Aaron B. Skolnik

Complications Following Antidotal Use of Intravenous Lipid Emulsion Therapy

The primary objective is to identify and describe the complications associated with the use of intravenous lipid emulsion (ILE) therapy as an antidote for lipophilic drug toxicity. This study is a retrospective chart review of patients treated with ILE at two academic medical centers between 2005 and 2012. Based on previously reported complications, we hypothesized that pancreatitis, ARDS, and lipemia-induced laboratory interference might occur. Clinical definitions of these complications were defined a priori. Subjects treated with ILE who did not develop at least one complication were excluded. A total of nine patients were treated with ILE during the study period, six of whom experienced potential complications as a result of the ILE. Two patients developed pancreatitis, and four patients had lipemia-induced interference of interpretation of laboratory studies, despite ultracentrifugation. Laboratory interference precluded one patient from being an organ donor. Three patients developed ARDS; although temporally associated, a causal relationship between ILE and the development of ARDS cannot be clearly established. As ILE is increasingly used for less severe cases of drug toxicity, clinicians should be aware of potential complications associated with its use. A risk–benefit assessment for the use of ILE should be implemented on a case-by-case basis.

Effect of a Medical Toxicology Admitting Service on Length of Stay, Cost, and Mortality Among Inpatients Discharged with Poisoning-Related Diagnoses

There are no published studies that have compared quality outcomes of hospitalized poisoned patients primarily under the care of physician medical toxicologists to patients treated by non-toxicologists. We hypothesized that inpatients primarily cared for by medical toxicologists would exhibit shorter lengths of stay (LOS), lower costs, and decreased mortality. Patients discharged in 2010 and 2011 from seven hospitals within the same health care system and greater metropolitan area with Medicare severity diagnosis-related groups for “poisoning and toxic effects of drugs” with and without major comorbidities or complications (917 & 918, respectively) were identified from a Premier® database. The database contained severity-weighted comparisons between expected and observed outcomes for each patient. Outcome parameters were differences between expected and observed LOS, cost, and percent mortality. These were then compared among groups of patients primarily admitted and cared for by (1) medical toxicologists at one hospital (Banner Good Samaritan Medical Center, BGS), (2) non-toxicologists at BGS, and (3) non-toxicologists at six other hospitals. Records of 3,581 patients contained complete data for assessment of at least one outcome measure. Patients cared for by medical toxicologists experienced favorable differences in LOS, costs, and mortality compared with other patient groups (p < 0.001). If patients cared for by non-toxicologists had experienced similar differences in observed over expected values for LOS, cost, and mortality as those cared for by medical toxicologists, there would have been a median savings of 1,483 hospital days,

Telemedicine and Toxicology: Back to the Future?

4.269 million, and a significant decrease in mortality during the 2-year study period. Differences between observed and expected LOS, cost, and mortality in patients primarily cared for by medical toxicologists were significantly better than in patients cared for by non-toxicologists, regardless of facility. These data suggest that significant reductions in patient hospital days, costs, and mortality are possible when medical toxicologists directly care for hospitalized patients.

Practice or perish: why bedside toxicology is essential to the survival of our specialty.

I was recently consulted via our poison control center (PCC) regarding a toddler who arrived at an Arizona pediatric intensive care unit. The child had first presented to a rural facility where he was evaluated and treated for presumed sepsis. The intensivist I spoke with on the phone was new to our state and suspected that the patient had an alternate diagnosis. After consenting the child’s mother, he securely transferred a short video of the child’s examination. We reviewed the video together on the phone and, after recognizing the opsoclonus characteristic of Centruroides envenomation, we treated the child with scorpion antivenom. The patient was safely discharged to home a few hours later, asymptomatic. Reflecting on the experience of this video diagnosis, it occurred to me that medical toxicologists were among the earliest pioneers in the field of telemedicine. However, the nature of telemedicine is rapidly growing and changing. Are toxicologists and poison centers doing enough to keep up with the tide of information technology? What will the remote toxicology practice of the future look like?

Case Studies in Medical Toxicology

One of the medical toxicologists in our group was recently asked a shocking question. She was providing recommendations via telephone to a rather upset and flustered emergency physician, when the caller interrupted her by asking, “Excuse me, are you even a clinician?” Working on a toxicology service that admits and consults on more than 1,200 patients per year, my colleague was understandably taken aback. Hearing the story later, I was dismayed but not surprised. Based on the current practice of many toxicologists, how can we fault the emergency physician for asking such a question? Medical toxicology has become a specialty in which the telephone has largely replaced the stethoscope as the primary tool of our trade. This is in no way meant to diminish the importance of poison control centers. Not only was the establishment of poison centers instrumental in the development of medical toxicology as a subspecialty [1], there is no doubt as to the public health benefit and system-wide cost savings engendered by poison centers [2–7]. My concern is the role played by toxicologists in our healthcare system. Presumably, fellowship training in medical toxicology allows us to make clinical recommendations and advise caregivers at a level beyond that of the emergency physician and poison information specialist. If this is true, how many patients does the medical toxicologist have to treat at the bedside to ensure the validity of our advice? What happens when the emergency physician on the other end of the telephone has laid hands on more poisoned patients in the preceding week than the toxicologist has in the preceding year? If we do not examine patients, treat them at bedside, and learn from our experience, what is it that distinguishes us from Poisindex™ or a poison information specialist?

