Christopher O. Hoyte

Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This Part of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) addresses cardiac arrest in situations that require special treatments or procedures other than those provided during basic life support (BLS) and advanced cardiovascular life support (ACLS). This Part summarizes recommendations for the management of resuscitation in several critical situations, including cardiac arrest associated with pregnancy (Part 10.1), pulmonary embolism (PE) (10.2), and opioid-associated resuscitative emergencies, with or without cardiac arrest (10.3). Part 10.4 provides recommendations on intravenous lipid emulsion (ILE) therapy, an emerging therapy for cardiac arrest due to drug intoxication. Finally, updated guidance for the management of cardiac arrest during percutaneous coronary intervention (PCI) is presented in Part 10.5. A table of all recommendations made in this 2015 Guidelines Update as well as those made in the 2010 Guidelines is contained in the Appendix. The special situations of resuscitation section (Part 12) of the 2010 AHA Guidelines for CPR and ECC 1 covered 15 distinct topic areas. The following topics were last updated in 2010: Additional information about drowning is presented in Part 5 of this publication, “Adult Basic Life Support and Cardiopulmonary Resuscitation Quality.” The recommendations in this 2015 Guidelines Update are based on an extensive evidence review process that was begun by the International Liaison Committee on Resuscitation (ILCOR) with the publication of the ILCOR 2010 International Consensus on CPR and ECC Science With Treatment …

An Outbreak of Exposure to a Novel Synthetic Cannabinoid

Young men in Colorado presented with altered mental status and seizures after ingestion of a synthetic cannabinoid known as “black mamba.” Medical toxicologists and public health and law enforcement officials identified 263 cases of exposure to this novel substance.

NBOMe and 2C substitute phenylethylamine exposures reported to the National Poison Data System

Abstract Background. Hallucinogenic designer drugs, especially NBOMe and the 2C substitute phenylethylamine series, have been increasing ubiquitous in past years. The purpose of this study is to characterize and compare clinical features of NBOMe and 2C exposures in humans. Method. This is a retrospective cohort study of all single agent exposures to NBOMe and 2C substitute phenylethlamine reported to the National Poison Data System (NPDS) from 1st September 2012 to 30th September 2014. Results. Over the study period, there were a total 341 cases including 148 NBOMe exposures and 193 2C exposures. The majority cases involved men (73.9%); median age was 18 years (Interquartile-range, 16–21). Similar clinical effects were reported in both groups including tachycardia (45.2%), agitation/irritable (44.3%), hallucination/delusion (32.0%), confusion (19.1%) and hypertension (18.5%). There were higher incidences of hallucination/delusion, single episode seizure and benzodiazepine administration in NBOMe exposures (40.5%, 8.8% and 50.0%respectively) than those of 2C exposures (25.4%, 3.1%, and 32.6% respectively). There were 2.3% death; no difference between two groups. Discussion. The higher rate of symptoms in NBOMe is consistent with the higher 5HT2A agonistic effects of NBOMe described in both molecular and animal studies. Conclusion. Common clinical effects of NBOMe and 2C exposures were tachycardia, agitation/irritable, hallucination/delusion, confusion, and hypertension. There were higher incidences of hallucination/delusion, single episode seizure and benzodiazepine administration in NBOMe.

Characterization of edible marijuana product exposures reported to United States poison centers

Abstract Context: Edible marijuana products are sold as brownies, cookies, and candies, which may be indistinguishable from counterparts without marijuana and are palatable to children and adults. The consumption of an entire product containing multiple dose-units may result in overdose. Objective: To characterize edible marijuana exposures reported to US poison centers with subgroup analysis by age. Methods: We analyzed single substance, human exposure calls coded to marijuana brownies, candies, cookies, beverages, or other foods reported to the National Poison Data System from January 2013 to December 2015. Calls were analyzed by state, age, gender, exposure route, clinical effect, therapies, and level of healthcare facility utilization. Results: Four-hundred and thirty calls were reported: Colorado (N = 166, 1.05/100,000 population/year) and Washington (96, 0.46) yielded the highest number of exposures. Three hundred and eighty-one (91%) calls occurred in states with decriminalized medical/recreational marijuana. The number of calls increased every year of the study. The most common age groups were: ≤5 years (N = 109, 0.15/100,000 population/year) and 13–19 (78, 0.09). The most frequent clinical effects were drowsiness/lethargy (N = 118, percentage = 43%), tachycardia (84, 31%), agitated/irritable (37, 14%), and confusion (37, 14%). Children ≤5 years have more drowsiness/lethargy, ataxia, and red eye/conjunctivitis. No deaths were reported. The most common therapies administered were intravenous fluids (85, 20%), dilute/irrigate/wash (48, 11 %), and benzodiazepines (47, 11%). Three patients (ages 4, 10, and 57 years) received intubation. 97 (23%), 217 (50%), and 12 (3%) calls were managed at home, treated/released, admitted to a critical care unit, respectively. Discussion: Although most clinical effects are minor, ventilatory support may be necessary for children and adults. We speculate the increasing exposures may be related to a combination of delayed absorption kinetics of Δ9-tetrahydrocannablnol, lagging packaging regulations, increased accessibility in decriminalized states, and increased familiarity of poison center specialists with edible product codes. Conclusions: Edible marijuana exposures are increasing and may lead to severe respiratory depression.

