Rais Vohra

Antidote Use in the Critically Ill Poisoned Patient

The proper use of antidotes in the intensive care setting when combined with appropriate general supportive care may reduce the morbidity and mortality associated with severe poisonings. The more commonly used antidotes that may be encountered in the intensive care unit ( N -acetylcysteine, ethanol, fomepizole, physostigmine, naloxone, flumazenil, sodium bicarbonate, octreotide, pyridoxine, cyanide antidote kit, pralidoxime, atropine, digoxin immune Fab, glucagon, calcium gluconate and chloride, deferoxamine, phytonadione, botulism antitoxin, methylene blue, and Crotaline snake antivenom) are reviewed. Proper indications for their use and knowledge of the possible adverse effects accompanying antidotal therapy will allow the physician to appropriately manage the severely poisoned patient.

High times, low sats: diffuse pulmonary infiltrates associated with chronic synthetic cannabinoid use.

IntroductionIn recent years, cases of severe adverse effects from recreational use of synthetic cannabinoids (SC) have established that these agents represent a novel toxicologic hazard.Case ReportA 21-year-old male presenting as a vehicular trauma victim was noted with diffuse pulmonary infiltrates related to chronic inhalation of multiple synthetic cannabinoid-containing products. Chest imaging revealed bilateral, subacute lung infiltrates; histopathological analysis of bronchial and alveolar tissues revealed an inflammatory process. An extensive workup failed to identify infectious, malignant, autoimmune, or hematologic causes of the syndrome, and toxicological analysis of the blood and body fluids confirmed the presence of multiple synthetic cannabinoids and metabolites. The patient recovered after an 8-day ICU course, wherein he received antibiotics, steroids, and mechanical ventilation.DiscussionThis case contributes to the currently evolving knowledge about SC agents, adding a rarely described pulmonary complication to the growing list of adverse effects associated with these products.

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

Chlorine-related inhalation injury from a swimming pool disinfectant in a 9-year-old girl.

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.

Use of RIFLE Criteria to Predict the Severity and Prognosis of Acute Kidney Injury in Emergency Department Patients with Rhabdomyolysis

Abstract: Chlorine is a potential respiratory hazard in both occupational and household settings. The clinical sequelae of inhalation are variable in severity and timing, and subacute presentation is a concern. We report the case of a 9-year-old girl who developed dyspnea, hypoxemia, and pneumonitis approximately 12 hours after exposure to chlorine released from aerosolized swimming pool purification tablets. Her course was characterized by improvement with supplemental oxygen and bronchodilator therapy. Follow-up pulmonary testing at 4 months after the episode revealed the presence of mild obstructive reactivity of the airways, but she was able to perform normal activities without requiring medications. We discuss the pathophysiology, symptoms, therapy, and long-term follow-up of chlorine inhalation injuries.

Fasciculations after rattlesnake envenomations: a retrospective statewide poison control system study.

BACKGROUND RIFLE criteria (Risk, Injury, Failure, Loss, End-stage) have not been evaluated in Emergency Department (ED) patients at risk of acute kidney injury (AKI). AKI occurs in rhabdomyolysis. STUDY OBJECTIVES To use RIFLE criteria to stratify the severity of AKI and predict prognosis in ED patients with acute rhabdomyolysis. METHODS This is a retrospective study of consecutive patients with rhabdomyolysis over a 44-month period. Data included ED admission anion gap, blood urea nitrogen (BUN), calcium, phosphate, potassium, urinalysis, toxicology screen, and hematocrit. Creatine kinase, creatinines, and hematocrits were followed serially. Hospital length of stay (LOS) and need for dialysis were also recorded. RESULTS RIFLE categories were calculated for 135 patients. At admission, 60 (44%) had no AKI, 20 (15%) had Risk, 32 (24%) had Injury, and 23 (17%) had Failure. These categories were significantly associated with increasing magnitude of volume depletion, potassium, phosphate, BUN, and the anion gap. They predicted differences in LOS, dialysis, discharge creatinine, and the rate of normalization of the admission creatinine. Mortality was low (2%), as was morbidity. Only 8/132 surviving patients (6%) were discharged with a creatinine >2 mg/dL. CONCLUSIONS The RIFLE categories correlated significantly with known markers of rhabdomyolysis and AKI. They also predicted LOS, dialysis, renal morbidity, and the timing of recovery. RIFLE criteria could be used to predict the outcome of ED patients and facilitate admission and discharge decisions.

