Anthony J. Scalzo

Validation of global rating scale and checklist instruments for the infant lumbar puncture procedure.

Introduction The Patient Outcomes in Simulation Education network has developed tools for the assessment of competency to perform the infant lumbar puncture (ILP) procedure. The objective of this study was to evaluate the validity and reliability of these tools in a simulated setting. Methods We developed a 4-point anchored global rating scale (GRS) and 15-item dichotomous checklist instrument to assess ILP performance in a simulated environment. Video recordings of 60 subjects performing an unsupervised lumbar puncture on an infant bench top simulator were collected prospectively; 20 performed by subjects in each of 3 categories (beginner, intermediate experienced, or expert). Three blinded, expert raters independently scored each subject’s video recording using the GRS and checklist instruments. Results The final version of the scoring instruments is presented. Across all subject groups, higher GRS scores were found with advancing level of experience (P < 0.01). Total checklist scores were similar between the expert and intermediate experienced groups (P = 0.54). Both groups scored higher than the beginner group on the checklist instrument (P < 0.01). For each rater, a significant positive correlation was found between GRS scores and total checklist scores (median &rgr; = 0.75, P < 0.01). Cronbach &agr; coefficient for the checklist was 0.77. The intraclass correlation coefficients between raters for the GRS and total checklist scores were 0.71 and 0.52, respectively. Conclusions This study provides some initial evidence to support the validity and reliability of the ILP-anchored GRS. Acceptable internal consistency was found for the checklist instrument. The GRS instrument outperformed the checklist in its discriminant ability and interrater agreement.

Unusual Presentation of Iatrogenic Phenytoin Toxicity in a Newborn

BackgroundMedication errors may produce severe toxicity resulting in hospitalization. This can be compounded if the physician obtains the wrong concentration from a reference manual and a pharmacy miscalculates the conversion. We report a child presenting with ileus, hypothermia and lethargy after receiving supratherapeutic dosing of phenytoin after a concentration miscalculation.Case ReportA one-month-old infant presented to the Emergency Department with progressive worsening of abdominal distension, diminished activity, and a one day history of difficulty feeding secondary to a decreased level of consciousness. The past medical history was significant for neonatal Group B Strep meningitis with seizures. Among the child’s discharge medications was a prescription for phenytoin (30 mg/5 mL) 2.5 cc by mouth three times daily. On exam, the child was hypothermic with pink mottled skin, poor responsiveness, prolonged capillary refill, abdominal distension with hypoactive bowel sounds, and a dysconjugate gaze. The Initial phenytoin serum concentration was 91.8 mcg/mL. She was admitted to the PICU and was started on ampicillin and cefotaxime for R/O sepsis. Phenytoin was withheld and subsequent serum concentrations revealed an extremely slow elimination (mcg/mL vs. time pair coordinates were 78.2/13.3h; 74.3/62.3h; 43.7/109.6h; 10.8/160.9h) reflecting zero-order kinetics. Post discontinuing antibiotics, phenytoin levels decreased at rates expected. She was discharged after resolution of symptoms. The MD who had written the phenytoin prescription had based it on theHarriet Lane Handbook, 2000 Ed. The 30 mg/5 mL formulation has been unavailable in the US for several years. A community pharmacy substituted the 125 mg/5 mL formulation, but miscalculated the dosage to be 1.6 cc (40 mg) tid.ConclusionsAbdominal distension and ileus may be presenting symptoms in children at toxic phenytoin levels. Ampicillin and cefotaxime may effect the elimination rate of phenytoin at such levels. We report one of the highest phenytoin levels recorded after therapeutic misadventure. Physicians must be aware of inaccuracies in reference manuals that may result in dosing errors.

