PROTOCOL FOR HUMAN EXPOSURE TO OPIOIDS AND CONCENTRATED MEDETOMIDINE USED IN FIELD APPLICATIONS.

Wildlife professionals routinely use potent sedatives and anesthetics when chemically immobilizing wildlife and zoo species in remote environments. Accidental exposure to these prescription veterinary drugs is rare but could be rapidly fatal. Commonly used agents include opioids and α2 adrenoreceptor agonists. These drugs can be reversed with specific antagonists; however, they are often not approved for human use. The protocol created here can be used by wildlife health professionals in a field setting with basic human emergency medical response training in coordination with local Emergency Medical Services (EMS). Key components include, building local relationships between EMS and wildlife professionals, focused EMS training, administering opioid and α2 adrenergic antagonists off label, and local evacuation procedures. This framework could allow wildlife management agencies or zoos to mitigate the risk of human exposures to these commonly used drugs, significantly improving occupational safety in an otherwise high-risk environment.

Physician assistant utilization in U.S. emergency departments; 2010 to 2017.

BACKGROUND: Physician Assistants (PAs) are widely used in United States (US) Emergency Departments (EDs). We sought to characterize ED PA utilization and practice characteristics in US EDs 2010-2017. METHODS: A retrospective, secondary analysis of the 2010 to 2017 Center for Disease Control's National Hospital Ambulatory Medical Care Survey (NHAMCS) was performed. National estimates of ED visits involving PAs alone (PA), PAs with physician involvement (PA+), or physician only (PHYS) were analyzed for patient demographics and hospital characteristics. RESULTS: Between 2010 and 2017, an estimated 1 billion US ED visits occurred. 5.0% (95% confidence interval [CI] ±2.7%) of visits were seen by a PA, and 8.2% (±2.7%) by a PA+; 76.3% (±7.2%) by PHYS. No linear trends by year were identified in PA or PA+ visits. PA acuity was highest for semi-urgent/nonurgent (56.4%, ±10.7%). PA see the minority of ambulance arrival [5.8% (±1.3)] and admit less patients [1.7% (±0.7%)]. Less laboratory [53.3% (±10.2%) vs. 67.0% (±6.2%)] and radiographic [38.8% (±6.6%) vs. 51.6% (±4.6%) studies were performed during PA vs. PHYS visits. PA visits were most common for patients 25-44 years old (yo) (32.9%, ±6.2%) and 15-24 yo (19.2%, ±3.7%). Most PA visits result in a length of stay (LOS) between 1 and 1.9 h (32.9%, ±6.7%) compared to most PHYS visits resulting in a LOS >3 h (40.3%, ±3%). CONCLUSIONS: From 2010 to 2017, no linear trends in US ED PA and PA+ utilization were identified. PHYS continue to see the majority of ED patients.

Clinical Utility of Carnett and closed eye sign in emergency department.

BACKGROUND: Carnett's sign (CAR) and Closed Eye sign (CE) have been suggested for use in the emergency department setting in the management of abdominal pain. The present study sought to determine the sensitivity/specificity of CAR and CE for pathological CT findings as a primary outcome and for subsequent hospital admission or surgical intervention as secondary outcomes in a community emergency department setting. METHODS: A convenience sample of adults (≥18 y) presenting with acute (<48 h) nontraumatic and non-postoperative abdominal pain determined by treating provider to warrant CT imaging were eligible for enrollment. Treating providers completed a datasheet describing physical examination findings prior to CT imaging. RESULTS: 320 patients were enrolled. 245/320 (76.5%) of enrolled patients had findings on CT Imaging. CAR+ was recorded in 145 and CAR- in 175 patients. CE+ was in 187 and CAR- in 133 patients. Sensitivity and specificity of CAR- for hospital admission was 42.2% and 38.9% and for surgery-44.8% and 43.1%. Sensitivity and specificity of CE- for hospital admission was 28% and 51.6% and for surgery-25.9% and 55%. CAR+ patients were more likely to be admitted or undergo surgery as compared to CAR-. CE+ patients were more likely to be admitted or undergo surgery as compared to CAR-. There were no differences in frequency of pathological CT findings between CAR+ and CAR- or CE+ and CE- patients. CONCLUSION: CAR and CE are neither sufficiently sensitive nor specific for use in the emergency department setting. CT findings were equally likely in CAR+ and CAR- patients. CT Findings were also equally likely in CE+ and CE- patients.

