Michael A. Darracq

A Review of Methylene Blue Treatment for Cardiovascular Collapse

BACKGROUND Historically, methylene blue (MB) has been used for multiple purposes, including as an antidote for toxin-induced and hereditary methemoglobinemia, ifosfamide-induced encephalopathy, and ackee fruit and cyanide poisoning; as an aniline dye derivative, antimalarial agent, and antidepressant. DISCUSSION Most recently, the use of MB has been advocated as a potential adjunct in the treatment of shock states. Our article reviews the role of MB in septic shock, anaphylactic shock, and toxin-induced shock. MB is proposed to increase blood pressure in these shock states by interfering with guanylate cyclase activity, and preventing cyclic guanosine monophosphate production and vasodilatation. SUMMARY MB may be an adjunct in the treatment of septic shock, anaphylactic shock, and toxin-induced shock.

Evidence-Based Treatment of Jellyfish Stings in North America and Hawaii

We performed a systematic review of the evidence supporting various treatments for envenomation by jellyfish (cnidarian) and related organisms in North America and Hawaii. Our review produced 19 pertinent primary articles. Current research demonstrates variable response to treatment, often with conflicting results according to species studied, which contributes to considerable confusion about what treatment is warranted and efficacious. Our review suggests that vinegar causes pain exacerbation or nematocyst discharge in the majority of species. Hot water and topical lidocaine appear more widely beneficial in improving pain symptoms and are preferentially recommended. Unfortunately, they may be difficult to obtain at the site of envenomation, such as the beach or diving sites. In these instances, removing the nematocysts and washing the area with saltwater may be considered. If the envenomation is thought to be due to the bluebottle (Physalia), vinegar may be beneficial.

Comprehensive analysis of “bath salts” purchased from California stores and the internet

Abstract Study objective. To analyze the contents of “bath salt” products purchased from California stores and the Internet qualitatively and quantitatively in a comprehensive manner. Methods. A convenience sample of “bath salt” products were purchased in person by multiple authors at retail stores in six California cities and over the Internet (U.S. sites only), between August 11, 2011 and December 15, 2011. Liquid chromatography-time-of-flight mass spectrometry was utilized to identify and quantify all substances in the purchased products. Results. Thirty-five “bath salt” products were purchased and analyzed. Prices ranged from

Preservation of active range of motion after acute elbow trauma predicts absence of elbow fracture

9.95 to 49.99 (U.S. dollars). Most products had a warning against use. The majority (32/35, 91%) had one (n = 15) or multiple cathinones (n = 17) present. Fourteen different cathinones were identified, 3,4-methylenedioxypyrovalerone (MDPV) being the most common. Multiple drugs found including cathinones (buphedrone, ethcathinone, ethylone, MDPBP, and PBP), other designer amines (ethylamphetamine, fluoramphetamine, and 5-IAI), and the antihistamine doxylamine had not been previously identified in U.S. “bath salt” products. Quantification revealed high stimulant content and in some cases dramatic differences in either total cathinone or synthetic stimulant content between products with the same declared weight and even between identically named and outwardly appearing products. Conclusion. Comprehensive analysis of “bath salts” purchased from California stores and the Internet revealed the products to consistently contain cathinones, alone, or in different combinations, sometimes in high quantity. Multiple cathinones and other drugs found had not been previously identified in U.S. “bath salt” products. High total stimulant content in some products and variable qualitative and quantitative composition amongst products were demonstrated.

