A gargantuan acetaminophen level in an acidemic patient treated solely with intravenous N-acetylcysteine.

The objective of this report is to describe an acidemic patient with one of the largest recorded acetaminophen ingestions in a patient with acidemia who was treated with supportive care and intravenous (IV) N-acetylcysteine. A 59-year-old female with a history of depression was found comatose. In the Emergency Department, she was obtunded with agonal respirations and immediately intubated. Activated charcoal was given through a nasogastric tube. An initial acetaminophen serum level was 1141 mg/L. The patient was started on IV N-acetylcysteine. The acetaminophen level peaked 2 hours later at 1193 mg/L. She was continued on the IV N-acetylcysteine protocol. The next day her aspartate aminotransferase was 3150 U/L, alanine aminotransferase was 2780 U/L, and creatinine phosphokinase was 16,197 U/L. There was no elevation in bilirubin or international normalized ratio (INR). Transaminase levels decreased on day 3 and normalized by day 4 when she was transferred to a psychiatric unit. Few cases have been reported of strikingly elevated acetaminophen levels in poisoned patients who did not receive hemodialysis. These patients did have increased lactate levels, and some had normal liver function tests. All of these patients received N-acetylcysteine and survived the poisoning without sequelae. This patient in this report was unique in that she had the highest reported serum acetaminophen level with acidosis and was treated successfully with only IV N-acetylcysteine and supportive care.

Bupropion: Does Its Efficacy Outweigh Potential Morbidity and Lethality?

Bupropion is a structurally and biochemically unique antidepressant that inhibits the neuronal uptake of dopamine and norepinephrine. Often prescribed for children and adolescents, bupropion displays both neurologic and cardiac toxicities in overdose more serious than toxicities resulting from poisonings by tricyclic antidepressants and selective serotonin reuptake inhibitors. Bupropion was briefly removed from the market in the 1980s. The incidence of bupropion poisonings in the United States, and resultant morbidity and mortality in children and adolescents, has been steadily increasing since 2012. Antidepressants less toxic than bupropion in overdose should be considered in the vulnerable 6- to 19-year-old patient population. [Pediatr Ann. 2023;52(5):e178-e180.].

Hot, blind, and mad: avoidable geriatric anticholinergic delirium.

The elderly are particularly sensitive to delirium-inducing medications. We report a case of a 93-year-old woman who developed anticholinergic delirium from subcutaneous diphenhydramine that she received in the emergency department. This patient was reportedly allergic to "caine" anesthetic agents, and thus, subcutaneous diphenhydramine was administered as an alternative local anesthetic, as recommended in emergency medicine textbooks. Within 20 minutes of administration, the patient developed agitation, tachycardia, dilated pupils, and dry skin, consistent with a classic anticholinergic toxidrome. Diphenhydramine use is associated with a high incidence of anticholinergic adverse effects, especially in the elderly. Clinicians should carefully consider using diphenhydramine in this vulnerable population.

Single-dose ziprasidone associated with QT interval prolongation.

Ziprasidone has been rarely associated with QT prolongation especially in patients (1) with no underlying cardiac or metabolic disorders, (2) who are receiving no concomitant medications known to prolong the QT interval, and (3) whom therapy is being initiated at a low dose. We report a 47-year-old patient who was agitated with suicidal ideation. He had a history of cocaine use, the last time being 72 hours before emergency department (ED) presentation. His electrocardiogram (ECG) on arrival in the ED showed a QT of 484 milliseconds and a QTc of 475 milliseconds with a pulse of 58 beats per minute. The patient was given 20 mg intramuscular (IM) ziprasidone for agitation. He reported feeling palpitations and weakness 45 minutes after receiving ziprasidone. His QT interval was prolonged on ECG and returned to baseline after 72 hours. Clinicians should consider obtaining an ECG before ziprasidone administration.

Chemical and traumatic occupational eye exposures in aviation personnel.