Anaphylaxis to black widow spider antivenom

Black widow spider envenomation is commonly reported to poison centers. Black widow spider envenomation produces a clinical syndrome, known as latrodectism, characterized by headache, nausea, vomiting, several muscle cramping and pain, joint stiffness, hypertension, and regional diaphoresis. Black widow spider antivenom (Merck & Co, Inc, West Point, PA USA) is an effective and relatively safe treatment option. There is 1 clear case of anaphylaxis secondary to black widow spider antivenom reported in the medical literature. Here, we report a case of anaphylaxis to antivenom. A 12-year-old boy presented to the emergency department (ED) with diffuse, severe pain 2 1/2 hours after being bitten by a black widow spider on the right lower extremity. In the ED, the patient failed analgesic therapy with fentanyl and was given black widow spider antivenom. Within 45 minutes, he exhibited signs and symptoms consistent with anaphylaxis, including wheezing, chest tightness, pruritus, and urticarial rash. The patient was given standard therapy for anaphylaxis, and all of his signs and symptoms (including the pain secondary to the black widow envenomation) resolved over 6 hours of observation. Leading experts agree that the use of antivenom is indicated in cases of severe envenomation not responsive to standard therapy. Despite concern that the antivenom is an equine-derived whole IgG and can precipitate early hypersensitivity reactions, there is only 1 other reported case of anaphylaxis to the antivenom in the medical literature.

Cardiac sodium channel blockade after an intentional ingestion of lacosamide, cyclobenzaprine, and levetiracetam: Case report.

Abstract Context. Lacosamide treats partial seizures by enhancing slow inactivation of voltage-gated sodium channels. The described cardiac toxicity of lacosamide in the literature to date includes atrioventricular blockade (PR prolongation), atrial flutter, atrial fibrillation, sinus pauses, ventricular tachycardia and a single cardiac arrest. We report a second case of cardiac arrest following an intentional lacosamide overdose. Case details. A 16 year-old female with a seizure disorder was found unresponsive in pulseless ventricular tachycardia after intentionally ingesting 4.5 g (76 mg/kg) lacosamide, 120 mg (2 mg/kg) cyclobenzaprine and an unknown amount of levetiracetam. Exact time of ingestion was unknown. Her initial electrocardiogram (ECG) demonstrated sinus tachycardia at 139 beats per minute, QRS duration 112 ms, and terminal R-wave in lead aVR > 3 mm. Despite treatment with 150 mEq of sodium bicarbonate, she had persistent EKG findings eight hours after presentation. Her serum lacosamide concentration nine hours after presentation was elevated at 22.8 μg/mL, while serum cyclobenzaprine concentration was 16 ng/mL (therapeutic: 10–30 ng/mL), and serum levetiracetam concentration was 22.7 μg/mL (therapeutic: 12–46 μg/mL). On hospital day three, ECG demonstrated resolution of the terminal R-wave with QRS of 78 ms. The patient recovered without physical or neurologic sequelae. Discussion. The patients lacosamide, cyclobenzaprine and levetiracetam overdose was associated with QRS prolongation and terminal right axis deviation – suggesting sodium channel blockade as a likely etiology for her cardiac arrest. Cyclobenzaprine has potential for sodium channel blockade and ventricular dysrhthmias although cardiac toxicity due to cyclobenzaprine alone is rare. The combination of cyclobenzaprine with lacosamide may have resulted in cardiovascular collapse. In conclusion, overdose of lacosamide combined with therapeutic concentrations of sodium channel blocking xenobiotics may cause cardiac conduction delays and cardiac arrest.

