The initial health-system response to the earthquake in Christchurch, New Zealand, in February, 2011.

At 1251 h on Feb 22, 2011, an earthquake struck Christchurch, New Zealand, causing widespread destruction. The only regional acute hospital was compromised but was able to continue to provide care, supported by other hospitals and primary care facilities in the city. 6659 people were injured and 182 died in the initial 24 h. The massive peak ground accelerations, the time of the day, and the collapse of major buildings contributed to injuries, but the proximity of the hospital to the central business district, which was the most affected, and the provision of good medical care based on careful preparation helped reduce mortality and the burden of injury. Lessons learned from the health response to this earthquake include the need for emergency departments to prepare for: patients arriving by unusual means without prehospital care, manual registration and tracking of patients, patient reluctance to come into hospital buildings, complete loss of electrical power, management of the many willing helpers, alternative communication methods, control of the media, and teamwork with clear leadership. Additionally, atypical providers of acute injury care need to be integrated into response plans.

Specialist medical toxicologist consultations provided by the New Zealand National Poisons Centre, 2018-2020.

AIMS: The National Poisons Centre (NPC) provides 24/7 specialist medical toxicologist consultations to healthcare professionals regarding the clinical management of poisoning cases. The use of toxicologist services was investigated to characterise the extent and content of consults to inform further development of this service. METHODS: A retrospective analysis of 2018-2020 medical toxicologist consultations summarised contact numbers, professional backgrounds and district health boards (DHBs) of the people contacting the NPC, and the patient(s) and substance(s) involved. RESULTS: There were 3,451 medical toxicologist consultations with 2,400 (67%) provided directly to healthcare professionals. Crude rates of consults increased across all DHBs. Of all 2,603 therapeutic substances that were consulted about during the study period, 1,492 (57.3%) were drugs affecting the nervous system, and paracetamol was the most common individual drug (528; 20.3%). Of all 1,185 non-therapeutic substance exposures that were advised on, 66 (5.6%) were unidentified mushrooms, 51 (4.3%) unidentified substances, and 47 (4.0%) lead exposures. CONCLUSIONS: There was increasing utilisation of the NPC service by healthcare professionals from all 24 areas of the country, covering a wide range of substance exposures and scenarios. The growing utilisation suggests healthcare professionals derive value from this consultation service for the care of their patients.

The clinical toxicology of ketamine.

