Kathryn R. Challoner

Castor bean intoxication

We report the cases of a child who ingested two or more castor beans and two adults who each ingested four beans. All three patients developed severe gastroenteritis and recovered without sequelae after receiving IV fluids. The literature contains reports of 424 cases of castor bean intoxication. Symptoms of intoxication include acute gastroenteritis, fluid and electrolyte depletion, gastrointestinal bleeding, hemolysis, and hypoglycemia. Delayed cytotoxicity has not been reported. Of the 424 patients, 14 died (mortality rates: 8.1% of untreated and 0.4% of treated). Deaths were due to hypovolemic shock. Recommended treatment for asymptomatic patients who have chewed one or more raw beans is emergency department evaluation, gastric decontamination, administration of activated charcoal, observation until four to six hours after ingestion, and discharge instructions to return if symptoms develop. After decontamination and activated charcoal, symptomatic patients require hospitalization for treatment with IV fluids, supportive care, and monitoring for hypoglycemia, hemolysis, and complications of hypovolemia. Monitoring for delayed cytotoxicity is unnecessary. Castor beans and their dust are highly allergenic and may cause anaphylaxis.

Corneal abrasions associated with pepper spray exposure

Pepper spray containing oleoresin capsicum is used by law enforcement and the public as a form of nonlethal deterrent. Stimulated by the identification of a case of a corneal abrasion associated with pepper spray exposure, a descriptive retrospective review of a physician-maintained log of patients presenting to a jail ward emergency area over a 3-year period was performed. The objective was to give some quantification to the frequency with which an emergency physician could expect to see corneal abrasions associated with pepper spray exposure. Of 100 cases of pepper spray exposure identified, seven patients had sustained corneal abrasions. We conclude that corneal abrasions are not rare events when patients are exposed to pepper spray and that fluorescein staining and slit lamp or Woods lamp examination should be performed on all exposed patients in whom corneal abrasions cannot be excluded on clinical grounds.

PENTAZOCINE (TALWIN@) INTOXICATION: REPORT OF 57 CASES

Overdose of pentazocine (Talwin), an agonist/antagonist opioid analgesic, is relatively uncommon. Fifty-seven cases occurring over ten years are reported. Twenty-three patients (40%) had ingested only pentazocine and did not have the classic opioid toxidrome of CNS and respiratory depression with miosis. Most patients were awake, and no patient had a respiratory rate below 12/minute. Other findings included: grand mal seizures, hypertension, hypotonia, dysphoria, hallucinations, delusions, and agitation. Eleven of 23 patients received IV naloxone (0.4-2.4 mg), but only two showed improvement. Thirty-four patients (60%) had coingested pentazocine with one to five additional substances. Patients who had ingested pentazocine with alcohol, a sedative/hypnotic drug, or an antihistamine, showed increased toxicity, including apnea, deep coma, and recurrent seizures. One patient developed opioid pulmonary edema. One patient died. Three of five patients with coma and inadequate respirations responded to IV naloxone in doses of 0.4 to 1.2 mg.

Dapsone intoxication: Two case reports

Two patients with dapsone intoxication, an adult and a 16-month-old child, are reported. Both developed symptomatic methemoglobin concentrations, of 35% and 37%, respectively, and improved with intravenous methylene blue. Methemoglobin levels subsequently rose in both cases to 25% at 24 and 37 hours, respectively. The recurrence of elevated methemoglobin levels resulted from either continued absorption of dapsone or its toxic metabolite from the gastrointestinal tract. Both patients were begun on serial oral activated charcoal and the child received a second methylene blue treatment. During the intoxication, serum hemoglobin concentrations dropped 2 gm with an increase in the reticulocyte count. Review of 20 cases of dapsone overdose from the literature showed that the major toxic manifestations are methemoglobinemia and hemolysis. Delayed sulfhemoglobinemia, reported in only one case, resolved spontaneously. The treatment of dapsone intoxication is intravenous methylene blue for symptomatic methemoglobinemia, gastric decontamination, and early administration of serial oral activated charcoal. Hemolysis is mild but transfusions may be required for patients with a glucose-6-phosphate dehydrogenase deficiency.

