Prehospital Intranasal Glucagon for Hypoglycemia.

BACKGROUND: Prehospital hypoglycemia is usually treated with oral or intravenous (IV) dextrose in a variety of concentrations. In the absence of vascular access, intramuscular (IM) glucagon is commonly administered. Occupational needle-stick injury remains a significant risk while attempting to obtain vascular access or administer medications intramuscularly in the prehospital setting. We sought to determine if intranasal (IN) glucagon is effective in the prehospital treatment of hypoglycemia. METHODS: We performed a retrospective analysis of all consecutive cases where recombinant glucagon was administered IN by paramedics from January 1, 2015 through December 31, 2020. Excluded were cases without pre or post administration blood glucose documentation, and cases where another form of treatment for hypoglycemia was administered at any time during the EMS encounter. The primary outcome was clinical response to IN glucagon documented by paramedics; secondary outcomes included pre and post administration blood glucose values. RESULTS: Out of 44 cases that met study inclusion criteria, 14 patients (32%) had substantial improvement, 13 patients (30%) had slight improvement, and 17 patients (38%) had no improvement in mental status after administration of IN glucagon. In cases with substantial improvement (n = 14), the mean pre administration blood glucose was 33.8 mg/dl and the mean post administration blood glucose was 87.1 mg/dl (mean increase 53.3 mg/dl, 95% CI: 21.5 to 85.1). In cases with slight improvement (n = 13), the mean pre administration blood glucose was 23.9 mg/dl and the mean post administration blood glucose was 53.8 mg/dl (mean increase 29.9 mg/dl, 95% CI = 2.9 to 56.9). In case with no improvement (n = 17) the mean pre administration blood glucose was 30.1 mg/dl and the mean post administration glucose was 33.1 mg/dl (mean difference 3.1 mg/dl, 95% CI: -10.1 to 3.9). CONCLUSION: Intranasal administration of recombinant glucagon for hypoglycemia resulted in a clinically significant improvement in mental status and a corresponding increase in blood glucose levels in select cases in the prehospital setting.

Acupuncture is a feasible alternative to procedural sedation for shoulder reduction in the emergency department.

Treating shoulder dislocations is common in the emergency department and often requires procedural sedation. The use of acupuncture for treatment of chronic pain has been shown to be successful in various outpatient settings, and some EDs have recently incorporated acupuncture as an analgesia adjunct for chronic painful conditions to avoid opioid therapy. Limited data describe acupuncture to facilitate ED procedures. Here we present two cases of acute shoulder dislocation that were successfully treated with acupuncture as an alternative to parenteral pharmacologic procedural sedation. A 50 year old male sustained an anterior shoulder dislocation after an altercation, and a 59 year old female sustained an anterior dislocation after a fall. Instead of using conventional pharmacologic sedation and analgesia during shoulder reduction, both were treated with acupuncture in the ED. Reduction in both cases was rapid, safe, and avoided use of any parenteral medications, procedural sedation monitoring, or prolonged nurse observation. Using acupuncture as alternative to opioids for ED procedures deserves future study for orthopedic and other common ED procedures.

The Beef Jerky Blues: Methemoglobinemia From Home Cured Meat.

Methemoglobinemia can result from ingestion of nitrite- or nitrate-containing foods. Here, we report a case where an adolescent girl and her father developed clinically significant methemoglobinemia after ingestion of "homemade" beef jerky prepared with sodium nitrate salt purchased at a local grocery store. Both had palpitations, dyspnea, and visible mucosal cyanosis. The daughter had a methemoglobin level of 44.2% and the father's methemoglobin level was 34.2%. Prompt recognition of methemoglobinemia is important for initiating antidotal therapy with methylene blue.

Haloperidol, a Novel Treatment for Cannabinoid Hyperemesis Syndrome.

Cannabinoid hyperemesis syndrome (CHS) is typically unresponsive to conventional pharmacologic antiemetics, and patients often require excessive laboratory and radiographic testing and hospital admission. We report 4 cases of CHS that failed standard emergency department therapy but improved significantly after treatment with haloperidol. Although the exact mechanism for CHS remains unclear, dysregulation at cannabinoid type 1 seems to play a role. Recent animal data demonstrate complex interactions between dopamine and cannabinoid type 1 signaling, a potential mechanism for haloperidol success in patients with CHS. Our success with haloperidol in these 4 patients warrants further investigation of haloperidol as an emergency department treatment for CHS.

Comparison of High-Fidelity Medical Simulation to Short-Answer Written Examination in the Assessment of Emergency Medicine Residents in Medical Toxicology.