Assessing Bleeding Risk in Patients With Intentional Overdoses of Novel Antiplatelet and Anticoagulant Medications

Laundry detergent (LD) pod ingestion is an increasing source of morbidity and mortality in the pediatric population. However, injury associated with unintentional ingestions of LD pods by adults has not been described in the literature. We report a case of a 50-year-old man who ingested a LD pod and had esophageal and gastric injuries.

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Study objective: In recent years, the use of novel anticoagulants and antiplatelet agents has become widespread. Little is known about the toxicity and bleeding risk of these agents after acute overdose. The primary objective of this study is to evaluate the relative risk of all bleeding and major bleeding in patients with acute overdose of novel antiplatelet and anticoagulant medications. Methods: This study is a retrospective study of acute ingestion of apixaban, clopidogrel, ticlopidine, dabigatran, edoxaban, prasugrel, rivaroxaban, and ticagrelor reported to 7 poison control centers in 4 states during a 10‐year span. The prevalence of bleeding for each agent was calculated, and hemorrhage was classified as trivial, minor, or major. Results: A total of 322 acute overdoses were identified, with the majority of cases involving clopidogrel (260; 80.7%). Hemorrhage occurred in 16 cases (4.9%), including 7 cases of clopidogrel, 6 cases of rivaroxaban, 2 cases of dabigatran, and 1 case of apixaban. Most cases of hemorrhage were classified as major (n=9). Comparing the novel anticoagulants with the P2Y12 receptor inhibitors, the relative risk for any bleeding with novel anticoagulant was 6.68 (95% confidence interval 2.63 to 17.1); the relative risk of major bleeding was 18.1 (95% confidence interval 3.85 to 85.0). Conclusion: Acute overdose of novel anticoagulants or antiplatelet agents is associated with a small risk of significant hemorrhage. The risk is greater with the factor Xa inhibitors and direct thrombin inhibitors than with the P2Y12 receptor antagonists.

Compartment Syndrome After “Bath Salts” Use: A Case Series

Keywords Bodypacker .Deferasirox .Hyperemesis .N-acetylcysteine .CannabisAaron B. Skolnik and Anne-Michelle Ruhade Bakker JK, Nanayakkara PW, Geeraedts LM Jr, deLange ES, Mackintosh MO, Bonjer HJ. Body Packers: aPlea for Conservative Treatment. Langenbecks ArchSurg. 2012 Jan; 397(1):125-30. Epub 2011 Oct 8.Background: Smuggling of drugs via internal concealment,known as “body packing,” is on the rise. Early methods ofinternal concealment relied on swallowed drug packets con-structed from available materials such as balloons and con-doms. Packet rupture was associated with high mortality.Modern drug packets are machine produced and carry alower risk of rupture. Body packers may present with non-life-threatening symptoms such as nausea or bowel obstruc-tion. The optimal approach to management of these patientsis not known.Research Question: This study aims to evaluate the effica-cyof aprotocol for diagnosis andtreatmentof body packers,including determining the need for surgical intervention.Methods: A retrospective chart review was performed overa 6-year period. Patients were identified by a recordeddiagnosis of “body packer.” All patients included in thestudy were treated according to a protocol including vitalsign monitoring, laboratory testing, and radiographs. If plainabdominal X-rays were inconclusive, a CT scan of theabdomen was performed. The study centers protocol man-dated surgical removal of drug packets for signs of drugintoxication, ileus, or persistence of drug packets in thestomach for >48 h. Surgically treated patients were com-pared to conservatively managed patients.Results: Cocaine was the most commonly found drug inboth surgically (n064) and conservatively managed (n079) patients. There was no significant difference in thenumber of packets ingested between groups. Surgicallymanaged patients had higher prevalence of abdominalpain (53 vs. 31 %) and vomiting (20 vs. 13 %) atpresentation. Sixteen percent of surgical patients devel-oped a wound infection, 16 % had a fascial dehiscence,and 8 % had both. Wound infection was associated witha longer length of hospitalization. Mean hospital lengthof stay was significantly prolonged in surgically man-aged patients (7 vs. 2 days). Comparing asymptomaticpatients who underwent surgery for packets remaining inthe stomach >48 h to those with drug packets in the stomachfor 48 vs. 48 h. Surgical treatment should be reserved for thosepatients with ileus or signs of drug intoxication.Critique: This study is limited by its retrospective nature.As a single-center study, the results may not be general-izable to different patient populations. The cutoff time of48 h to determine surgery was chosen arbitrarily. Optimaltiming of surgical intervention in asymptomatic patients isstill not certain. The ideal surgical approach to packetretrieval is unknown and the surgical method in this studywas not standardized. The authors note that wound compli-cations occurred at higher frequency than expected for lap-arotomy when compared to several references. Alternative