The toxicity of energy drinks: Myth or reality?

The fi rst commercially available energy drink named Krating Daeng was introduced and sold in Thailand in 1976. Krating Daeng served as the inspiration for the creation of Red Bull ® in 1987 which is currently the most popular energy drink in the world. Many other manufacturers such as Hansen ® , Monster Energy ® , and Rockstar have entered the market with their own products. With the introduction of these products, the consumption of energy drinks has increased signifi cantly the last decade. Globally, the number of energy drinks consumed in 2010 was 6 billion increasing from 2.3 billion in 2005. 1 In the United States (US), 13,114 cases of toxicity secondary to energy drink consumption presented to emergency departments in 2009 increasing from 1,128 in 2005. 2 Many of these products are marketed towards adolescents and young adults, and single use among adolescents has been estimated at 30 – 50%. 3

Management of diethylene glycol ingestion

Context. Diethylene glycol is a toxic alcohol used as an industrial solvent in various products. Human exposure to diethylene glycol has resulted in multisystem organ dysfunction and death in cases of acute intentional ingestions as well as epidemics of mass poisoning. Debate remains as to whether the parent compound or metabolite, 2-hydroxyethoxyacetic acid, is responsible for the majority of the toxicity seen in diethylene glycol poisoning. Therefore, cases of diethylene glycol poisoning create management dilemmas when deciding whether to administer alcohol dehydrogenase inhibitors, hemodialysis, or both. Case details: A 35-year-old male was presented to the emergency department reporting that he intentionally ingested brake fluid containing diethylene glycol 8 hours prior to arrival. The patient complained only of epigastric abdominal pain, had a normal physical exam, with a serum bicarbonate of 22 mmol/L, serum creatinine of 0.9 mg/dL, and an undetectable serum ethanol. The management dilemma in this case was whether to initiate fomepizole therapy, administer hemodialysis, or both given the high risk circumstances of the presentation. The decision was made not to administer any therapy other than usual supportive care. Serial basic metabolic panels were sent showing the development of no acidosis or renal dysfunction until his serum diethylene glycol concentration returned undetectable. Discussion. Diethylene glycol ingestion can be life threatening. This case highlights the difficulty regarding management of these cases while attempting to balance resource utilization, diagnosis, monitoring, and therapy. Due to continued debate, these decisions remain practitioner specific. Keywords Toxic alcohols; fomepizole; hemodialysis

Common marijuana-related cases encountered in the emergency department

In 2000, Colorado voters decriminalized marijuana for medical use; however, because marijuana use remained illegal under federal law, the number of users was low.[1][1] In 2009, President Obama instructed federal officials not to enforce marijuana laws that were in conflict with state laws, and the

Pyridoxine for the treatment of isoniazid-induced seizures in intentional ingestions: The experience of a national poison center

Background Pyridoxine (vitamin B6) is used as an antidote for isoniazid (INH) overdose, especially in intentional ingestions. The active form of pyridoxine is pyridoxal 5′‐phosphate (P5P), a cofactor for glutamic acid decarboxylase in gamma aminobutyric acid (GABA) synthesis. INH inhibits this enzymatic pathway causing a decrease in brain levels of GABA, the major inhibitory neurotransmitter in the central nervous system, with resultant increase in susceptibility to seizures. The aim of this study was to evaluate and document the role of pyridoxine in the treatment of patients with intentional ingestion of INH and to report our experience. Methods Medical records of affected patients were reviewed; data collected included exposure history, clinical manifestations, physical examination, laboratory values and clinical outcomes. Results There were 16 cases of INH intoxication associated with intentional ingestions, 11 were associated with substantial ingestions with the maximum dose ingested being 15 g. In 9 cases the patients suffered seizures while other clinical manifestations included hypertension, drowsiness and vomiting. Pyridoxine was administered prophylactically in only 3 patients, none of whom developed seizures. Conclusion Intentional ingestion of INH is one of the causes of drug‐induced seizures. Early recognition and specific treatment with pyridoxine can prevent mortality. Our series suggests that patients with large‐dose intentional ingestions have a substantial risk of multiple seizures that can be treated successfully with 1 g of pyridoxine intravenously or 1 g of pyridoxine per gram of isoniazid ingestion. This antidote is safe and effective. Consideration can be given to administering pyridoxine prophylactically in some circumstances.