Physician assistant and nurse practitioner utilization in U.S. emergency departments, 2010 to 2017.

BACKGROUND: Physician Assistants (PAs) and Nurse Practitioners (NPs) are widely utilized in United States (US) Emergency Departments(EDs). We sought to characterize ED PA and NP utilization and practice characteristics in US EDs 2010-2017. METHODS: A retrospective, secondary analysis of the Center for Disease Control's National Hospital Ambulatory Medical Care Survey was performed. National estimates of ED visits involving PAs/NPs alone (PA/NP), PAs/NPs with physician involvement (PA/NP+), or physician only (PHYS) were analyzed for patient demographics and hospital characteristics. RESULTS: Between 2010 and 2017, 1 billion US ED visits occurred. 8.4% (±4.2%) of visits were seen by a PA/NP, and 11.8% (±4.5%) by a PA/NP+; 76.3% (±7.2%) by PHYS. There was an increase in utilization by PA/NP observed in 2016. PA/NP acuity was highest for semi-urgent/nonurgent (53.2%, ±8.6%). PA/NP see the minority of ambulance arrivals [5.4% (±1.2%)] and admit less patients overall [1.6% (±0.7%)]. Less laboratory [53.6% (±10.0%) vs. 67.0% (±6.2%)] and radiographic [38.0% (±7.0%) vs. 51.6% (±4.6%)] studies were performed during PA/NP only vs. PHYS visits. PA/NP visits were most common for patients 25-44 years old (yo) (31.1%, ±5.5%) and 0-15 yo (23.9%, ±4.7%). Most PA/NP visits result in a length of stay (LOS) between 1 and 1.9 h (33.4%, ±5.7%) compared to most PHYS visits resulting in a LOS greater than 3 h (40.3%, ±3%). CONCLUSIONS: From 2010 to 2015, PA/NP utilization remained stable until an increase in 2016. There was a decrease in 2017. Various PA/NP patient characteristics are significant compared to PHYS. PHYS continue to see most ED patients.

Does the U Stand for Useless? The Urine Drug Screen and Emergency Department Psychiatric Patients.

BACKGROUND: Behavioral emergencies account for a significant portion of emergency department (ED) visits in the United States. Substance abuse is common in this population and may precipitate or exacerbate preexisting psychiatric illness. Contrary to ED policy guidelines, many behavior health centers (BH) require a urine drug screen (UDS) in stable patients prior to transfer. OBJECTIVE: We sought to determine the role of the UDS in ED length of stay (LOS), cost, and charges to patients and inpatient psychiatric care. METHODS: We performed a retrospective chart review of all patients transferred to an in-network BH from September 1-30, 2014. Clinical data were extracted and analyzed from our electronic medical record, including records from both the ED visit and the BH stay. RESULTS: There were 205 patient encounters identified; 89 patients had a UDS performed in the ED and 89% were obtained after the ED medical clearance. LOS were similar between the two groups, however, time to ED departure from time of medical clearance was delayed in the UDS group. BH providers mentioned UDS results < 25% of the time and no confirmatory tests were performed. There was no difference in BH LOS or discharge diagnosis of substance-abuse disorder. Patient charges for UDS over the month totaled $21,093. CONCLUSION: The UDS did not seem to have any significant effect on inpatient psychiatric care; whereas ED LOS and cost were both negatively affected. Based on these results, the UDS seems to be of little-to-no benefit in the setting of acute psychiatric illness.

Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department.

