J. Ward Donovan

Concomitant use of activated charcoal and N-acetylcysteine

Activated charcoal is a safe, effective, inexpensive adjunct in the management of most toxic ingestions. It has the ability to adsorb a wide variety of drugs and chemicals, one of which is acetaminophen. N-acetylcysteine (NAC) is the specific antidote available for serious overdoses of acetaminophen. Current management of acetaminophen overdose, however, does not recommend the concomitant oral administration of these two useful agents because adsorption and inactivation of NAC by charcoal is believed to occur. Our study was designed to help evaluate the effect of activated charcoal on N-acetylcysteine absorption. Ten healthy male volunteers were each given in the first, or control, phase of the study an oral dose of 140 mg/kg NAC, and venous blood samples were obtained. In the second phase, after a washout period, each subject received 60 g activated charcoal orally followed immediately by 140 mg/kg NAC. NAC serum levels were measured using gas-liquid chromatography, and levels were compared with and without the concomitant administration of charcoal. Although only a small number of the subjects completed the study, the results showed that in both phases there were no significant differences in the peak NAC levels, the plasma half-life of NAC, or the calculated area under the curve. We recommend that NAC and activated charcoal not be used clinically until further studies are completed.

Attending supervision of nonemergency medicine residents in a university hospital ED

There have been a limited number of studies assessing the impact of attending physician supervision of residents in the emergency department (ED). The objective of this study is to describe the changes in patient care when attending emergency physicians (AEPs) supervise nonemergency medicine residents in a university hospital ED. This was a prospective study including 1,000 patients, 32 second- and third-year nonemergency medicine residents and eight AEPs. The AEPs classified changes in care for each case as major, minor, or none, according to a 40-item data sheet list. There were 153 major changes and 353 minor changes by the AEP. The most common major changes were ordering laboratory or x-ray tests that showed a clinically significant abnormality, and eliciting important physical exam findings. Potentially limb- or life-threatening errors were averted by the AEP in 17 patients. Supervision of nonemergency medicine residents in the ED resulted in frequent and clinically important changes in patient care.

Whole-bowel irrigation as adjunctive treatment for sustained-release theophylline overdose

STUDY OBJECTIVE To determine a therapeutic benefit for whole-bowel irrigation (with polyethylene glycol-electrolyte lavage solution) as adjunctive treatment to multiple doses of activated charcoal following an overdose of sustained-release theophylline. DESIGN Randomized crossover study. Three treatment arms were separated by one-week intervals. SETTING Animal care facility housing. TYPE OF PARTICIPANTS Eight female mongrel dogs. INTERVENTIONS Unanesthetized dogs were given approximately 75 mg/kg of sustained-release theophylline. In treatment arm 1, 1 g/kg activated charcoal was administered by nasogastric tube at two hours after ingestion followed by 0.5-g/kg doses at five and eight hours. During treatment arm 2, beginning two hours after theophylline ingestion, 25 mL/kg whole-bowel irrigation solution was administered every 45 minutes for four doses followed by activated charcoal. In treatment arm 3, the first dose of activated charcoal was given ten minutes before beginning the whole-bowel irrigation protocol. MEASUREMENTS AND MAIN RESULTS Serum theophylline levels were measured at zero, two, four, five, eight, 12, 16, and 24 hours after ingestion. Mean serum theophylline levels, area under the curve (P = .13), and terminal half-lives (P = .69) for each treatment group were not statistically different. This negative study had an 81% power to detect a 50% reduction in the area under the curve by whole-bowel irrigation treatment. CONCLUSION In this model, whole-bowel irrigation did not add to the therapeutic benefits of activated charcoal.

Significant envenomation from a preserved rattlesnake head (in a patient with a history of immediate hypersensitivity to antivenin)

We present a case of significant envenomation from a severed, preserved rattlesnake head in a 22-year-old man. The patient was treated successfully with 15 vials of Crotalidae polyvalent antivenin despite a history of severe immediate hypersensitivity reaction to antivenin. The patient developed a mild case of serum sickness five days after antivenin infusion that was treated successfully with a course of steroids. The patient experienced complete recovery. This case demonstrates the hazard of even preserved snake heads and fangs.

Tricyclic Antidepressant Toxicity Treated With Massive Sodium Bicarbonate

Tricyclic antidepressant (TCA) morbitity is primarily due to cardiac arrhythmias and hypotension, which become more refractory to treatment as acidosis progresses (Ann Emerg Med. 1985;14:1-9; Clin Toxicol. 2007;45:203-233; Flomenbaum N, Goldfrank L, Hoffman R, et al. Goldfranks toxicologic emergencies. 8th ed. McGraw-Hill Companies, Inc, 2006). Early recognition and aggressive treatment are necessary for patient survival.

Posttraumatic aneurysms of the hand

Aneurysms should be suspected in patients with a mass in the hand following either open or closed trauma. Posttraumatic aneurysms are classified as true or false. False aneurysms usually result from penetrating trauma and can occur in any disrupted vessel. In contrast, true aneurysms usually occur in either the thenar or hypothenar eminence a few weeks following closed hand injuries. Pulsations may be evident. Symptoms are coolness or paresthesia of the digits and dull pain aggravated by exercise. A positive Allens test is a helpful confirmatory sign in diagnosis. Treatment is surgical with resection of the aneurysm and primary anastomosis or vein graft when possible.

Disaster Management During a Nuclear Accident

This paper offers some guidelines on the basic components of a plan for effective handling of a nuclear accident. Special referencni 9q made to emergency medical services, regional planning, evacuation, communication, decontamination and triage priorities