INTRODUCTION: Ketamine is a pharmaceutical drug possessing both analgesic and anaesthetic properties. As an anaesthetic, it induces anaesthesia by producing analgesia with a state of altered consciousness while maintaining airway tone, respiratory drive, and hemodynamic stability. At lower doses, it has psychoactive properties and has gained popularity as a recreational drug. OBJECTIVES: To review the epidemiology, mechanisms of toxicity, pharmacokinetics, clinical features, diagnosis and management of ketamine toxicity. METHODS: Both OVID MEDLINE (January 1950-April 2023) and Web of Science (1900-April 2023) databases were searched using the term "ketamine" in combination with the keywords "pharmacokinetics", "kinetics", "poisoning", "poison", "toxicity", "ingestion", "adverse effects", "overdose", and "intoxication". Furthermore, bibliographies of identified articles were screened for additional relevant studies. These searches produced 5,268 non-duplicate citations; 185 articles (case reports, case series, pharmacokinetic studies, animal studies pertinent to pharmacology, and reviews) were considered relevant. Those excluded were other animal investigations, therapeutic human clinical investigations, commentaries, editorials, cases with no clinical relevance and post-mortem investigations. EPIDEMIOLOGY: Following its introduction into medical practice in the early 1970s, ketamine has become a popular recreational drug. Its use has become associated with the dance culture, electronic and dubstep dance events. MECHANISM OF ACTION: Ketamine acts primarily as a non-competitive antagonist on the glutamate N-methyl-D-aspartate receptor, causing the loss of responsiveness that is associated with clinical ketamine dissociative anaesthesia. PHARMACOKINETICS: Absorption of ketamine is rapid though the rate of uptake and bioavailability is determined by the route of exposure. Ketamine is metabolized extensively in the liver. Initially, both isomers are metabolized to their major active metabolite, norketamine, by CYP2B6, CYP3A4 and CYP2C9 isoforms. The hydroxylation of the cyclohexan-1-one ring of norketamine to the three positional isomers of hydroxynorketamine occurs by CYP2B6 and CYP2A6. The dehydronorketamine metabolite occurs either by direct dehydrogenation from norketamine via CYP2B6 metabolism or non-enzymatic dehydration of hydroxynorketamine. Norketamine, the dehydronorketamine isomers, and hydroxynorketamine have pharmacological activity. The elimination of ketamine is primarily by the kidneys, though unchanged ketamine accounts for only a small percentage in the urine. The half-life of ketamine in humans is between 1.5 and 5 h. CLINICAL FEATURES: Acute adverse effects following recreational use are diverse and can include impaired consciousness, dizziness, irrational behaviour, hallucinations, abdominal pain and vomiting. Chronic use can result in impaired verbal information processing, cystitis and cholangiopathy. DIAGNOSIS: The diagnosis of acute ketamine intoxication is typically made on the basis of the patient's history, clinical features, such as vomiting, sialorrhea, or laryngospasm, along with neuropsychiatric features. Chronic effects of ketamine toxicity can result in cholangiopathy and cystitis, which can be confirmed by endoscopic retrograde cholangiopancreatography and cystoscopy, respectively. MANAGEMENT: Treatment of acute clinical toxicity is predominantly supportive with empiric management of specific adverse effects. Benzodiazepines are recommended as initial treatment to reduce agitation, excess neuromuscular activity and blood pressure. Management of cystitis is multidisciplinary and multi-tiered, following a stepwise approach of pharmacotherapy and surgery. Management of cholangiopathy may require pain management and, where necessary, biliary stenting to alleviate obstructions. Chronic effects of ketamine toxicity are typically reversible, with management focusing on abstinence. CONCLUSIONS: Ketamine is a dissociative drug employed predominantly in emergency medicine; it has also become popular as a recreational drug. Its recreational use can result in acute neuropsychiatric effects, whereas chronic use can result in cystitis and cholangiopathy.

Rising Kawasaki disease incidence in New Zealand: analysis of national population incidence and outcomes 2000-2017.

OBJECTIVE: The recent epidemiology of Kawasaki disease (KD) in New Zealand (NZ) is unknown. Our aim was to describe the incidence, seasonal variation, long-term outcomes and mortality for KD in NZ. DESIGN: Retrospective national database analysis. SETTING: New Zealand. PATIENTS: First hospitalisation and deaths diagnosed with KD. MAIN OUTCOME MEASURES: Data were extracted for all hospital admissions in NZ coded as KD (International Classification of Diseases (ICD)-9 and ICD-10) from the National Minimum Dataset 1 January 2000 to 31 December 2017. Age, sex, ethnicity and associated diagnoses were available to review. Intervention rates for immunoglobulin administration were also analysed. RESULTS: Over the study period, there were 1008 children with initial hospitalisation for KD. The mean age was 39.8 months (SD 37) and 592 (59%) were boys. The annual incidence rate of KD has increased from 12.2 to 19.5 per 100 000 children <5 years old (0.46 case increase per year; 95% CI 0.09 to 0.83). Children of Asian and Pacific Island ethnicities had the highest incidence (51.2 and 26.1/100 000, respectively). The highest growth in incidence was among East Asian children. The case mortality rate was low (12 of 1008, 1.2%); however, Maori were over-represented (6 of 12 deaths). CONCLUSIONS: There is evidence of increasing KD hospitalisation in NZ, similar to recent studies from Northeast Asia and Australia. KD incidence data were available for retrospective review from a national database, but data on complications and outcomes were incomplete. Notification for KD and an active national surveillance system are recommended to improve care. Future work should focus on factors contributing to poorer outcomes in Maori.

