, exposure circumstances, clinical course, management, disposition, and outcome. The primary outcome was survival after lipid emulsion therapy. Survival was stratified by the log of the intoxicant's octanol-water partition coefficient. We also assessed the association between intoxicant lipophilicity and an increase in systolic blood pressure after lipid emulsion administration. RESULTS: We identified 134 patients, including 81 (60.4%) females. The median age was 40 years (interquartile range 21-75). One hundred and eight (80.6%) patients survived, including 45 (33.6%) with cardiac arrest during their intoxication. Eighty-two (61.2%) were hypotensive, and 98 (73.1%) received mechanical ventilation. There was no relationship between survival and the log of the partition coefficient of the intoxicant on linear analysis (P = 0.89) or polynomial model (P = 0.10). Systolic blood pressure increased in both groups. The median (interquartile range) systolic blood pressure before lipid administration was 68 (60-78) mmHg for those intoxicants with a log partition coefficient < 3.6 compared with 89 (76-104) mmHg after lipid administration. Among those drugs with a log partition coefficient > 3.6, the median (interquartile range) was 69 (60-84) mmHg before lipid and 89 (80-96) mmHg after lipid administration. CONCLUSION: Most patients in this cohort survived. Lipophilicity was not correlated with survival or the observed changes in blood pressure. The study did not address the efficacy of lipid emulsion.
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Emulsões Gordurosas Intravenosas , Intoxicação , Adulto , Feminino , Humanos , Masculino , Estado Terminal , Emulsões Gordurosas Intravenosas/uso terapêutico , Estudos Prospectivos , Adulto Jovem , Pessoa de Meia-Idade , Idoso , Intoxicação/terapiaRESUMO
INTRODUCTION: Exposure to single-use detergent sacs (SUDS), or laundry pods, have declined in the pediatric population between 2015 and 2018. Older adult exposures are less well described, and it is unclear if there is an increased risk of unintentional exposure to SUDS in older adults, especially in those with dementia. This study aims to review SUDS exposures in adults greater than 60-year-old between 2012 and 2020. METHODS: Using the National Poison Data System (NPDS), a query was performed for cases involving an acute single substance exposure with substance coded as "laundry detergent unit dose" (Generic code: 0201181, 0201182, and 0201183) in adults greater than 60-years-old between January 1, 2012 and December 31, 2020. Exclusion criteria included unknown age, age less than 60 years, any multi-substance exposure, and chronic or acute-on-chronic acuity. The distribution of cases was analyzed for demographics, exposure circumstances, management, clinical effects, and medical outcome. RESULTS: SUDS exposure reported to NPDS increased from 46 cases in 2012 to 219 cases in 2020. Among the 1289 total reported cases, 94.9% (n = 1223) were unintentional exposures with an average age of 75-year-old. The majority of exposures occurred in females (69%, n = 883). More than 1 exposure route was reported in 90 cases (7%), and the most common route of exposure was ingestion (64.9%, n = 836). Major effects were identified in 1% (n = 13) of exposures, and 0.5% (n = 7) of cases resulted in death. CONCLUSIONS: Despite a declining incidence of pediatric SUDS exposure, older adult exposures have increased over 400% between 2012 and 2020.
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Detergentes , Venenos , Idoso , Criança , Feminino , Humanos , Incidência , Pessoa de Meia-Idade , Centros de Controle de IntoxicaçõesAssuntos
Hiperamonemia/diagnóstico , Hiperamonemia/etiologia , Metanol/intoxicação , Adolescente , Diagnóstico Diferencial , Diagnóstico por Imagem , Oxigenação por Membrana Extracorpórea , Evolução Fatal , Feminino , Escala de Coma de Glasgow , Humanos , Hiperamonemia/terapia , Terapia de Substituição Renal , SuicídioRESUMO
INTRODUCTION: Anaphylactoid reactions are well-documented adverse events associated with the intravenous administration of N-acetylcysteine (NAC) in patients with acetaminophen overdose. Most reactions are mild, occurring within the first 1-5 hours of initiation. This report presents the case of an adolescent with a delayed, life-threatening anaphylactoid reaction 24.5 hours after starting NAC, where discontinuing NAC could have resulted in fulminant hepatic failure (FHF) and death. CASE REPORT: A 17-year-old previously healthy female presented with nausea, vomiting, and abdominal pain 10 hours after an acute acetaminophen ingestion. Her 11-hour serum acetaminophen concentration was above the treatment line (149 µg/mL), and she had elevated transaminases (AST = 202 U/L, ALT = 284 U/L). She was treated with intravenous NAC, which was suspended for 3 hours after she developed an apparent life-threatening anaphylactoid reaction with angioedema and respiratory distress 24.5 hours after treatment initiation. Given her high risk of progression to FHF, NAC was resumed at double the previous rate along with scheduled corticosteroids and antihistamines after resolution of her symptoms. Her AST increased to 10,927 U/L, and INR peaked at 3.6, but she had no further anaphylactoid symptoms. She was discharged in her normal state of health after 6 days. DISCUSSION: Discontinuing NAC in this case of severe, delayed anaphylactoid reaction could have resulted in FHF requiring liver transplant. The reason for her reaction is unclear but could be related to patient risk factors or medication error. Guidelines for reinitiation of NAC after development of delayed anaphylactoid reactions are not well-established. Close observation beyond the first 1-5 hours of NAC administration is warranted.
