Frank Daly

Acute Myocardial Infarction Associated With Amphetamine Use

Myocardial infarction is a rarely reported complication of amphetamine use. We report the case of a healthy 31-year-old man who presented to our emergency department with no clinical evidence of an acute coronary event after intravenous injection of amphetamines. However, he subsequently experienced a non-Q-wave anterior wall myocardial infarction associated with the use of amphetamines.

Olanzapine overdose mimicking opioid intoxication

We report significant central nervous system depression and the previously unreported phenomenon of pupillary constriction after acute overdose of olanzapine (Zyprexa) in 4 patients. Phase 2 trials describe a typically benign course in overdose, and published abstracts note a wide spectrum of clinical effects with supratherapeutic ingestion of olanzapine. Our patients demonstrated profound central nervous system depression, and 2 required advanced airway support. All 4 patients recovered with supportive care. Olanzapine should be added to opioid and alpha(2)-adrenergic agonist intoxication in the differential diagnosis of the patient with depressed mental status and miosis.

Neutralization of Latrodectus mactans and L.hesperus venom by redback spider (l.hasseltii) antivenom

Objective: To test the effectiveness of L. hasseltii (redback spider) antivenom in neutralizing the lethal effects of L. hesperus and L. mactans(North American black widow) venoms. Methods: LD50 values for the L. hesperus and L. mactans venom preparations were determined. A prospective, randomized, double-blind antivenom efficacy experiment was then performed for each venom using a mouse envenomation model. The following treatments were premixed and incubated at 25°C for 1 hour prior to intraperitoneal injection: 1) saline control + protein control, 2) saline control + L. hasseltii antivenom, 3)L. hesperus or L. mactans venom + protein control, and 4) L. hesperus or L. mactans venom + L. hasseltii antivenom. The study endpoints were time elapsed until death and survival at 24 hours. Results: The mouse LD50 values for L. hesperus and L. mactans venoms were 0.64 mg/kg and 0.26 mg/kg, respectively. In the efficacy trial, all mice in group 3 (L. hesperus or L. mactans venom and protein control) died. In both experiments, all mice in group 4 (L. hesperus or L. mactans venom + antivenom) survived (p < 0.0001). Conclusion: This is the first study to derive mouse LD50 values for L. hesperus and L. mactans venom obtained by electrical stimulation of live adult spiders. Redback spider antivenom is effective in neutralizing the lethal effects of L. hesperus and L. mactans venoms in a mouse envenomation model. While this study is limited by the optimized premixing of antigen with antibody, it generates the hypothesis that red-back antivenom would be effective in the treatment of latrodectism in humans caused by the two clinically relevant species of North American widow spiders.

Increased hospital costs associated with red blood cell transfusion

Red blood cell (RBC) transfusion is independently associated in a dose‐dependent manner with increased intensive care unit stay, total hospital length of stay, and hospital‐acquired complications. Since little is known of the cost of these transfusion‐associated adverse outcomes our aim was to determine the total hospital cost associated with RBC transfusion and to assess any dose‐dependent relationship.

A risk assessment based approach to the management of acute poisoning

Early assessment and management of poisoning constitutes a core emergency medicine competency. Medical and psychiatric emergencies coexist; the acute poisoning is a dynamic medical illness that represents an acute exacerbation of a chronic underlying psychosocial disorder. The emergency physician must use an approach that ensures early decisions address potentially time critical interventions, while allowing management to be tailored to the individual patient’s needs in that particular medical setting. This article outlines a rationale approach to the management of the poisoned patient that emphasises the importance of early risk assessment. Ideally, this approach should be used in the setting of a health system designed to optimise the medical and psychosocial care of the poisoned patient.

Overuse of non-prescription analgesics by dental clinic patients

BackgroundMany patients present to dental clinics for treatment of painful conditions. Prior to seeking treatment, many of these patients will self-medicate with non-prescription analgesics (NPA), and some will unintentionally overdose on these products. The objective of this study is to describe the use of NPA among dental patients.MethodsAll adult patients presenting to an urban dental clinic during a two-week period in January and February of 2001 were approached to participate in this research project. Trained research assistants using a standardized questionnaire interviewed patients. Patient demographics and the NPA usage over the 3 days preceding the office visit were recorded. We defined a supra-therapeutic dose as any dose greater than the total recommended daily dose stated on package labeling.ResultsWe approached 194 patients and 127 participated. The mean age of participants was 35.5 years, 52% were male. Analgesic use preceding the visit was reported by 99 of 127 patients, and most (81/99) used a NPA exclusively. Fifty-four percent of NPA users were taking more than one NPA. NPA users reported using ibuprofen (37%), acetaminophen (27%), acetaminophen/aspirin combination product (8%), naproxen (8%), and aspirin (4%). Sixteen patients reported supra-therapeutic use of one or more NPA (some ingested multiple products): ibuprofen (14), acetaminophen (3), and naproxen (5).ConclusionNPA use was common in patients presenting to a dental clinic. A significant minority of patients reported excessive dosing of NPA. Ibuprofen was the most frequently misused product, followed by naproxen and acetaminophen. Though mostly aware of the potential toxicity of NPA, many patients used supra-therapeutic dosages.