BACKGROUND: Gastroparesis associated nausea, vomiting & abdominal pain (GP N/V/AP) are common presentations to the emergency department (ED). Treatment is often limited to antiemetic, prokinetic, opioid, & nonopioid agents. Haloperidol (HP) has been shown to have analgesic & antiemetic properties. We sought to evaluate HP in the ED as an alternative treatment of GP N/V/AP. METHODS: Using an electronic medical record, 52 patients who presented to the ED w/GP N/V/AP secondary to diabetes mellitus and were treated w/HP were identified. Patients who received HP were compared to themselves w/the most recent previous encounter in which HP was not administered. ED length of stay (LOS), additional antiemetics/prokinetics administered, hospital LOS, and morphine equivalent doses of analgesia (ME) from each visit were recorded. Descriptive statistics, categorical (Chi Square Test or Z-Test for proportion) and continuous (Wilcoxon Signed Rank Test) comparisons were calculated. Statistical significance was considered for two tail p-values less than 0.05. RESULTS: A statistically significant reduction in ME (Median 6.75 [IQR 7.93] v 10.75 [IQR12]: p=0.001) and reduced admissions for GP (5/52 v 14/52: p=0.02) when HP was administered was observed. There were no statistically significant differences in ED or hospital LOS, and additional antiemetics administered between encounters in which HP was administered and not administered. No complications were identified in patients who received HP. CONCLUSIONS: The rate of admission and ME was found to be significantly reduced in patients with GP secondary to diabetes mellitus who received HP. HP may represent an appropriate, effective, and safe alternative to traditional analgesia and antiemetic therapy in the ED management of GP associated N/V/AP.

Nebulized fentanyl vs intravenous morphine for ED patients with acute abdominal pain: a randomized double-blinded, placebo-controlled clinical trial.

OBJECTIVES: Patients with acute abdominal pain commonly present to emergency departments. The safe and effective relief of discomfort is a concern to patients and physicians. Intravenous opioids are the traditional method used to provide pain relief in this setting, but intravenous access is time consuming and not always achievable. Alternative methods of pain control may therefore be necessary for the acute management of painful conditions without adding to the overall physical or psychological discomfort. The purpose of this study was to evaluate the feasibility of nebulized fentanyl (NF) in the alleviation of acute and undifferentiated abdominal pain. We also sought to compare NF with intravenous morphine (IVM) and to assess patient and provider satisfaction with NF. Nebulized fentanyl (2 µg/kg) was compared to IVM (0.1 mg/kg) at 10, 20, 30, and 40 minutes; and patient and physician satisfaction was recorded. The NF group experienced more rapid pain relief and more sustained and clinically significant pain relief over the 40-minute study interval. There were no adverse effects noted in the NF group. Both patient and physician satisfaction scores were higher in the NF group. Fentanyl citrate at a dose of 2 µg/kg through a breath-actuated nebulizer appears to be a feasible and safe alternative to IVM (0.1 mg/kg) in the treatment of acute abdominal pain.

Orbeez: the magic water absorbing bead--risk of pediatric bowel obstruction?

OBJECTIVES: In December 2012, the U.S. Consumer Product Safety Commission recalled the water-absorbing toy WaterBalz after reports of small intestine obstruction after ingestion by children. Orbeez, another water-absorbing bead, remains available and is marketed as a children's toy. We sought to determine the extent to which Orbeez enlarge in various liquid media and the potential risk for bowel obstruction. METHODS: Three Orbeez beads were added to 210 mL of the following liquid media: room temperature tap water, whole milk, simulated gastric fluid, GoLytely (polyethelyelene glycol, 3350 and electrolytes), and vodka (40% ethanol by volume). Diameters before exposure to media were measured using a caliper to the nearest 0.1 mm and again at 1, 2, 4, 6, 12, and 24 hours. Ten beads were then added to the beads already immersed in simulated gastric fluid and water and observed for an additional 72 hours (96 hours total) for clumping or increase in diameter. Clumping was defined as two or more beads remaining persistently adherent to one another despite gentle circular movement (swirling) of the liquid. RESULTS: Growth in each of the media was observed. Growth in simulated gastric fluid was minimal, whereas the beads were observed to be the largest after 24 hours in vodka. Clumping of the beads was not observed to occur. CONCLUSIONS: Orbeez beads enlarge to a different extent in different liquid media. It is unlikely that Orbeez beads would expand to sizes or demonstrate clumping that would be concerning for intestinal obstruction.