Prevalence of psychoactive drugs in injured patients presenting to an emergency department.

OBJECTIVE: The aim of the present study was to obtain an unbiased understanding of the prevalence of psychoactive drugs in trauma patients presenting to a large ED. METHODS: Consecutive adult patients presenting to the ED with an injury resulting in a trauma call had an anonymised, additional blood test taken for detection of over 2000 drugs. Laboratory testing was to judicial standards. Drugs given by ambulance pre-hospital were detected but excluded from the analysis. RESULTS: Over 6 months 276 (74.7%) of 371 patients were tested. Of the 276 patients tested, 158 (57.2%) had one or more psychoactive drug present. Recreational drugs were detected in 101 (36.6%) patients and medicinal drugs in 88 (31.8%) patients, with a combination of both detected in 31 (11.2%) patients. The most common drugs detected were cannabis (22.1%), antidepressants (18.4%), alcohol (15.5%), opioids (10.1%), benzodiazepine/z-drugs (9.4%) and methamphetamine (7.2%). The prevalence of psychoactive drugs differed by age group, sex and cause of injury. CONCLUSIONS: The prevalence of psychoactive drugs in injury presentations to an ED is high, and provides an opportunity to reduce harm. The present study demonstrates the feasibility of an approach which limits bias and obtains results that accurately reflect the drug prevalence in injured cohorts. Systematic testing of injured patients is an important contribution to the epidemiology of injury.

Use of recreational drug 1,3 Dimethylamylamine (DMAA) [corrected] associated with cerebral hemorrhage.

Dimethylamylamine (DMAA) was a forgotten pharmaceutical that was patented in 1944 as a nasal decongestant. DMAA has recently gained popularity as a dietary supplement, with claims of effectiveness as an athletic performance enhancer and weight loss aid. It is also sold as a recreational stimulant drug. DMAA is a sympathomimetic and potent pressor agent. This report describes 3 cases of cerebral hemorrhage in adults after the use of DMAA. The status of this substance as a synthetic or naturally occurring compound is also discussed.

Paediatric exploratory ingestion presentations to Christchurch Hospital emergency department during 2019.

AIM: To quantify and describe presentations to a New Zealand tertiary hospital emergency department (ED) associated with paediatric exploratory ingestions (PEIs) during 2019 in comparison to 1999. METHODS: A retrospective descriptive study was conducted of PEI presentations by children under 7 years of age to Christchurch Hospital ED between 1 January and 31 December 2019. Data were studied for demographic and management details and compared to data from 1999. RESULTS: There were 111 PEI presentations in children under 7 years during 2019, out of 9,445 presentations for this age group (1.2%). The estimated incidence of PEIs was 223.8 per 100,000. PEI presentations relative to total paediatric presentations had reduced compared to 1999 (X2=94.7, p<0.001). Two year olds were most likely to have PEIs (odds ratio (OR)=15.01, 95% confidence interval (CI)=6.78, 33.22). Children of Asian (OR=0.50, 95% CI=0.26, 0.95) and Pacific (OR=0.34, 95% CI=0.12, 0.93) ethnicity were less likely to present with PEIs. Paracetamol was the most commonly ingested substance (15.3%), followed by opioids (11.7%). CONCLUSION: Paediatric presentations due to exploratory ingestions reduced between 1999 and 2019. However, there was a concerning increase in ingestions of medications like opioids that have a significant risk of toxicity at low doses.

Temporal clustering of Kawasaki disease cases around the world.