Effect of civil war on medical education in Liberia

BackgroundFrom 1980 to 2003 Liberia entered into a period of conflict and civil wars. During this time Liberias health and educational services were severely disrupted. Equipment and supplies were stolen from the Medical School and the buildings damaged severely. A majority of health care workers, university faculty, and hospital and medical school administrators fled the country.ObjectiveThe objective of this study was to evaluate the impact of civil war on the training of medical students and physicians, and to identify a feasible intervention.MethodsThe authors compiled data from three sources at an Emergency Medicine symposium held at the A.M. Dogliotti School of Medicine, in Monrovia, Liberia, in September 2007. These were (1) data from 13 anonymous surveys completed by symposium participants who were physicians or physicians in training, and (2) answers from six open discussion groups at the symposium concerning perceived barriers to medical training. (3) Supporting documents volunteered by the Dean from interviews in 2002, 2007 and 2009 or published on line in 2002 and 2006 were incorporated, and a focused literature review was performed.ResultsThe 12 medical students and 1 physician who returned completed surveys and attended the symposium all reported a delay in their training, with 75% of respondents citing a past and current lack of Clinical and Basic Science faculty as a major delaying factor. The six open discussion groups at the symposium and the information provided by the Dean substantiated these findings.ConclusionsVolunteer Basic Science and Clinical faculty for the medical school and teaching hospitals from a coalition of concerned partnering institutions would be a targeted intervention to assist in re-building the medical educational capacity of Liberia.

Nontraumatic abdominal surgical emergencies in the pregnant patient

Although most EPs are aware of the diverse presentations of ectopic pregnancy, this diagnosis remains a formidable challenge in the ED. The diagnosis of abdominal surgical emergencies in pregnant patients continues to challenge EPs, surgeons, and obstetricians alike. Understanding how the gravid state can obscure common conditions such as appendicitis, cholecystitis. bowel obstruction, and adnexal torsion might help the EP identify suspicious cases early, preventing serious consequences to the mother and fetus.

The flexible baton TM-12 : A case report involving a new police weapon

The purpose of this case report is to describe a new type of police weapon and the injuries sustained by an individual after being shot with it. The Flexible Baton is a type of ammunition that consists of a fabric bag, filled with lead shot pellets, that is shot from a shotgun. It is predicted that this bag may cause bruising, abrasions, and blunt trauma. In our patient, the fabric bag burst and the pellets penetrated the skin of the elbow, resulting in cortical violation of the distal humerus. As more guns with this ammunition have been introduced throughout the United States, we conclude that injuries from this weapon will be seen with greater frequency.

Ammonium nitrate cold pack ingestion.

Disposable ammonium nitrate cold packs are widely used in emergency departments instead of ice bags. Five confused or suicidal patients who tore open a pack and ingested from 64 to 234 grams of ammonium nitrate in a single dose, and another patient who attempted to do so, are reported. It is known that chronic ingestion of 6 to 12 grams/day of ammonium nitrate may cause gastritis, acidosis, isosmotic diuresis, and nitrite toxicity manifesting as methemoglobinemia or vasodilatation. None of these patients developed severe toxicity, although three had symptoms of gastritis, three had slight methemoglobinemia, and two had mild hypotension. The product was removed from the stomach promptly in three of the five patients. None had pre-existing renal or intestinal dysfunction, which are known to enhance ammonium nitrate toxicity.

Scrofula: emergency department presentation and characteristics

BackgroundIn the US, scrofula is generally uncommon, but it may be the manifestation of disseminated tuberculosis in immunocompromised patients. Given the delay to obtain PPD results, AFB results, and cultures for TB, the emergency physician (EP) must rely on the history and physical examination to make the diagnosis of scrofula.AimsTo illustrate a set of criteria that would be useful to the emergency physician to identify cases of scrofula.MethodsWe retrospectively reviewed the charts of patients with a final diagnosis of scrofula at our institution to identify the characteristics of patients who present to the emergency department with a neck mass that was eventually diagnosed as scrofula.ResultsWe found that being foreign born, being HIV+, and having a prior history of a positive PPD appeared to be associated with a diagnosis of scrofula.ConclusionsThis review suggests that scrofula should be included in the EP’s differential diagnosis of neck in masses when patients present subacutely and they have significant TB risk factors. In such cases, the EP should strongly consider ruling out pulmonary TB.