Kathleen E Kane

Management of isolated yew berry toxicity with sodium bicarbonate: A case report in treatment efficacy

IntroductionTaxus species are known to be toxic and may result in significant dysrhythmias. Treatment of taxus induced cardiac dysrhythmias is based largely on case reports. We describe a case of a 24-year-old male withTaxus cuspidate (yew berry) toxicity initially treated with amiodarone bolus and infusion and subsequently managed with sodium bicarbonate boluses and continuous infusion.Case ReportThe patient was found at home by his parents with witnessed “seizure-like” activity 2 hours after reportedly chewing and swallowing 168 yew seeds. The initial prehospital rhythm strip demonstrated ventricular tachycardia (VT); the patient was hypotensive with fluctuating levels of alertness. Prehospital cardioversion was attempted without success.Staff at the local presenting emergency department (ED) consulted toxicology for management of the presumed yew berry ingestion, complicated by cardiac dysrhythmias and mental status change with seizure. Amiodarone 300-mg IV and diazepam 5-mg IV were given. Cardioversion was attempted 4 times without change in the wide complex tachycardia, presumed to be VT, at a rate of 166. An amiodarone drip at 1 mg/min was initiated. The patient was transferred to an intensive care unit (ICU) at a regional toxicology center.On arrival to the toxicology center the patient was alert and verbally appropriate without complaints. Initial heart rate was 76 and regular with premature ventricular contractions (PVCs). A wide complex tachycardia associated with hypotension recurred; however, normal mental status was maintained. A bolus of 100 mEq of sodium bicarbonate (NaHCO3) was given intravenously followed by sodium bicarbonate infusion at 37.5 mEq/hr. The amiodarone drip was discontinued. Subsequent electrocardiograms (EKG’s) revealed a prolonged, but steadily narrowing QRS complex. Ultimately, the QRS complex closed to 92 ms, with a rate of 94, PR 154 and a QT/QTc of 390/487.ConclusionThis case describes successful treatment of an isolatedTaxus cuspidate (yew berry) ingestion with significant toxicity initially with amiodarone bolus and infusion. Due to lack of significant change in telemetry recordings with amiodarone, treatment with sodium bicarbonate bolus and infusion was initiated. While the QRS narrowed significantly temporally related to the bicarbonate, it is difficult to determine if correction of the cardiac dysrhythmias was solely due to the sodium bicarbonate, or the synergism of sodium bicarbonate and amiodarone, or possibly spontaneous improvement due to taxine clearance. One should use caution while drawing conclusions from a single case; however, based on the clinical improvement of this patient, both with EKG recordings and vital signs, this report would suggest that isolatedTaxus cuspidate ingestion from yew berry plants can be treated with sodium bicarbonate.

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.

Recurrent (stump) appendicitis: a case series.

Stump appendicitis is a rare but serious postoperative complication of an appendectomy. In the emergency department, diagnosticians are likely to rule out appendicitis when a surgical history of an appendectomy is reported. We describe 2 patients in this case series who presented to the emergency department with right lower quadrant abdominal pain and a history of previous appendectomy. Both patients were identified with a remnant appendiceal stump and stump appendicitis. Upon admission to a surgical service, a nonoperative approach in management allowed each patient to stabilize and be discharged after treatment with antibiotics. The purpose of this article is to raise awareness about the diagnosis of stump appendicitis, as well as to discuss the treatments for it.

Simultaneous Very Late Angiographic Stent Thrombosis of 2 Drug-Eluting Stents: A Case Report

Very late angiographic stent thrombosis (VAST) is a known serious complication of drug-eluting stents (DESs). Most VAST events occur shortly after the discontinuation of aspirin and/or clopidogrel. This case is unique in that the patient had recently discontinued only aspirin and involves simultaneous VAST of 2 separate stents. Although the safety profile of DES does not seem to differ from those of bare metal stents in regard to thrombosis in the acute (within 24 hours) and subacute (24 hours-30 days) phases, data suggest an increase in thrombotic events in the late (after 30 days) and very late (after 12 months) phases after DES deployment. Results from a recent pooled analysis suggest that DES does not increase the risk of stent thrombosis under appropriate multidrug antiplatelet therapy. In this case, the patient self-discontinued daily aspirin 2 months before the simultaneous total occlusion of 2 DESs 37 months after placement. This was 34 months after an initial 3-month course of clopidogrel and 13 months after a 30-day course of clopidogrel. This case provides additional evidence to the importance of continued dual antiplatelet therapy and attention to compliance in patients with DESs.

The ‘‘ICE’’ Study: Feasibility of Inexpensive Commercial Coolers on Mobile EMS Units

INTRODUCTION Prehospital postresuscitation induced hypothermia (IH) has been shown to reduce neurological complications in comatose cardiac-arrest survivors. Retrofitting ambulances to include equipment appropriate to initiate hypothermia, such as refrigeration units for cooled saline, is expensive. The objective of this nonhuman subject research study was to determine if inexpensive, commercially available coolers could, in conjunction with five reusable ice packs, keep two 1 L bags of precooled 0.9% normal saline solution (NSS) at or below 4°C for an average shift of eight to 12 hours in a real-world environment, on board in-service Emergency Medical Service (EMS) units, over varying weather conditions in all seasons. METHODS The coolers were chosen based on availability and affordability from two nationally available brands: The Igloo MaxxCold (Igloo Products Corp., Katy, Texas USA) and Coleman (The Coleman Company, Wichita, Kansas USA). Both are 8.5 liter (nine-quart) coolers that were chosen because they adequately held two 1 L bags of saline solution, along with the reusable ice packs designated in the study design, and were small enough for ease of placement on ambulances. Initial testing of the coolers was conducted in a controlled environment. Thereafter, each EMS unit was responsible to cool the saline to less than 4°C prior to shift. Data were collected by emergency medical technicians, paramedics, and resident physicians working in seven different ambulance squads. Data analysis was performed using repeated measurements recorded over a 12-hour period from 19 individual coolers and were summarized by individual time points using descriptive statistics. RESULTS Initial testing determined that the coolers maintained temperatures of 4°C for 12 hours in a controlled environment. On the ambulances, results based on the repeated measurements over time revealed that the saline solution samples as defined in the protocol, remained consistently below 4°C for 12 hours. Utilizing the lower bound of the 2-sided 95% exact binomial confidence intervals, there was less than a five percent chance that saline samples could not be maintained below 4°C for 12 hours, even during the summer months. CONCLUSIONS Simple, commercially available coolers can maintain two 1 L bags of 0.9% NSS at 4°C for 12 hours in ambulances in varying environmental conditions. This suggests that EMS agencies could inexpensively initiate prehospital IH in appropriate cases.