Measuring the incidence of hospital-acquired complications and their effect on length of stay using CHADx

Objectives: To use an automated Classification of Hospital Acquired Diagnoses (CHADx) reporting system to report the incidence of hospital‐acquired complications in inpatients and investigate the association between hospital‐acquired complications and hospital length of stay (LOS) in multiday‐stay patients.

Coagulopathy from tiger snake envenoming and its treatment

[Extract] Sir, We would like to make some comments on two articles recently published on tiger snake bite and the resultant coagulopathy that occurs with envenoming. Both articles discuss important issues relating to the coagulopathy associated with Australasian elapid envenoming. They correctly make the distinction between snake venominduced activation of the coagulation cascade (VIACC) and disseminated intravascular coagulation (DIC). VIACC is often loosely referred to as defibrination, but is more accurately termed fibrinogen depletion. The article on eastern tiger snake envenoming provides important new information by reporting serial measurements of prothrombin cleavage fragments which has not been previously investigated. It demonstrates that the presence of F1 + 2 levels are possibly highly sensitive tests for envenoming.

Deliberate self‐poisoning with tiagabine: An unusual toxidrome

Tiagabine is an anticonvulsant acting by selective inhibition of neuronal and glial gamma‐aminobutyric acid uptake, resulting in increased gamma‐aminobutyric acid‐mediated inhibition in the brain. Few reports in the literature describe the clinical course of severe tiagabine intoxication. A 44‐year‐old woman presented after deliberate self‐poisoning with 100 tiagabine 15 mg tablets (1500 mg; 25 mg/kg). Serum tiagabine level was 4600 µg/L (1725 mmol/L) at presentation, 20 times levels associated with therapeutic dosing. Intoxication was manifested by profuse vomiting, coma, myoclonus, generalized rigidity, bradycardia, hypertension, hypersalivation and generalized piloerection within 2 h of ingestion. The patient was intubated and management was supportive. Coma lasted until 10 h post‐ingestion, but recovery was complicated by severe agitated delirium lasting 12 h. The patient recovered fully within 26 h of ingestion. Tiagabine deliberate self‐poisoning was associated with the rapid onset of coma and an unusual toxidrome. Recovery, although complicated by agitated delirium, was complete within 26 h.

A PROSPECTIVE STUDY OF NON‐FATAL HEROIN OVERDOSE

Aims: We aimed to study the prevalence, characteristics and outcomes of patients presenting with non‐fatal heroin overdose. Design: Prospective observational study. Setting: Emergency Department (ED). Participants: Patients attending with non‐fatal heroin overdose. Intervention: Nil. Measurement: Descriptive and epidemiological data. Findings: Two‐hundred‐and‐forty‐nine overdoses in 224 patients (61.2% male, range 15–49 years). Mean reported age of first heroin use was 18.8 years (range 10–42). Forty‐two per cent reported a previous heroin overdose requiring hospital intervention. Co‐ingestants included benzodiazepines (61, 27.2%), alcohol (35, 15.6%), cannabis (25, 11.1%), amphetamines (13, 5.8%) and hallucinogens (3, 1.3%). Most patients experienced a benign course; 81 of 115 ambulance presentations (70.4%) received prehospital naloxone and 23 (9.2%) received naloxone in the ED; 67.9% had no investigations and complications were uncommon (two aspiration, one hypoxic brain injury). Median length of stay was 180 min (15 min to 48 h). Only 29 (11.6%) presentations required admission. There were 15 individuals (6.7%) who had 40 (16.1% of the total) repeat presentations. Conclusions: Heroin overdose tends to occur in experienced users who commonly co‐ingest other drugs. There is a trend of overdose occurring with increasing frequency in teenage females. Repeat overdosing is common. However, while morbidity is low, these patients require considerable resources.