Bryan Corbett

Altitude Sickness in Climbers and Efficacy of NSAIDs Trial (ASCENT): Randomized, Controlled Trial of Ibuprofen Versus Placebo for Prevention of Altitude Illness

OBJECTIVE To study the effectiveness of ibuprofen versus placebo in preventing acute mountain sickness (AMS) and high altitude headache (HAH). METHODS Double-blind, randomized, placebo-controlled trial. RESULTS Two hundred ninety-four healthy Western trekkers were recruited on the Everest approach at 4280 m or 4358 m and randomly assigned to receive either 600 mg of ibuprofen or placebo 3 times daily before and during ascent to 4928 m. One hundred eighty-three of 294 participants completed the trial. Of the participants who did not complete the trial, 62 were lost to follow-up and another 49 broke trial protocol. In an intent-to-treat analysis (232 participants), ibuprofen was found to be more effective than placebo in reducing the incidence of AMS (24.4% vs 40.4%; P = .01) and the incidence of HAH (42.3% vs 60.5%; P < .01). Ibuprofen was also superior to placebo in reducing the severity of HAH (4.9% vs 14.7%; P = .01). The end point of oxygen saturation was also higher in the ibuprofen group (80.8 % vs 82.4%; P = .035). For the 183 participants who completed the trial and conformed to the protocol, the incidence of AMS between placebo and treatment groups was not significant (32.9% vs 22.7%; P = .129 for AMS incidence, 9.6% vs 8.2%; P = .74 for AMS severity, 54.8% vs 42.7%; P = .11 for HAH incidence, and 8.2% vs 3.6%; P = .18 for HAH severity). CONCLUSIONS Ibuprofen was found to be effective in preventing AMS in the intent-to-treat analysis group but not in those who completed the trial. This loss of significance in the subjects who completed the trial may be explained by persons in the placebo group having a higher burden of illness and associated decreased compliance with the protocol. An important limitation of this study may be the possibility that ibuprofen can mask headache, which is a compulsory criterion for the diagnosis of AMS.

Loperamide Trends in Abuse and Misuse Over 13 Years: 2002–2015

With the increasing amount of information available on the Internet describing techniques for using loperamide either for self‐treatment of opioid withdrawal syndromes or for recreational use (so‐called legal highs), the objective was to describe a statewide poison control systems experience with loperamide misuse and abuse, with specific interest in cases of cardiotoxicity, and to determine if reported loperamide misuse or abuse cases have recently increased.

North American Snake Envenomation

Native US snakes that produce clinically significant envenomation can be divided into 2 groups, crotalids and elapids. The crotalids include rattlesnakes, cottonmouths, and copperheads. Crotalid envenomation can result in significant local tissue damage as well as thrombocytopenia and coagulopathy. Rarely are bites fatal. Native US elapids are all coral snakes that possess neurotoxic venom that can cause weakness, respiratory paralysis, and rarely death. Treatment of both types of envenomation revolves around general supportive care and antivenom administration when indicated. Previously advocated treatments, such as tourniquets, venom extraction, and bite site excision are not recommended.

Psychiatric Emergencies for Clinicians: Emergency Department Diagnosis and Management of Steroid Psychosis

*Department of Emergency Medicine and Division of Medical Toxicology, UC San Diego Health System, University of California at San Diego, San Diego, California, †Division of Medical Toxicology, UC San Diego Health System, University of California at San Diego, San Diego, California, ‡Department of Behavioral Health, Denver Health Medical Center, Denver, Colorado, §University of Colorado School of Medicine, Aurora, Colorado, and kDepartment of Behavioral Emergencies Research, UC San Diego Health System, University of California at San Diego, San Diego, California Reprint Address: Bryan Corbett, MD, Department of Emergency Medicine and Division of Medical Toxicology, UC San Diego Health System, University of California at San Diego, 200 W. Arbor Drive, San Diego, CA 92103

Common Medications Which May Mimic Psychiatric Symptoms

Virtually any medication which crosses the blood-brain barrier may cause neuropsychiatric effects. Nonetheless, some common drug classes are more predisposed to this. Below are common classeswhich may present with alterations in mental status or behavior:

Neuropsychiatric Complications of Steroids

Steroids are ubiquitous medications used to treat myriad disease processes.They are not without complications or side effects, however.In addition to weight gain, hyperglycemia, and immunosuppression, neuropsychiatric complications may also be present.Often referred to as “steroid psychosis” the neuropsychiatric complications of steroid use are much more diverse and not necessarily so obvious as the moniker implies.Manifestations range from an increased sense of well-being to hypomania, mania, depression, and frank psychosis.In addition, cognitive symptoms may be present such as difficulty with attention, concentration, and memory impairment.Symptoms generally start within days to weeks of starting steroids.Cases have occurred hours after starting therapy as well as after discontinuation of steroids, however.The true incidence is unclear and various studies report a broad range of 2–60%.Higher doses of steroids do convey an increased risk for developing neuropsychiatric symptoms, however, doses as low as 2.5 mg of prednisone daily have resulted in symptoms.In addition, essentially all routes of administration have been associated with the development of symptoms including inhaled, intra-articular, epidural, topical, and of course oral.Outcomes are generally good with resolution of neuropsychiatric symptoms within 6 weeks for 90% of individuals.Cognitive insults may take months to fully resolve.Treatment details are discussed below.