We compared high-fidelity medical simulation to short-answer written examination in the assessment of emergency medicine residents (EMR) on a month-long medical toxicology rotation. Knowledge-based assessment tools using cases of an aspirin overdose and a tricyclic antidepressant overdose were used to assess all consecutive rotating EMR (n=53). Assessment by simulation had similar accuracy and precision but higher satisfaction rates when compared to written examination. Incorporating simulation into the ABEM certifying examination warrants further study.

Characteristics of heroin-dependent patients seeking asthma care in the ED.

BACKGROUND: Limited data suggest that heroin worsens asthma severity, but little is known about heroin-dependent patients who seek emergency department (ED) care for asthma. OBJECTIVES: To describe what heroin-dependent patients know about their asthma and how they use health care resources. METHODS: A prospective study of heroin-dependent patients seeking care for "asthma" at an urban ED with 130000 annual visits was conducted. Eligible subjects were English-speaking heroin-dependent adults seeking care for mild to moderate asthma symptoms. A closed-format survey instrument to assess opioid use, asthma knowledge, and health care use was developed by content experts, piloted for study performance, revised, and then administered to eligible patients prior to ED discharge. Descriptive analysis was done. RESULTS: Thirty subjects participated. Mean age was 47.5 years; 21 (70%) were male. Most used heroin several times weekly. Intranasal was the most common route (93%). Almost half (47%) stated that their asthma was diagnosed in the ED, 13% by a primary care physician, 13% by a lung specialist, and 27% did not know how diagnosed. The ED was used as the primary source for asthma medications in 73% cases; 43% used the ED for breathing issues at least once per month. Most subjects (77%) felt that heroin worsened their asthma symptoms. Only 7 (23%) also abused prescription opioids, and only 7 (23%) knew about prescription naloxone. CONCLUSION: Patients with heroin dependence frequently use the ED for their health care needs related to asthma. Most do not have other health care providers, most have limited health literacy, and all would benefit from referral to a primary care provider and substance abuse resources.

A senior scholars forum can enhance the scholarship process.

BACKGROUND: The purpose of our study was to evaluate the educational value of an annual Senior Scholars Forum (SSF) of graduating Emergency Medicine resident participants and attendees. DESCRIPTION: This study was conducted at an urban academic medical center with a PGY1-4 year residency program. After completion of the 2nd annual SSF, a web-based survey instrument was sent to all resident and faculty attendees. The instrument was a 3-part tool adapted from previous studies on postgraduate scholarship. Data were analyzed using descriptive statistics. EVALUATION: Forty-two of the 44 (95%) attendees completed the survey, including 100% of the PGY4 resident presenters. Prior to the SSF, 52% of respondents did not have a full understanding of senior scholarly activities. After the SSF, 67% reported an improved understanding and 88% had a better understanding of the scope of potential scholarly projects. Sixty-four percent reported the SSF introduced them to departmental resources available for completion of their own scholarly projects, and 69% would have liked to have heard the lessons communicated earlier in residency. Most (79%) agreed the SSF demonstrated the value of communal scholarly activities. Most senior residents (67%) felt most of the department would not know about their scholarship if they had not participated in the SSF. CONCLUSIONS: Our innovative SSF enhanced the scholarship process by allowing graduating senior residents an opportunity to share their scholarly productivity with a larger audience, provided attendees critical insights into the process of scholarship, and encouraged communal learning. Because the Accreditation Council for Graduate Medical Education and Residency Review Committee require all residents to participate in scholarly activity, other training programs may benefit from a similar educational experience.

Use of Registries and Large Databases for Toxicology Research.

The advancement of medical toxicology knowledge has traditionally relied on case reports and case series because of the ethical challenges involved in studying poisoned patients. The growing availability of several large databases and registries now allows researchers to describe and analyze patterns in poisoned patients who share a particular exposure, outcome, or condition. A large database or registry can be useful in generating hypotheses, supporting extramural funding applications, and planning more rigorous studies. Knowing how to access and interpret data in registries such as NPDS, NHAMCS, and HCUP is essential for all stakeholders engaged in medical toxicology research. This review describes the strengths and limitations of different toxicology-relevant registries and databases and how to leverage these powerful tools to advance the science in the field of medical toxicology.

Acetaminophen overdose: analysis of 2018 US nationwide emergency database.