Altered mental status due to pruno intoxication.

BACKGROUND: The diagnosis of alcohol intoxication might not be considered in patients coming from locations where access to alcohol is severely restricted or not permitted. OBJECTIVE: We present a case of alcohol intoxication in a patient presenting from a military prison. The patient ingested an alcoholic beverage made in his prison cell with produce stolen from the prison cafeteria. We also discuss potential complications of "prison-brewed" alcoholic beverages. CASE REPORT: A 22-year-old male presented to the emergency department after being found in his cell with a depressed level of consciousness and next to a mouthwash bottle filled with a foul-smelling liquid. Physical examination revealed a heart rate of 111 beats/min, a Glasgow Coma Scale score of 11, no signs of injury or track marks on the skin, and intermittent agitation alternating with somnolence. Laboratory evaluation was significant for a serum ethanol level of 279 mg/dL. After a period of observation, mental status returned to normal and the patient admitted to making "pruno." CONCLUSIONS: Alcohol intoxication might be unexpected or not considered in patients that should have no access to common sources of ethanol. Awareness of methods of novel fermentation, even in incarcerated individuals, can assist in the differential diagnosis of patients presenting with altered mental status.

A review of methylene blue treatment for cardiovascular collapse.

BACKGROUND: Historically, methylene blue (MB) has been used for multiple purposes, including as an antidote for toxin-induced and hereditary methemoglobinemia, ifosfamide-induced encephalopathy, and ackee fruit and cyanide poisoning; as an aniline dye derivative, antimalarial agent, and antidepressant. DISCUSSION: Most recently, the use of MB has been advocated as a potential adjunct in the treatment of shock states. Our article reviews the role of MB in septic shock, anaphylactic shock, and toxin-induced shock. MB is proposed to increase blood pressure in these shock states by interfering with guanylate cyclase activity, and preventing cyclic guanosine monophosphate production and vasodilatation. SUMMARY: MB may be an adjunct in the treatment of septic shock, anaphylactic shock, and toxin-induced shock.

Hemodialysis and extracorporeal removal after pediatric and adolescent poisoning reported to a state poison center.

BACKGROUND: There is currently limited literature regarding the use of hemodialysis after acute pediatric and adolescent poisoning. OBJECTIVE: We sought to characterize the use of hemodialysis (HD) and other extracorporeal removal techniques (ECR) in the treatment of acutely poisoned children and adolescents reported to a state poison control system over a 10-year period. METHODS: After institutional review board approval, a state poison control system database was queried for all cases coded for hemodialysis and other ECR after pediatric and adolescent (0-19 years old) poisoning. We also analyzed National Poison System Data to determine national trends. RESULTS: Ninety patients were reviewed after exclusions for errors in coding or incomplete documentation. HD was the principle method of ECR employed. One case of hemoperfusion and hemofiltration was reported. HD was used, on average, nine times per year. ECR was used predominantly in adolescent patients (age ≥ to 12 years) (84 patients, 93%) for intentional ingestions (82 patients, 91%). Fifteen different toxins were encountered, with salicylates (29 patients) and ethylene glycol (23 patients) most commonly encountered. Ethylene glycol and methanol blood levels were not available before initiation of hemodialysis in all but one case. CONCLUSIONS: All salicylate-poisoned patients who underwent HD demonstrated clinical findings indicative of toxicity even in the absence of elevated levels advocated by some as indication for HD. HD and other ECR are rarely used in the management of pediatric and adolescent poisoning.