A cyanotic toddler

OBJECTIVE Previous studies indicate that an inability to fully extend the elbow after elbow trauma is indicative of fracture. We hypothesized that maintenance of active range of motion (ROM) of the elbow in flexion, extension, pronation, and supination after elbow trauma is very specific for the absence of fracture or effusion, and limitation of ROM is sensitive for fracture or effusion. METHODS This was a prospective observational study with convenience sampling of a carefully selected patient population. This would allow certain types of patients to be excluded from the study. Patients with elbow injury receiving radiographs and meeting enrollment criteria were enrolled between June 2006 and March 2007 at 4 emergency departments in the local region. Demographics, active ROM, and presence of point tenderness at the olecranon, epicondyles, and radial head were recorded by enrolling clinicians. All enrolled patients received standard elbow radiographs. Radiographs were reviewed by blinded radiologists for the presence of fracture and effusion. Sensitivity, specificity, and 95% confidence intervals (CIs) of examination findings were calculated. RESULTS One hundred thirteen patients were enrolled. Limitation of active ROM was 100% (95% CI, 0.93-1.00) sensitive for fracture or effusion. Preservation of active ROM was 97% (95% CI, 0.89-1.00) specific for the absence of fracture. Point tenderness was also highly sensitive but not specific. CONCLUSION Individuals with preservation of active ROM after acute elbow trauma have a very low risk of associated fracture and may not require radiographic studies.

Nebulized fentanyl vs intravenous morphine for ED patients with acute abdominal pain: a randomized double-blinded, placebo-controlled clinical trial☆

A previously healthy 3-year-old boy (15 kg) presented to the emergency department with perioral and nail bed cyanosis. On the morning before presentation, he complained of tooth pain and was treated with a topical local anesthetic purchased at a grocery store. On the morning of presentation, his mother saw him swallow a small amount of this topical anesthetic. Within 2 hours of ingestion, he seemed ‘‘dusky’’ and developed clearly demarcated cyanosis of the lips and nail beds. His mother described no similar episodes in the past and no recent viral or diarrheal illnesses. He lives with his parents at home without any ill contacts. Upon examination, he had central and peripheral cyanosis but was without stridor, coughing, nasal flaring, retractions, or significant respiratory distress. He was seen playing quietly by himself in the room. Initial vital signs include the following: heart rate of 90 beats per minute, blood pressure of 100/50 mm Hg, respiratory rate of 25 breaths per minute, temperature of 37.18C, and oxygen saturation (as measured by peripheral transcutaneous pulse-oximetry) of 74% in ambient air. A nonrebreather mask (15 L/min) was immediately placed, without improvement in the child’s color and with no remarkable change in the oxygen saturation. An intravenous line was started, and laboratory studies were sent. The nurse noted that the child’s blood was dark brown in color and that it did not improve with exposure to air. He was taking no medications except the topical anesthetic. Can you pick your poison? Pick Your Poison

Castor bean seed ingestions: A state-wide poison control system's experience

OBJECTIVES Patients with acute abdominal pain commonly present to emergency departments. The safe and effective relief of discomfort is a concern to patients and physicians. Intravenous opioids are the traditional method used to provide pain relief in this setting, but intravenous access is time consuming and not always achievable. Alternative methods of pain control may therefore be necessary for the acute management of painful conditions without adding to the overall physical or psychological discomfort. The purpose of this study was to evaluate the feasibility of nebulized fentanyl (NF) in the alleviation of acute and undifferentiated abdominal pain. We also sought to compare NF with intravenous morphine (IVM) and to assess patient and provider satisfaction with NF. Nebulized fentanyl (2 μg/kg) was compared to IVM (0.1 mg/kg) at 10, 20, 30, and 40 minutes; and patient and physician satisfaction was recorded. The NF group experienced more rapid pain relief and more sustained and clinically significant pain relief over the 40-minute study interval. There were no adverse effects noted in the NF group. Both patient and physician satisfaction scores were higher in the NF group. Fentanyl citrate at a dose of 2 μg/kg through a breath-actuated nebulizer appears to be a feasible and safe alternative to IVM (0.1 mg/kg) in the treatment of acute abdominal pain.