Neuroleptic Malignant Syndrome

Neuroleptic Malignant Syndrome (NMS) is the result of dopamine receptor blockade in the CNS.Classically it is characterized by the tetrad of altered mental status, rigidity, hyperthermia, and autonomic dysfunction.In practice, however, NMS exists on a spectrum and not all four features need be present for the diagnosis.It is also important to understand that less severe dopamine receptor blockade may present only with dystonia or akathisia.While not classified as NMS, these manifestations are the result of the same pathophysiologic mechanism.

Trifluoroacetic acid: Three times the fluoride, three times the toxicity?

Trifluoroacetic acid (TFAA) is a carboxylic acid, similar to acetic acid, used industrially and in laboratories. There is a paucity of data regarding exposure and the concern is that toxicity may mimic that of hydrofluoric acid (HF), causing electrolyte abnormalities, dysrhythmia, and cardiac arrest. We report a case of a 27-year-old male that presents with a dermal exposure to TFAA. His exam was remarkable for a 4% body surface area partial thickness burn to the right forearm. There were no initial electrolyte abnormalities or dysrhythmias and the patient was admitted to telemetry monitoring overnight. Serial laboratories were normal, dysrhythmias did not occur, and patient was ultimately discharged with routine burn care of the wound. Previously reported TFAA exposures are uncommon and tend to be very small body surface area chemical burns without clear systemic toxicity. HF as well as sodium and ammonium bifluorides have been shown to cause clinically significant electrolyte disturbances that can lead to dysrhythmias and fatalities. While TFAA may be structurally similar, it does not appear to have similar toxicity. This is an important difference in presentation and treatment that emergency physicians should be aware of as occupational exposures are likely to present to the emergency department.

A Case of Acute Pericarditis Following Intravenous Injection of Crushed Morphine Tablets

ABSTRACT A 37-year-old male presented with sharp, severe chest pain following seven days of intravenous injection of crushed morphine tablets. The chest pain was positional and pleuritic in nature and resolved with leaning forward. Work-up was notable for an ECG with inferior and anterolateral PR depressions as well as a CT chest with diffuse centrilobular nodules. Per radiology, the CT findings along with the patient’s history were concerning for pulmonary granulomatosis from deposition of talc or some other foreign body. Cardiology was consulted and diagnosed the patient with acute pericarditis, given his typical symptoms and ECG changes. On review of the literature, pulmonary granulomatosis following intravenous injection of foreign bodies is well documented. There are numerous studies documenting foreign body deposition and granulomatosis in organs other than the lungs on post-mortem analyses of individuals with a history of IV injection of crushed tablets. We are suggesting that intravenous injection of crushed morphine tablets can cause pericardial irritation and a syndrome of acuter pericarditis. To our knowledge, there has not been a previous report of acute pericarditis secondary to intravenous injection of crushed tablets.

Inadvertent Methylergonovine Administration to a Neonate.

Patient: Male, Newborn Final Diagnosis: Accidental methylergonovine poisoning Symptoms: Respiratory distress Medication: — Clinical Procedure: — Specialty: Pediatrics and Neonatology Objective: Diagnostic/therapeutic accidents Background: Methylergonovine is an ergot alkaloid used to treat post-partum hemorrhage secondary to uterine atony. Mistaking methylergonovine for vitamin K with accidental administration to the neonate is a rare iatrogenic illness occurring almost exclusively in the delivery room setting. Complications of ergot alkaloids in neonates include respiratory depression, seizures, and death. Case Report: A term infant was inadvertently given 0.1 mg of methylergonovine intramuscularly in the right thigh. The error was only noted when the vial of medication was scanned, after administration, identifying it as methylergonovine rather than vitamin K. The local poison center was notified, and the infant was transferred to the neonatal intensive care unit for observation. Two hours after transfer, the infant was noted to have oxygen desaturations and required oxygen via nasal cannula. Supplemental oxygen was continued for 4 hours until the neonate was able to maintain normal oxygen saturations in room air. Feeding was started by 10 hours of life, and the infant was discharged home in good condition after a 72-hour stay without further complications. Conclusions: Because of the potential for serious adverse events, vigilance is required to prevent accidental administration of methylergonovine to the neonate as a result of possible confusion with vitamin K in the early post-partum period.