INTRODUCTION: The eye is vulnerable to chemical exposure and foreign body infiltration in the occupational setting. Individuals working in the aviation field are prone to these types of exposures. METHODS: We conducted a 28-mo retrospective chart review to document the number of airline workers complaining of chemical or foreign body exposure to the eye at an onsite airport medical clinic. The International Classification of Diseases, Ninth Revision (ICD-9), code for chemical conjunctivitis (372.5), was used to identify patients' charts. We documented the type of treatment that was initiated and whether there was eye damage. We further investigated the chemical composition of the products and whether there was any associated toxicity. RESULTS: Few instances of chemical exposure and foreign body infiltration were found. Patients were exposed to the following products: lubricants (e.g., naphthenic oils), hydraulic fluid (e.g., petroleum or phosphate ester based), jet fuel (e.g., kerosene), and de-icing agents (e.g., propylene glycol). There was no documentation regarding the use of personal protection equipment in the patients' charts. All patients received eye irrigation with normal saline. No sequelae were documented. CONCLUSION: Airline personnel are exposed to a variety of chemical agents in the workplace. None of the agents that workers were exposed to in this small study exhibited toxic effects to the eye. Proper use of personal protection equipment in aviation personnel may limit the number of chemical and foreign body eye exposures.

It's Just Math-Unless It's Toxic!

OBJECTIVE: The objective was to determine emergency medicine residents' ability to perform pharmaceutical calculations. METHODS: A six-question needs-assessment survey of emergency medicine residents was conducted at a citywide conference in 2016. Residents performed simple pharmaceutical calculations and were queried regarding resources they typically use to aid in performing calculations. RESULTS: Fifty-three emergency medicine residents out of 110 attendees (48%) completed the survey (postgraduate year [PGY]-1 n = 27, PGY-2 n = 13, PGY-3 n = 8, PGY-4 or above n = 5). Nearly 80% (n = 42) of all residents responded correctly to at least four of six questions (PGY-1 = 70%, PGY-2 = 86%, PGY-3 = 88%, and PGY-4 and above = 100%). Sixty-five percent of PGY-1s, 50% of PGY-2s, and 75% of PGY-3s thought that it was very important to correctly perform basic calculations. Google and Up To Date were frequently used to assist with calculations. More than 70% of all residents utilize clinical pharmacy (PharmD) staff for calculating doses. PharmD services were available at all times in the majority of survey responses. CONCLUSIONS: Emergency medicine residents performed poorly when completing pharmaceutical calculations. This may contribute to increased patient morbidity and mortality. Internet resource use increased as the years of training increased. PharmD services were extensively utilized by all resident regardless of years of training.

Bupropion-associated QRS prolongation unresponsive to sodium bicarbonate therapy.

We describe a case of bupropion-associated QRS prolongation that was unresponsive to intravenous bolus therapy of sodium bicarbonate. Bupropion may cause seizures and conduction delays similar to tricyclic antidepressants in the overdose setting by an unknown mechanism.

Hemorrhagic gastritis from topical isopropanol exposure.

OBJECTIVE: To report the occurrence of hemorrhagic gastritis after topical isopropanol application in an infant. CASE SUMMARY: A 2-year-old Hispanic boy developed coffee-ground emesis during emergency department evaluation for lethargy and fever. After an initial inconclusive workup for sepsis, further history revealed an isopropanol rubdown for fever reduction. Isopropanol concentrations and acetone metabolites were elevated, the patient recovered with supportive therapy, and other causes for hemorrhagic gastritis were excluded. DISCUSSION: Isopropanol sponge bathing is commonly used as a home remedy for infants with fever. Topical absorption of isopropanol has previously been reported to cause mental status changes, ketosis, and metabolic acidosis. We report a case of hemorrhagic gastritis as a complication of topical isopropanol absorption in a febrile infant. An objective causality assessment revealed that the adverse event was probably caused by the isopropanol. Previous reports of pediatric isopropanol poisoning and its management are discussed. CONCLUSIONS: Severe morbidity from topical isopropanol exposure may occur in young children.