MALPOSITION OF PEDIATRIC GASTRIC LAVAGE TUBES DEMONSTRATED RADIOGRAPHICALLY

Gastric lavage may be indicated in the initial treatment of toxic substance ingestion. We retrospectively surveyed the charts of 36 pediatric patients who underwent gastric lavage to evaluate the clinical and radiographic evidence indicating proper tube placement. Only 14 patients had a radiograph prior to lavage, and 50% of these documented malposition. The most common was excess tube insertion, stretching the stomach inferiorly towards the pelvis. The traditionally acceptable clinical test by auscultation of insufflated air was favorable in 100% of patients, thus failing to detect all of the malpositionings documented radiographically. We suggest that initial insertion of tube length be based on the patients height or length using an adaptation of Strobels previously published formula for esophageal pH probe placement: Tube Insertion Depth (TID), orogastric = 9.7 cm + (0.226 x length of patient in cm) and TID, nasogastric = 8 cm + (0.252 x length of patient in cm). These formulae have been displayed in graphic form for easy use. Diagnostic imaging remains the only certain means to document tube placement. Prospective studies to validate the formulae in clinical use are ongoing.

Case of brodifacoum-contaminated synthetic cannabinoid

The 4-hydroxycoumarin pesticide brodifacoum, a Vitamin K epoxide reductase inhibitor, is a common cause of poisoning. It is tasteless and odorless, combines readily with other compounds, and exposure occurs via ingestion, inhalation, or skin contact. Toxicity may induce fatal hemorrhages as vitamin-K-dependent coagulation factors deplete, unless they are quickly replaced. Herein we report a case of synthetic cannabinoids laced with this toxin. Our patient, a 25-year-old southeastern Missouri male, presented to our emergency department with gross hematuria, retroperitoneal hematomas, epistaxis, easy bruising, nausea/vomiting/cramping, and weakness. There was no trauma or bleeding disorder history. He ate a balanced diet. He denied medication or drug use, including marijuana and synthetic cannabinoid receptor agonist (SCRA) products. He had no occupational exposure to rodenticides. Laboratory testing showed acute kidney injury, hemoglobin 6.5 g/dL, and normal platelet count. Coagulation studies revealed a PT/INR >10 s and APTT >212.0 s. AST and ALT were normal, fibrinogen activity was 575mg/dL and D-dimer was 1.93 mg/mL FEU. Initial toxicology screens were negative, including salicylates. Human immunodeficiency virus/hepatitis testing was negative. PT/INR and PTT mixing studies showed a factor deficiency pattern. Lupus anticoagulant was not detected. Coagulation factor testing revealed decreased activity of vitamin Kdependent factors (II, VII, IX, X) and normal activity of factors V and VIII. With high-dose intravenous phytonadione and fresh frozen plasma initially, the coagulopathy corrected. Lipophilic vitamin levels were normal, ruling out malabsorption. Qualitative anticoagulant testing by liquid chromatography tandem mass spectrometry (LC-MS/MS) detected brodifacoum in blood. At this time, the patient admitted to smoking SCRAs 3 weeks prior. Our regional poison control center informed us of several additional recent Midwestern cases of SCRA-related brodifacoum poisoning. The patient’s admission urine and blood sample were analyzed by liquid chromatography high resolution mass spectrometry (LC-HRMS) for the presence of synthetic cannabinoids [1]. A metabolite of AB-FUBINACA, the hydrolysis metabolite of the primary amine (CAS registry No. – 1877243-60-1), was detected and confirmed in both the urine and blood. This metabolite has been previously described as one of the predominant metabolites in authentic cases of AB-FUBINACA exposure [2]. No additional described metabolites or the parent compound were identified in this case. An outbreak of severe unexplained hemorrhage cases and four deaths following ingestion of “King Kong” – a brodifacoum laced SCRA – were initially observed in the Chicago area and reported to the Illinois Poison Center and Department of Health. These and other cases including ours in Missouri are tallied in a recent Morbidity & Mortality Weekly Report [3]. Most of the patients self-reported use of SCRAs. We were the first in the region to identify an SCRA metabolite in one of these patients. With treatment, the patient’s bleeding resolved and labs normalized. He agreed to avoid SCRAs and take high doses of oral Vitamin K with outpatient follow-up.