In a single-site study (San Diego, CA, USA), we previously showed that Kawasaki Disease (KD) cases cluster temporally in bursts of approximately 7 days. These clusters occurred more often than would be expected at random even after accounting for long-term trends and seasonality. This finding raised the question of whether other locations around the world experience similar temporal clusters of KD that might offer clues to disease etiology. Here we combine data from San Diego and nine additional sites around the world with hospitals that care for large numbers of KD patients, as well as two multi-hospital catchment regions. We found that across these sites, KD cases clustered at short time scales and there were anomalously long quiet periods with no cases. Both of these phenomena occurred more often than would be expected given local trends and seasonality. Additionally, we found unusually frequent temporal overlaps of KD clusters and quiet periods between pairs of sites. These findings suggest that regional and planetary range environmental influences create periods of higher or lower exposure to KD triggers that may offer clues to the etiology of KD.

The clinical toxicology of cannabis.

Cannabis is one of the most widely used recreational drugs in the world. Tetrahydrocannabinol (THC) is the psychoactive principal constituent of the cannabis plant (Cannabis sativa). It is taken either orally or by inhalation, resulting in sedation, euphoria, relaxation and loss of social inhibition. Adverse effects from higher doses can include fear, distrust and a profound state of unease, hallucinations, ataxia, stupor and seizures. Long-term use can result in respiratory and cardiovascular toxicity and has been associated with a range of psychiatric conditions. Cannabinoid hyperemesis syndrome can occur with chronic use. Driving under the influence of THC is associated with approximately double the risk of motor vehicle crashes. The intensity and duration of symptoms is proportional to the concentration of THC in the blood. Following acute use, THC only remains in the blood for several hours before it is converted into a carboxylic derivative of THC and this partitions into the fat, from where it leaches out and can be detected in urine for weeks after use. Treatment of acute intoxication mainly consists of appropriate symptom-directed supportive care. Children are more susceptible to cannabis toxicity, particularly seizures and coma, and therefore may require additional supportive care for these potential symptoms. The aim of this narrative review is to provide a brief overview of the acute and chronic effects of cannabis, its pharmacokinetics, toxicity and the medical management of intoxication.

Corneal abrasion and alkali burn secondary to automobile air bag inflation.

A 59-year-old woman self presented to the emergency department with a painful right eye following a motor vehicle accident. She had reduced visual acuity and the eye had an alkaline pH with complete corneal uptake of fluorescein. Diagnosis of corneal abrasion and alkali burn to her right eye secondary to inflation of a driver's automobile airbag was made. The eye was irrigated with normal saline. Such injuries, although rare, can easily be identified within the emergency department by the history of exposure, evidence of facial injuries or burns, and an alkaline pH in the inferior cul-de-sac of the eye. Early detection and management with ophthalmology review is therefore imperative to prevent irreversible visual impairment.

Case series: toxicity from 25B-NBOMe--a cluster of N-bomb cases.

Background A new class of hallucinogens called NBOMes has emerged. This class includes analogues 25I-NBOMe, 25C-NBOMe and 25B-NBOMe. Case reports and judicial seizures indicate that 25I-NBOMe and 25C-NBOMe are more prevalently abused. There have been a few confirmed reports of 25B-NBOMe use or toxicity. Report Observational case series. This report describes a series of 10 patients who suffered adverse effects from 25B-NBOMe. Hallucinations and violent agitation predominate along with serotonergic/stimulant signs such as mydriasis, tachycardia, hypertension and hyperthermia. The majority (7/10) required sedation with benzodiazepines. Analytical method 25B-NBOMe concentrations in plasma and urine were quantified in all patients using a validated liquid chromatography-tandem mass spectrometry (LC-MS/MS) method. Peak plasma levels were measured between 0.7-10.1 ng/ml. Discussion The NBOMes are desired by users because of their hallucinogenic and stimulant effects. They are often sold as LSD or synthetic LSD. Reported cases of 25B- NBOMe toxicity are reviewed and compared to our series. Seizures and one pharmacological death have been described but neither were observed in our series. Based on our experience with cases of mild to moderate toxicity, we suggest that management should be supportive and focused on preventing further (self) harm. High doses of benzodiazepines may be required to control agitation. Patients who develop significant hyperthermia need to be actively managed. Conclusions Effects from 25B-NBOMe in our series were similar to previous individual case reports. The clinical features were also similar to effects from other analogues in the class (25I-NBOMe, 25C-NBOMe). Violent agitation frequently present along with signs of serotonergic stimulation. Hyperthermia, rhabdomyolysis and kidney injury were also observed.