INTRODUCTION: Recognized risk factors for acetaminophen overdose include alcohol, opioids, and mood disorders. The aim of this study is to assess additional risk factors for acetaminophen overdose evaluated in the emergency department (ED). METHODS: A retrospective study was performed using the 2018 US Nationwide Emergency Department Sample (NEDS). All adult ED visits for acetaminophen overdose were included in the study group and those without it were taken as control. STATA, 16.1 was used to perform multivariable logistic regression analysis and adjusted odds ratios (ORadj) were reported. RESULTS: We identified 27,792 ED visits for acetaminophen overdose. Relative to non-acetaminophen ED visits, this group was younger (median age 32 vs 47 years; p < 0.0001), more often female (66.1% vs 57.0%; p < 0.0001), had higher ED charges ($3,506 vs $2,714; p < 0.0001), higher proportion of alcohol-related disorders (15.8% vs 3.5%; p < 0.0001), anxiety disorders (30.2% vs 8.3%; p < 0.0001), cannabis use (8.7% vs 1.4%; p < 0.0001), hematology/oncology diagnoses (13.3% vs 10.9%; p < 0.0001), mood disorders (52.4% vs 7.9%; p < 0.0001), opioid-related disorders (4.1% vs 1.0%; p < 0.0001), and suicide attempt/ideation (12.2% vs 1.1%; p < 0.0001). Multivariable analysis showed alcohol-related disorders (ORadj 2.67), anxiety disorders (ORadj 1.24), cannabis (ORadj 1.63), females (ORadj 1.45), Income Q3 (ORadj 1.09), hematology/oncology diagnoses (ORadj 1.40), mood disorders (ORadj 10.07), opioid-related disorders (ORadj 1.20), and suicide attempt/ideation (ORadj 1.68) were associated with acetaminophen overdose. CONCLUSION: In addition to previously recognized risks, our study demonstrated that cannabis use and hematologic/oncologic comorbidities were more common among acetaminophen-overdose ED visits. These new findings are concerning because of rapid legalization of cannabis and the increasing incidence of cancer worldwide. Additional investigation into these risks should be a priority for clinicians, policymakers, and researchers.

The American College of Medical Toxicology Annual Scientific Meeting: A Look Back and the Path Forward.

More than 20 years that have elapsed since the inaugural American College of Medical Toxicology Spring Conference in 2002. During this time, the now ACMT Annual Scientific Meeting has grown in many ways, as demonstrated by the increase in attendance and abstract submissions, and diversification of educational offerings, and partners. Most importantly, the scientific rigor and presentation of new knowledge has continued to mature, and the conference is now firmly rooted in the annual educational schedule for medical toxicologists. In anticipation of the upcoming 2025 ASM, we reflect upon the evolution and growth of ACMT's research and educational agendas, and the Annual Scientific Meeting itself.

American College of Medical Toxicology Research Agenda 2024-2030.

ACMT recognizes the pivotal role of high-quality research in advancing medical science. As such, the establishment of a formal research agenda for ACMT is a leap forward in communicating the priorities of the College, its members, and the patient populations we serve. This thoughtfully crafted agenda will serve as a strategic compass for ACMT, guiding our pursuit of scientific discovery, fostering innovation, and enhancing outcomes for patients and communities affected by poisonings and exposures.

Direct comparison of 20-hour IV, 36-hour oral, and 72-hour oral acetylcysteine for treatment of acute acetaminophen poisoning.

There is no general consensus among clinicians on the superior route or duration of treatment with N-acetylcysteine (NAC) for acute acetaminophen (APAP) poisoning, and head-to-head studies comparing intravenous (IV) and oral NAC have not been done. Recent 20-hour IV NAC protocol failures in the United States prompted some to question its safety. Our objective was to determine if treatment with the 20-hour IV NAC protocol results in clinical outcomes different from the longer 36-hour oral or 72-hour oral NAC protocols in cases of acute APAP poisoning. We performed a retrospective analysis of all consecutive cases of acute APAP overdose where NAC treatment was initiated within 8 hours of ingestion between January 1, 2002, and December 31, 2007. Outcomes were survival, transplant, and death; secondary outcomes were based on King's College Criteria; interrater reliability was calculated with a kappa score. Out of 4642 cases of APAP overdose, 795 met study inclusion criteria: 213 were treated with 20-hour IV protocol, 213 with the 36-hour oral protocol, and 369 with the 72-hour oral protocol. The mean age in these groups was 25 years [95% confidence interval (CI): 22-26], 26 years (95%CI: 23-29), and 27 years (95%CI: 25-28), respectively. The mean 4-hour APAP concentration was 199 µg/mL (95%CI: 188-211), 174 µg/mL (95%CI: 164-184), and 205 µg/mL (95%CI: 195-216), respectively. No cases of transplant or death occurred, and secondary outcomes were rare. When administered within 8 hours of acute APAP poisoning, the 20-hour IV treatment protocol was as effective as the longer 36-hour oral and 72-hour oral treatment protocols. Further study is needed to determine outcome differences between IV and oral NAC when treatment is initiated >8 hours after overdose or in cases of coingestion with other drugs.