Gerald F. O'Malley

Routine Packing of Simple Cutaneous Abscesses Is Painful and Probably Unnecessary

OBJECTIVES The objective was to determine whether the routine packing of simple cutaneous abscesses after incision and drainage (I&D) confers any benefit over I&D alone. METHODS In a prospective, randomized, single-blinded trial, subjects with simple cutaneous abscesses (less than 5 cm largest diameter) underwent incision, drainage, irrigation, and standard abscess preparation in the usual manner. Subjects were then randomized to either packing or no-packing. Visual analog scales (VAS; 100 mm) of pain were recorded in the emergency department (ED). All patients received trimethoprim-sulfamethoxazole (TMP-SMX), ibuprofen, and narcotic prescriptions, recorded twice daily VAS pain scores, and returned in 48 hours at which time dressings and packing, if present, were removed and a physician blinded to the randomization and not part of the initial visit repeated measurements and determined the need for further intervention. RESULTS Forty-eight subjects were included in the final analysis. There were no significant differences in age, sex, abscess location, or initial pain scores between the two groups. There was no significant difference in need for a second intervention at the 48-hour follow-up between the packed (4 of 23 subjects) and nonpacked (5 of 25 subjects) groups (p = 0.72; relative risk = 1.3, 95% confidence interval [CI] = 0.4 to 4.2). Patients in the group that received packing reported higher pain scores immediately postprocedure (mean difference = 23.8 mm; p = 0.014, 95% CI = 5 to 42 mm) and at 48 hours postprocedure (mean difference = 16.4 mm; p = 0.03, 95% CI = 1.6 to 31.2 mm), as well as greater use of ibuprofen (mean difference = 0.32; p = 0.12, 95% CI = -1.4 to 2.0) and oxycodone/acetaminophen (mean difference = 2.19; p = 0.03, 95% CI = 0.2 to 4.1). CONCLUSION In this pilot study, not packing simple cutaneous abscesses did not result in any increased morbidity, and patients reported less pain and used fewer pain medications than packed patients.

A Preliminary Study of Tricyclic Antidepressant (TCA) Ovine FAB for TCA Toxicity

Background. Animal studies suggest that tricyclic antidepressant antibody fragments (TCA Fab) may be a useful therapy for tricyclic antidepressant poisoning. The objective of this study is to determine if TCA Fab increases total serum TCA levels without raising free serum TCA levels in human overdose patients, indicating that TCA Fab effectively binds TCA. Methods. This was a prospective, dose escalation study of patients with mild to moderate TCA poisoning. Patients were treated with an escalating intravenous infusion totaling 7 or 14 gm of TCA Fab. The outcomes of interest were serum TCA levels (total and free), worsening of TCA toxicity, and adverse effects. Results. Seven patients were treated with Fab. Infusion of TCA Fab was associated with a dramatic increase in total serum TCA levels, while free TCA levels fell in both dosing groups. There were no significant changes in QRS duration, heart rate or mean arterial pressure associated with the Fab Infusion. Worsening of TCA toxicity did not occur despite marked elevation of total serum TCA concentrations. The two patients with the greatest prolongation of QRS showed a prompt shortening in their QRS duration temporally associated with the Fab infusion. Mild wheezing was observed in one asthmatic patient. Conclusions. 1) TCA Fab raises total serum TCA levels while lowering free levels in TCA poisoned patients; 2) no toxic effects were associated with the increase in TCA levels and no severe adverse effects were observed during the hospital course following Fab infusion.

Esophageal obstruction from a hygroscopic pharmacobezoar containing glucomannan

Glucomannan is a dietary fiber that is the main polysaccharide obtained from the tubers of the Amorphophallus konjac plant. It has been used as a dietary fiber for more than 1,000 years in eastern cultures, and has gained popularity in many western countries over the last 20 years. This soluble fiber has very substantial water-holding properties, and forms highly viscous solutions when dissolved in water. It also has considerable hygroscopic properties, expanding rapidly to many times the size of the original material. These properties have made glucomannan an ideal diet agent as the material swells in the GI tract after ingestion, producing a feeling of satiety and fullness. It has also been reported to have hypocholesterolemic, hypoglycemic, hypoinsulinemic and anti-constipatory effects. The negative effects reported include flatulence, abdominal pain, gastrointestinal obstruction, and possible modification of the bioavailability of other medications. This report describes a 37-year-old female who developed delayed esophageal obstruction after ingesting an over-the-counter diet aid containing glucomannan. The patient ultimately cleared the obstruction through forceful emesis, just prior to upper gastrointestinal endoscopy. The patient was noted to have an esophageal web during outpatient endoscopy. This case illustrates the potential dangers of glucomannan and other hygroscopic medications in patients with a history of upper gastrointestinal pathology.