Emergency department overcrowding: the Emergency Department Cardiac Analogy Model (EDCAM).

Increasing patient numbers, changing demographics and altered patient expectations have all contributed to the current problem with 'overcrowding' in emergency departments (EDs). The problem has reached crisis level in a number of countries, with significant implications for patient safety, quality of care, staff 'burnout' and patient and staff satisfaction. There is no single, clear definition of the cause of overcrowding, nor a simple means of addressing the problem. For some hospitals, the option of ambulance diversion has become a necessity, as overcrowded waiting rooms and 'bed-block' force emergency staff to turn patients away. But what are the options when ambulance diversion is not possible? Christchurch Hospital, New Zealand is a tertiary level facility with an emergency department that sees on average 65,000 patients per year. There are no other EDs to whom patients can be diverted, and so despite admission rates from the ED of up to 48%, other options need to be examined. In order to develop a series of unified responses, which acknowledge the multifactorial nature of the problem, the Emergency Department Cardiac Analogy model of ED flow, was developed. This model highlights the need to intervene at each of three key points, in order to address the issue of overcrowding and its associated problems.

Gastrointestinal decontamination in paediatric exploratory ingestions.

AIM: To review the effect of treatment changes in paediatric exploratory ingestion at Christchurch Hospital. METHODS: We carried out a retrospective review of paediatric patients presenting with potentially toxic ingestion during six month periods of 1994, 1996 and 1999. RESULTS: All three groups were comparable in respect to age and gender. There were minor changes in the range and proportion of substances ingested - with those in the 1999 group more likely to have taken paracetamol. In 1994, 36% of children were treated with syrup of ipecac. By 1996, only 9% were given ipecac, with 49% treated with activated charcoal. By 1999, 12% were treated with activated charcoal, while 88% received no decontamination. There was a lower admission rate in the 1999 group with no overall change in outcome. CONCLUSIONS: It is rare for paediatric exploratory ingestions to result in significant toxicity. Gastrointestinal decontamination should not be routinely used in these patients as the risk of the procedure may outweigh the risk of the poison exposure.

Toxic cocktail: methanol poisoning in a tourist to Indonesia.

Methanol poisoning has become very uncommon in Australasia with regulations that have reduced its retail availability. This report describes a young tourist who developed sudden onset visual failure and rapid breathing 2 days after ingestion of a complimentary local drink called Arrack when travelling in Indonesia. She presented to a hospital in New Zealand with severe metabolic acidosis and a highly toxic methanol level at 17 mmol/L. The cocktail was consumed at a popular tourist bar but is likely to have been mixed from home-brewed or 'moonshine' alcohol tainted with methanol. The aetiology of methanol poisoning, its optic toxicology and therapeutic measures are discussed, as is the concerning number of methanol poisoning cases among tourists to Indonesia over recent years.

Shifting Gas Artefact Sign: Early sonographic detection of pneumoperitoneum.

This case report describes the use of ultrasound to diagnose pneumoperitoneum in an unstable patient with abdominal pain. Gas in peritoneum produces a specific sonographic appearance. The use of dynamic manoeuvres improves confidence in the ultrasound diagnosis of free gas. The Shifting Gas Artefact Sign is explained. The literature on sonographic detection of pneumoperitoneum is reviewed. The detection of pneumoperitoneum is a significant finding in non-traumatic abdominal pain and also in blunt abdominal trauma. In both settings more research is required to validate the utility of the test in the acute setting.