Cost of hemodialysis versus fomepizole-only for treatment of ethylene glycol intoxication

Abstract Context. Ingestions of the seed of the castor bean plant (Ricinus communis) carries the risk of toxicity from ricin, a potent inhibitor of protein synthesis. Objective. We sought to describe characteristics of castor bean seed exposures reported to a state-wide poison control system. Methods. This was an observational case series. A state-wide poison control systems database was reviewed for exposures to castor bean plant seeds from 2001 to 2011. Case notes were reviewed and data collected, when available, included age, gender, circumstances surrounding exposure, number of castor beans consumed, whether beans were chewed or crushed, symptoms described, laboratory values (aspartate aminotransferase [AST], alanine aminotransferase [ALT], prothrombin time [PT] and international normalized ratio [INR]), duration of follow-up, treatment, and patient outcomes. Results. Eighty-four cases were identified. Ingestions were unintentional in 50 cases (59%) cases and intentional in 34 (40%) cases. A median of 10 seeds (range: 1–20) were ingested in intentional cases versus 1 seed (range: 1–40) in unintentional cases. In 49 (58%) of cases the seeds were reported to have been chewed or crushed. Gastrointestinal symptoms were the most commonly reported symptoms. Vomiting (n = 39), nausea (n = 24), diarrhea (n = 17), and abdominal pain (n = 16) predominated. One patient developed hematochezia and vomiting after reportedly ingesting and intravenously injecting castor bean seeds. Laboratory values were documented in 17 (20%) cases. Only one abnormality was noted; an asymptomatic patient one week following ingestion had AST/ALT of 93 U/L and 164 U/L, respectively. Ricinine was confirmed in the urine of two patients. Twenty-three (27%) cases received activated charcoal. Seventy-two (86%) of cases were calls from health care facilities or referred to health care facilities by the poison control center. Twenty-two (26%) cases were admitted for a median of 2 days (range: 1–10). Admitted cases ingested a median of 8.5 seeds (range: 1–20). Intentional ingestions were followed for median of 37.5 h (range: 0.5–285.5) while unintentional cases were followed for 14 h (range: 1–182). No delayed symptoms, serious outcomes, or deaths were reported. Discussion. Due to the presence of ricin, there is concern for serious outcomes after ingestions of the seeds of the castor bean plant. In this study GI symptoms were most commonly reported but serious morbidity or mortality was not present. The true risk of castor bean plant seed ingestions should continue to be re-evaluated. Conclusion. In this retrospective review, gastrointestinal symptoms were the most common symptoms described after reported exposures to castor bean seeds. These exposures were not associated with serious morbidity, mortality, or delayed symptoms.

HEMODIALYSIS AND EXTRACORPOREAL REMOVAL AFTER PEDIATRIC AND ADOLESCENT POISONING REPORTED TO A STATE POISON CENTER

Levine et al. recently published a study describing the use of fomepizole therapy alone in the treatment of ethylene glycol (EG) intoxication in patients without renal compromise or acidosis on arrival. 1 Our toxicology service was recently involved in managing such a patient. We performed an estimate of the cost (not charge) at our institution of fomepizole therapy alone and fomepizole with hemodialysis (HD) and described the practical challenges associated with fomepizole-alone therapy.

Orbeez: the magic water absorbing bead--risk of pediatric bowel obstruction?

BACKGROUND There is currently limited literature regarding the use of hemodialysis after acute pediatric and adolescent poisoning. OBJECTIVE We sought to characterize the use of hemodialysis (HD) and other extracorporeal removal techniques (ECR) in the treatment of acutely poisoned children and adolescents reported to a state poison control system over a 10-year period. METHODS After institutional review board approval, a state poison control system database was queried for all cases coded for hemodialysis and other ECR after pediatric and adolescent (0-19 years old) poisoning. We also analyzed National Poison System Data to determine national trends. RESULTS Ninety patients were reviewed after exclusions for errors in coding or incomplete documentation. HD was the principle method of ECR employed. One case of hemoperfusion and hemofiltration was reported. HD was used, on average, nine times per year. ECR was used predominantly in adolescent patients (age ≥ to 12 years) (84 patients, 93%) for intentional ingestions (82 patients, 91%). Fifteen different toxins were encountered, with salicylates (29 patients) and ethylene glycol (23 patients) most commonly encountered. Ethylene glycol and methanol blood levels were not available before initiation of hemodialysis in all but one case. CONCLUSIONS All salicylate-poisoned patients who underwent HD demonstrated clinical findings indicative of toxicity even in the absence of elevated levels advocated by some as indication for HD. HD and other ECR are rarely used in the management of pediatric and adolescent poisoning.