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Acetaminofen/intoxicação , Acetilcisteína/efeitos adversos , Analgésicos não Narcóticos/intoxicação , Anafilaxia/induzido quimicamente , Antídotos/efeitos adversos , Hipersensibilidade a Drogas/etiologia , Overdose de Drogas/tratamento farmacológico , Acetilcisteína/administração & dosagem , Adolescente , Corticosteroides/uso terapêutico , Anafilaxia/diagnóstico , Anafilaxia/tratamento farmacológico , Antídotos/administração & dosagem , Hipersensibilidade a Drogas/diagnóstico , Hipersensibilidade a Drogas/tratamento farmacológico , Overdose de Drogas/diagnóstico , Feminino , Antagonistas dos Receptores Histamínicos/uso terapêutico , Humanos , Infusões Intravenosas , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do TratamentoRESUMO
Since August 2019, the pulmonary disease termed e-cigarette or vaping product-use associated lung injury (EVALI), has resulted in 2758 hospitalizations and 64 deaths in the United States. EVALI is considered in patients who have vaped or dabbed within 90 days of symptom onset, and have abnormal lung imaging in the absence of any pulmonary infection. The majority of EVALI patients are otherwise healthy adolescents and young adults. The leading etiology of EVALI is contamination of delta-9-tetrahydrocannabinoid (THC) e-liquids with vitamin E acetate. Although the exact pathophysiology of vitamin E acetate-induced lung injury is unknown, vitamin E acetate may lead to pulmonary lipid accumulation and/or interfere with surfactant functioning. EVALI symptoms are vague but consist of a constellation of constitutional, pulmonary, and gastrointestinal symptoms. Patients often present multiple times to healthcare facilities as their clinical condition worsens with a considerable mortality risk. The diagnosis of EVALI hinges on obtaining history leading to the recognition of vaping/dabbing. Physicians need to be persistent, but nonjudgmental, in obtaining vaping histories, especially in THC-prohibited states. Radiographical findings of nonspecific bilateral ground-glass infiltrates are best detected on computed tomography. Management for EVALI requires a multidisciplinary approach focused on supportive respiratory care and ruling-out infectious causes. Corticosteroids may be of benefit. Most patients who are hypoxic, have comorbidities, or lack appropriate follow-up within 24-48 hours should be admitted for monitoring. Patients may benefit from substance abuse counseling and should be instructed to avoid vaping. As the outbreak continues, cases should be reported to local health departments and poison control centers.
RESUMO
Electronic cigarettes (e-cigarettes) are battery-operated devices to insufflate nicotine or other psychoactive e-liquid aerosols. Despite initial claims of e-cigarettes as a nicotine-cessation device, aggressive marketing of e-cigarettes has led to an explosion in adolescents' and young adults' use over the last few years. Coupled with a lack of adequate investigation and regulation of e-cigarettes, the USA is facing an outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) starting in mid-2019. While little long-term health hazard data are available, the components and constituents of e-cigarettes may adversely impact health. Propylene glycol and glycerin are humectants (water-retaining excipients) that generate pulmonary irritants and carcinogenic carbonyl compounds (e.g., formaldehyde, acetaldehyde, and acrolein) when heated in e-cigarettes. Metals contained in heating coils and cartridge casings may leach metals such as aluminum, chromium, iron, lead, manganese, nickel, and tin. Flavoring agents are considered safe for ingestion but lack safety data for inhalational exposures. Diacetyl, a common buttery flavoring agent, has known pulmonary toxicity with inhalational exposures leading to bronchiolitis obliterans. In 2019, clusters of lung injury associated with e-cigarette use were identified in Wisconsin and Illinois. Patients with EVALI present with a constellation of respiratory, gastrointestinal, and constitutional symptoms. Radiographically, patients have bilateral ground glass opacifications. As of February 18, 2020, the Centers for Disease Control has identified 2807 hospitalized patients diagnosed with either "confirmed" or "probable" EVALI in the US. Currently, vitamin E acetate (VEA) used as a diluent in tetrahydrocannabinol vape cartridges is implicated in EVALI. VEA cuts tetrahydrocannabinol oil without changing the appearance or viscosity. When inhaled, pulmonary tissue lacks the mechanism to metabolize and absorb VEA, which may lead to its accumulation. While most EVALI patients were hospitalized, treatment remains largely supportive, and use of corticosteroids has been associated with clinical improvement. The outbreak of EVALI highlights the need for regulation of e-cigarette devices and e-liquids. Clinicians need to be aware of the health hazards of e-cigarettes and be vigilant in asking about vaping.