Atrial fibrillation with rapid ventricular response resulting from low-voltage electrical injury.

BACKGROUND: Cardiac dysrhythmias after electrical injury have been reported previously, however, atrial fibrillation after low-voltage electrical injury is extremely rare. We present a case of atrial fibrillation with rapid ventricular response resulting from a low-voltage electrical injury. CASE REPORT: A 24-year-old active duty Navy sailor presented to the emergency department after an electrical shock from a 440-V furnace. He experienced severe pain in both hands and a racing sensation in his chest. He denied other symptoms. An electrocardiogram was performed demonstrating atrial fibrillation with a rapid ventricular response (132 beats/min). After analgesia and sedation, synchronized cardioversion (100 J) was performed with complete resolution of cardiac symptoms and restoration of normal sinus rhythm (75 beats/min). Cutaneous wounds were bandaged and the patient was discharged with cardiology follow-up. At follow-up, the patient reported no symptoms and an echocardiogram revealed no structural abnormalities. CONCLUSIONS: Atrial fibrillation in the setting of electrical injury is rarely reported in the published medical literature. In patients without history suggestive of cardiac structural abnormalities, synchronized cardioversion is a potential option for restoration of normal sinus rhythm and resolution of symptoms after electrical injury-induced atrial fibrillation with rapid ventricular response.

Evidence-based treatment of jellyfish stings in North America and Hawaii.

We performed a systematic review of the evidence supporting various treatments for envenomation by jellyfish (cnidarian) and related organisms in North America and Hawaii. Our review produced 19 pertinent primary articles. Current research demonstrates variable response to treatment, often with conflicting results according to species studied, which contributes to considerable confusion about what treatment is warranted and efficacious. Our review suggests that vinegar causes pain exacerbation or nematocyst discharge in the majority of species. Hot water and topical lidocaine appear more widely beneficial in improving pain symptoms and are preferentially recommended. Unfortunately, they may be difficult to obtain at the site of envenomation, such as the beach or diving sites. In these instances, removing the nematocysts and washing the area with saltwater may be considered. If the envenomation is thought to be due to the bluebottle (Physalia), vinegar may be beneficial.

A different challenge with Benadryl: adolescent diphenhydramine ingestions reported to National Poison Database System, 2007-2020.

BACKGROUND: The US Food and Drug Administration released a warning related to potential adverse effects related to intentional misuse or abuse ingestions of diphenhydramine in September 2020. We sought to evaluate adolescent-aged (13-19 y) diphenhydramine ingestions reported to US poison control centers to characterize these exposures, adverse effects, outcomes, and trends in outcomes and reasons for ingestion. METHODS: The US National Poison Database System was queried for all exposures to diphenhydramine between January 1, 2007 and December 31, 2020. RESULTS: 47,644 ingestions were included for analysis. An increase in the number of ingestions, percentage of cases due to an intentional reason for ingestion and suspected suicide was observed. More serious outcomes, cardiac complications, seizures, and deaths were more common following intentional ingestions and specifically suspected suicide over misuse or abuse. CONCLUSIONS: Adolescent ingestions of diphenhydramine increased between 2007 and 2020. More serious outcomes, intentional reasons, and suspected suicide also increased over the study interval. Suspected suicide was associated with cardiac complications, seizures, coma, and death at higher rates than misuse or abuse. While misuse and abuse remain a concern, public health interventions focusing on the risk that diphenhydramine pose as an agent of suicide attempt may be of higher impact.

Comparing Physician Assistant and Nurse Practitioner Practice in U.S. Emergency Departments, 2010-2017.