An infant with a heartbreaking medication error.

Introduction. Rattlesnake envenomation occasionally results in repetitive small-muscle fasciculations known as myokymia. We report the results of a retrospective inquiry of this phenomenon from a statewide poison centers database. Methods. Data was obtained from a poison system database for the years 2000–2003, inclusive, for rattlesnake envenomation exposures coded as having fasciculations. Results. A total of 47 cases were identified, and nine other cases were found from previously published literature. There was no consistent temporal pattern by monthly analyses in incidence or proportion of reported snakebites with myokymia. All four of the reviewed cases with myokymia of the shoulders were intubated and none without it were intubated. Conclusions. A review of four consecutive years of data revealed no pattern to correlate the incidence of fasciculations with the month. The development of respiratory failure associated with myokymia, sometimes despite antivenom, is a newly reported occurrence. Clinicians are reminded to monitor closely airway and inspiratory capacity in patients with severe myokymia.

Sonographic signs of snakebite

A 7-month-old boy is left in the care of his aunt for the night. Diagnosed with ectopic atrial tachycardia at 2 months of age, he is on a strict medication regimen that must be taken at the same time each morning. His aunt faithfully administers a liquid medication, using a demarcated syringe, just as the boy’s mother had instructed her to do. However, minutes later, she finds that he is no longer at his cheerful baseline and is instead becoming pale and distressed. Recognizing the urgency of her nephew’s condition, she calls to activate an emergency medical response. When paramedics arrive, they encounter a child who appears to be deteriorating, while cardiac monitors display runs of wide-complex tachycardia (Fig. 1). They immediately transport the baby to the emergency department, where the child is found to have a thready, irregular pulse rate of 130 beats/min, respirations of 40 breaths/min, blood pressure of 73/47 mm Hg, and a blood glucose level of 116 mg/dL. The child is still awake at this point, but listless, and visibly uncomfortable. Intravenous access is obtained, pacer pads are placed, and a bolus of normal saline is given intravenously. Meanwhile, a 12-lead electrocardiogram

Paradise nut paradox: alopecia due to selenosis from a nutritional therapy.

Abstract Background. Crotaline snakebites are routinely assessed with serial external examinations. We sought to correlate external findings with changes observed on ultrasound imaging. Methods. This was a prospective, observational study of consecutive rattlesnake envenomation in patients treated at a single hospital in central California. Information recorded for each case included clinical data, gross external examination, and ultrasound images of tissue edema, localized fluid collections, and video footage of muscle fasciculations. Results. Thirteen patients were enrolled. Ultrasound imaging of the bitten extremity was consistent with external examination of the bitten limb. The most common sonographic finding was subcutaneous tissue edema. Edema and necrosis in 3 patients with rapidly progressive leg swelling spared the deeper muscle layers and fascial planes. In 2 patients with bites on the fingers, edema and tendon involvement were readily visualized using a water-bath technique (placement of the hand in a pool of water, allowing more detailed examination of the tissue planes). Conclusion. Ultrasound imaging may allow for a more complete understanding of the local effects of snakebite. We were also able to document normal deeper muscle integrity in cases with diffuse leg edema. More studies are needed to fully elaborate the strengths and limitations of bedside ultrasound as a diagnostic adjunct in envenomation assessment.

Epidemiology and clinical outcomes of snakebite in the elderly: a ToxIC database study*

Selenium is a micronutrient. It presents a nutritional conundrum because of its twin status as an essential as well as a highly toxic trace element. Here, we report a case of acute non-intentional selenium toxicity due to increased ingestion of “paradise nuts” (Lecythis ollaria) which resulted in massive alopecia.