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Vapor do Cigarro Eletrônico/efeitos adversos , Sistemas Eletrônicos de Liberação de Nicotina , Exposição por Inalação/efeitos adversos , Lesão Pulmonar/epidemiologia , Vaping/efeitos adversos , Adolescente , Adulto , Feminino , Humanos , Lesão Pulmonar/diagnóstico , Lesão Pulmonar/terapia , Masculino , Prognóstico , Medição de Risco , Fatores de Risco , Fatores de Tempo , Vaping/epidemiologia , Adulto JovemRESUMO
BACKGROUND: In the United States in 2019, there was an outbreak of electronic cigarette, or vaping, product use-associated lung injury (EVALI). The manifestations of EVALI in adolescents are not well characterized. We describe the diagnosis, evaluation, and management of EVALI in adolescents hospitalized at a tertiary care, university-affiliated children's hospital. METHODS: A multidisciplinary committee developed an EVALI algorithm on the basis of guidelines from the Centers for Disease Control and Prevention. A retrospective chart review was conducted on patients diagnosed with EVALI. Descriptive analyses included sociodemographic characteristics, clinical presentation, laboratory and imaging results, pulmonary function testing, oxygen requirements, and clinic follow-up. RESULTS: Thirteen hospitalized adolescents were diagnosed with confirmed or probable EVALI. The majority were female (54%) with a mean age of 15.9 years. Sixty-nine percent of patients presented with respiratory symptoms, whereas gastrointestinal symptoms were prominent in 85% of patients. Vaping Δ-9-tetrahydrocannabinol was reported in 92% of patients, and vaping nicotine was reported in 62% of patients. All had bilateral ground-glass opacities on the chest computed tomography (CT) scan. Treatment with glucocorticoids led to clinical improvement in 11 of 12 patients. Treatment with glucocorticoids led to improvement in both forced expiratory volume in 1 second and forced vital capacity (P < .05). Four patients required home oxygen on the basis of 6-minute walk test results. CONCLUSIONS: Diagnosis of EVALI should be suspected on the basis of vaping history and clinical presentation. Glucocorticoid treatment led to an improvement in symptoms and lung function. The 6-minute walk test may help determine oxygen needs at discharge.
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Sistemas Eletrônicos de Liberação de Nicotina , Lesão Pulmonar/epidemiologia , Lesão Pulmonar/etiologia , Vaping/efeitos adversos , Vaping/epidemiologia , Adolescente , Feminino , Humanos , Lesão Pulmonar/diagnóstico , Lesão Pulmonar/terapia , Masculino , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
CASE DETAILS: A 51-year-old man presented with rapid onset encephalopathy and respiratory failure after a suspected intravascular envenomation from a North American pit viper. The patient received antivenom and was transferred to a tertiary care facility where he had cardiovascular collapse and persistent coagulopathy requiring 28 vials of Crotalidae polyvalent immune Fab antivenom for initial control and six vials for maintenance. The patient's coagulopathy was monitored using "traditional" measures (platelets, fibrinogen, and prothrombin time/international normalized ratio) and rotational thromboelastometry (ROTEM®). The patient also subsequently developed intestinal necrosis requiring exploratory laparotomy with ileum and colonic resections, and anuric renal failure requiring continuous renal replacement therapy. After coordinated multidisciplinary management, he was discharged to an acute inpatient rehabilitation on hospital day 25 and has since made a full recovery. DISCUSSION: In the setting of a severe intravascular pit viper envenomation, thromboelastometry correlated well with "traditional" measures. During recovery, ROTEM® demonstrated measurable improvements in the extrinsic coagulation pathway while the INR remained between 1.5 and 1.6. Patient's intestinal necrosis may have resulted from microvascular thrombosis due to Crotalinae venom. The patient's ultimate recovery necessitated a coordinated multidisciplinary effort. ROTEM® abnormalities after North American pit viper envenomation may be more sensitive than "traditional" measures and may have prognostic value to determine the severity of envenomation, but further research to define its utility is required.