INTRODUCTION: We sought to compare physician assistant (PA) and nurse practitioner (NP) practice in United States emergency departments (ED) based on ED visits as reported by the National Hospital Ambulatory Medical Care Survey (NHAMCS). METHODS: We performed a retrospective, secondary analysis of the 2010 to 2017 NHAMCS with analysis of ED visits, patient demographics, and hospital characteristics. RESULTS: Between 2010 to 2017, 21.0% (95% confidence interval, [CI] +/-3.1%) of ED visits were seen by either a PA/NP (with and without physician involvement) and 8.6% (+/-2.9%) were seen by PA/NP alone. We identified an increase for NP visits between 2014-2016 and found that PA/NP visits share many of the same characteristics. CONCLUSION: While emergency medicine has predominately been a specialty for PAs, the number of ED visits with NPs has been increasing over the past several years. While there are some differences, PAs/NPs share many similar practice characteristics in the ED.

Respiratory depression following medications for opioid use disorder (MOUD)-approved buprenorphine product oral exposures; National Poison Database System 2003-2019.

BACKGROUND: Medications for opioid use disorder (MOUD) including buprenorphine is recommended for patients with opioid use disorders. We sought to evaluate the frequencies of respiratory depression, intubation, and naloxone administration, and clinical outcomes among patients reported to the National Poison Database System (NPDS) following single-substance and multiple-substance buprenorphine oral exposures. METHODS: NPDS was queried for all MOUD-approved buprenorphine product exposures between 1 January 2003 and 31 December 2019. Data abstracted included year, route, gender, age, site of exposure, management site, medical outcome, recorded "related" respiratory depression ("respiratory rate <10 breaths/min and/or a SpO2 (pulse oximetry)≤90%), reported administration of naloxone and intubation in oral exposure cases followed to known outcome. Concomitant products were also recorded in multiple-substance buprenorphine cases. RESULTS: 27,275 (11,010 multiple and 16,265 single) buprenorphine oral exposures were identified and followed to known outcome. A 65-fold increase in reported cases was reported over the study interval. A steady increase in the frequency of more serious outcomes by year was also observed. Respiratory depression occurred at a frequency of 11.8% (pediatric single-substance), 11.2% (pediatric multiple-substance), 11.3% (adult single-substance), and 11.9% (adult multiple-substance). Among oral exposures of buprenorphine and only one other product, benzodiazepines, opioids, ethanol, and amphetamines were most common. CONCLUSIONS: Oral exposures have increased substantially between 2003 and 2019. More serious outcomes including deaths following oral exposures to buprenorphine have also increased over the same interval for both adult and pediatric patients. Clinically significant rates of respiratory depression in both adult and pediatric patients when taken alone and with additional substances were observed.

Sustained stimulation? Characteristics of modified release and immediate release stimulant exposures reported to the national poison data system.

OBJECTIVE: We sought to examine ADHD modified release (MR) and immediate release (IR) stimulant ingestion exposures reported to the National Poison Data System (NPDS) to characterize the nature of the exposures and the outcomes associated with them. METHODS: The NPDS was queried for all single-substance exposures to MR and IR ADHD preparations between January 1, 2007 and December 31, 2017. MR and IR preparations were identified by a generic code of "amphetamine and related compounds" or "methylphenidate" and specific product name containing XR, CD, ER, LA, and SR. RESULTS: A total of 15,796 MR ingestions and 23,418 IR ingestions were identified and followed to known outcome. The majority of ingestions occurred in male patients and in own residence. More serious outcomes (moderate, major, or death) were more common in adult IR and MR ingestions as compared to pediatric; rates of serious outcome increased with age amongst pediatric ingestions. Unintentional ingestions were more common in both MR and IR pediatric cases while intentional ingestions occurred more frequently in adult cases. Symptoms consistent with a hyperadrenergic state were experienced in adult and pediatric patients for both MR and IR ingestions. Supportive care including benzodiazepine administration was more common in IR than MR ingestions. Decontamination with whole bowel irrigation was infrequent. CONCLUSION: Rates of more serious outcome were similar between IR and MR ADHD stimulant ingestions. More serious outcomes were associated with advancing age and intentional ingestions. Similar rates of agitation, tachycardia, and hypertension were experienced by pediatric IR and MR ingestions while more common in adult IR as compared to MR ingestions. Rates of decontamination with whole bowel irrigation were overall low.