Pediatric Ziprasidone Overdose

We describe the first ziprasidone overdose with quantitative serum levels of a pediatric patient in coma and with pinpoint pupils. This case is an important contribution to the pediatric ziprasidone literature because it illustrates that ingestion of just 1 pill may result to profound mental status and respiratory depression in a child. H.C., a 30-month-old girl, presented to the emergency department approximately 30 minutes after an accidental ingestion of an adult family members medication. The child was found on the floor surrounded by numerous pills and was witnessed to have ingested at least 1 tablet by a caregiver. After finding the child with the pills, the family observed the child for a brief period but transported her to the hospital after she became lethargic and unresponsive. The child received 2 doses of 0.4 mg of intravenous naloxone without change in her neurologic status. The child then underwent a rapid sequence intubation for airway protection and subsequently received gastrointestinal decontamination with 15 g of activated charcoal via the orogastric tube. Ziprasidone is an atypical antipsychotic drug that was approved by the Food and Drug Administration in February 2001 for the general treatment of schizophrenia in adults. Previously reported pediatric ziprasidone overdoses describe a syndrome of sedation, tachycardia, hypotonia, and coma consistent with that of the patient described in this paper. In pediatric ziprasidone overdose, QTc prolongation and hypotension have also been illustrated, but seizures have not been reported. An interesting aspect of this case is the development of pinpoint pupils unresponsive to naloxone. This phenomenon has been reported before with overdose of olanzapine, a similar atypical antipsychotic. The mechanism of miosis associated with overdose of atypical antipsychotics is unclear but is likely related to interference with central innervation of the pupil. Pupil size is maintained by a balance between sympathetic and parasympathetic neurohumeral tones. We propose that an overdose of an alpha-1 receptor blocking agent, such as ziprasidone, results in unopposed parasympathetic stimulation resulting in miosis.

Eye Irrigation is More Comfortable With a Lidocaine: Containing Irrigation Solution Compared With Normal Saline

BACKGROUND Is eye irrigation with a Morgan lens more comfortable with a lidocaine-containing solution compared with standard saline? METHODS Prospective randomized double-blind volunteer placebo controlled study. Subjects received two drops of 2% tetracaine in each eye. Morgan lenses were applied to each eye and connected to separate 1-L bags of room temperature 0.9% saline. Subjects were randomized to continuous irrigation with 0.01% lidocaine solution (10 mL of 1% lidocaine [100 mg] in 1 L saline) in either the right or left eye with the opposite eye serving as control. pH was measured and fluid flow rate set at 35 mL/min. Blinded interviewers asked the subjects at 5 minutes intervals to rate their discomfort on a five-point Likert scale. Differences in mean Likert scores and standard deviation at 5, 10, 15, 20, and 25 minutes in each eye were calculated. Data were analyzed using one-way analysis of variance and the Bonferroni (BON) multiple comparison test (paired sample t test). RESULTS One-way analysis of variance p value for the combined time sets was very significant (<0.0001). The difference in mean Likert scores for 5 minutes was not statistically significant; approached statistical significance at 10 minutes and were very significant at 15 minutes {1.22 [95% confidence interval (CI) 0.16-2.28]; BON 3.02}, 20 minutes [1.44 (95% CI 0.38-2.5); BON 3.57], and 25 minutes [1.55 (95% CI 0.62-2.88); BON 4.09]. There were no reported long-term adverse effects. CONCLUSIONS Continuous irrigation of the eye with a lidocaine-saline solution and a Morgan lens causes less discomfort than saline alone in healthy volunteers.

Letters, Libel, and the Law

Authors of scientific articles and journal editors are subject to antidefamation publication laws. We describe our experience with an accusation of libel. We define libel as it involves the medical literature and explain the ways in which threats of libel influence editorial decisionmaking and lead to negative publication bias by presenting examples drawn from the medical and legal literature.

Accessing the Poison ControlCenter in the 21st Century. Howdo Patients Find and Contacttheir Poison Control Center

Methods of accessing public services have evolved. It is unclear how the public locates contact phone numbers and communicates with poison centers. Methods: Prospective, observational survey on human exposure calls to the Rocky Mountain Poison & Drug Center over a 5-day period. Respondents were asked how they obtained the phone number for the poison center and whether they were calling from a cell phone or a landline. Results: The largest percentage of respondents (43%) located the poison center phone number via the internet and the majority of respondents (74%) called on a cell phone. Conclusion: Most callers use internet sources to find poison center phone numbers and cell phones to access poison centers.

Analytic Reviews : Management of Acetaminophen Toxicity in the Intensive Care Unit: Kuffner EK, Heard K, O'Malley GF Management of Acetammophen Toxicity in the Intensive Care Unit J Intensive Care Med 1999,14 157-165

patients can be safely managed outside the ICU, serious toxicity can result in hepatic failure and death. N-acetylcysteine has been shown to prevent liver injury when administered early and reduce mortality for patients with hepatic failure. The proposed mechanism of acetaminophen toxicity and N-acetylcysteine therapy are discussed, as well as extrahepatic toxicity of acetaminophen. Other topics that are discussed include the interaction of ethanol consumption and acetaminophen toxicity and recent advances in the man-