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Antivenenos/uso terapêutico , Transtornos da Coagulação Sanguínea/etiologia , Transtornos da Coagulação Sanguínea/patologia , Venenos de Crotalídeos/toxicidade , Fragmentos Fab das Imunoglobulinas/uso terapêutico , Mordeduras de Serpentes/patologia , Tromboelastografia , Animais , Doenças do Colo/patologia , Doenças do Colo/cirurgia , Crotalinae , Humanos , Masculino , Necrose , Mordeduras de Serpentes/tratamento farmacológico , TexasRESUMO
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, ß-adrenergic receptor antagonists (also known as ß-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
Assuntos
Humanos , Reanimação Cardiopulmonar , Suporte Vital Cardíaco Avançado/normas , Overdose de Drogas/complicações , Intoxicação/complicações , Parada Cardíaca/terapia , Antídotos/uso terapêuticoRESUMO
Prostanoid synthesis in mammalian tissues is regulated at the level of prostaglandin H synthase (PGHS) cyclooxygenase catalysis by the availability and structure of substrate fatty acid and the availability of peroxide activator. Two major PGHS isoforms, with distinct pathophysiological functions and catalytic regulation, have been characterized in mammals; a functionally homologous PGHS isoform pair has been cloned from an evolutionarily distant vertebrate, brook trout. The cyclooxygenase activities of recombinant brook trout PGHS-1 and -2 were characterized to test the generality of mammalian regulatory paradigms for substrate specificity, peroxide activation, and product shifting by aspirin. Both trout cyclooxygenases had much more restrictive substrate specificities than their mammalian counterparts, with pronounced discrimination toward arachidonate (20:4n-6) and against eicosapentaenoate (20:5n-3) and docosahexaenoate (22:6n-3), the latter two prominent in trout tissue lipids. Aspirin treatment did not increase lipoxygenase-type catalysis by either trout enzyme. Both trout enzymes had higher requirements for peroxide activator than their mammalian counterparts, though the preferential peroxide activation of PGHS-2 over PGHS-1 seen in mammals was conserved in the fish enzymes. The divergence in cyclooxygenase characteristics between the trout and mammalian PGHS proteins may reflect accomodations to differences among vertebrates in tissue lipid composition and general redox state.
Assuntos
Ácido Araquidônico/metabolismo , Ciclo-Oxigenase 1/metabolismo , Ciclo-Oxigenase 2/metabolismo , Proteínas de Peixes/metabolismo , Peróxidos/metabolismo , Animais , Ácido Araquidônico/química , Aspirina/farmacologia , Inibidores de Ciclo-Oxigenase/farmacologia , Cromatografia Gasosa-Espectrometria de Massas , Humanos , Masculino , Ovinos , Especificidade da Espécie , Especificidade por Substrato , Temperatura , Truta/metabolismoRESUMO
CONTEXT: The use of marijuana and cannabis concentrates is increasing, especially following decriminalization in several states. Psychosis and cardiotoxicity have been reported following cannabis use; however, myocardial injury from "dabbing" has not yet been reported. We report a case of hyperthermia, tachycardia, hypertension, severe agitation, neuro-, and cardiotoxicity following the use of "dabs" where there is concomitant confirmatory biological and sample testing. CASE DETAILS: A 17-year-old athletic man developed agitation requiring sedation and intubation for safety, with peak systolic blood pressures in the 190s and hyperthermia (to 102 °F). He developed elevated serum troponins with persistent tachycardia despite sedation and no clear non-intoxicant etiology. It was discovered that the patient had recently been "dabbing"; an exhaustive search of his home found a sample of the "dabs" which was analyzed along with a comprehensive urine drug screen by tandem liquid mass spectroscopy (t-LCMS) for confirmation. DISCUSSION: Tetrahydrocannabinol (THC) has been increasingly associated with agitation and cardiotoxicity, while cannabidiol (CBD) has been associated with neuroprotective, inhibitory states. We propose that increasing concentrations of THC as well as THC:CBD ratios seen in cannabis concentrates such as "dabs" may cause agitation and end-organ damage through sympathomimetic and serotonergic pathways.