Travis D. Olives

Bath Salts: The Ivory Wave of Trouble

Mephedrone and MDPV are both β-ketophenethylamine derivatives of cathinone, a compound isolated from the East African plant Catha edulis (khat, qat). Mephedrone is commonly referred to as plant food, MCAT, 4-MMC, meow meow, meph, and drone; MDPV is commonly called MTV, MDPK, Magic, and Super Coke. Both are structurally similar to amphetamines, with mephedrone sharing close similarities with methamphetamine and MDPV with ecstasy (3,4-methylenedioxymethamphetamine; MDMA). Bath salts pose an increasing public health risk in the United States, with reports of toxicity and mortality increasing along with calls to poison centers throughout the United States. Packages labeled with innocuous monikers such as White Ice, Ivory Wave, Ocean Snow, Lunar Wave, and Vanilla Sky intentionally belie the dangerous substances within, which are by no means intended to replace legitimate bath products. The white or tan crystalline powder commonly is administered by nasal insufflation or oral ingestion; however, rectal suppository and less commonly, intramuscular or intravenous injection, are also reported.1,2 n nA movement to ban these substances is growing in the United States, following similar actions in Europe.3 Although successfully outlawed in some locales, this movement has not eliminated the public health hazards posed by mephedrone or MDPV. Emergency physicians (EP) should thus be knowledgeable in the epidemiology of bath salt abuse, the clinical toxidrome with which bath salt toxicity presents, and appropriate treatment strategies to reduce morbidity and mortality in patients presenting with bath salt toxicity.

Hunger and Food Insecurity among Patients in an Urban Emergency Department

Introduction: To determine the prevalence of hunger and food insecurity among patients presenting to the emergency department (ED) over 3 consecutive years. Methods: This was a cross-sectional study of patients presenting to the ED at Hennepin County Medical Center, and urban, Level I trauma center. We prospectively screened adult (age >18) patients presenting to the ED during randomized daily 8-hour periods between June 1 and August 31, 2007 and 2008, and randomized every-other-day periods between June 1 and August 31, 2009. We excluded patients with high acuity complaints, altered mental status, prisoners, those who did not speak Spanish or English, or those considered to be vulnerable. Consenting participants completed a brief demographic survey. The main outcome measures included age, gender, ethnicity, employment, housing status, insurance, access to food, and having to make choices between buying food and buying medicine. All responses were self reported. Results: 26,211 patients presented during the study; 15,732 (60%) were eligible, 8,044 (51%) were enrolled, and 7,852 (98%) were included in the analysis. The rate of patients reporting hunger significantly increased over the 3-year period [20.3% in 2007, 27.8% in 2008, and 38.3% in 2009 (p<0.001)]. The rate of patients reporting ever having to choose between food and medicine also increased [20.0% in 2007, 18.5% in 2008, and 22.6% in 2009 (p=0.006)]. Conclusion: A significant proportion of our ED patients experience food insecurity and hunger. Hunger and food insecurity have become more prevalent among patients seen in this urban county ED over the past 3 years. Emergency physicians should be aware of the increasing number of patients who must choose between obtaining food and their prescribed medications, and should consider the contribution of hunger and food insecurity to the development of health conditions for which ED treatment is sought.

Intubation of Profoundly Agitated Patients Treated with Prehospital Ketamine

BACKGROUNDnProfound agitation in the prehospital setting confers substantial risk to patients and providers. Optimal chemical sedation in this setting remains unclear.nnnOBJECTIVEnThe goal of this study was to describe intubation rates among profoundly agitated patients treated with prehospital ketamine and to characterize clinically significant outcomes of a prehospital ketamine protocol.nnnMETHODSnThis was a retrospective cohort study of all patients who received prehospital ketamine, per a predefined protocol, for control of profound agitation and who subsequently were transported to an urban Level 1 trauma center from May 1, 2010 through August 31, 2013. Identified records were reviewed for basic ambulance run information, subject characteristics, ketamine dosing, and rate of intubation. Emergency Medical Services (EMS) ambulance run data were matched to hospital-based electronic medical records. Clinically significant outcomes are characterized, including unadjusted and adjusted rates of intubation.nnnRESULTSnOverall, ketamine was administered 227 times in the prehospital setting with 135 cases meeting study criteria of use of ketamine for treatment of agitation. Endotracheal intubation was undertaken for 63% (85/135) of patients, including attempted prehospital intubation in four cases. Male gender and late night arrival were associated with intubation in univariate analyses (χ2=12.02; P=.001 and χ2=5.34; P=.021, respectively). Neither ketamine dose, co-administration of additional sedating medications, nor evidence of ethanol (ETOH) or sympathomimetic ingestion was associated with intubation. The association between intubation and both male gender and late night emergency department (ED) arrival persisted in multivariate analysis. Neither higher dose (>5mg/kg) ketamine nor co-administration of midazolam or haloperidol was associated with intubation in logistic regression modeling of the 120 subjects with weights recorded. Two deaths were observed. Post-hoc analysis of intubation rates suggested a high degree of provider-dependent variability.nnnCONCLUSIONSnPrehospital ketamine is associated with a high rate of endotracheal intubation in profoundly agitated patients; however, ketamine dosing is not associated with intubation rate when adjusted for potential confounders. It is likely that factors not included in this analysis, including both provider comfort with post-ketamine patients and anticipated clinical course, play a role in the decision to intubate patients who receive prehospital ketamine. Olives TD , Nystrom PC , Cole JB , Dodd KW , Ho JD . Intubation of profoundly agitated patients treated with prehospital ketamine. Prehosp Disaster Med. 2016;31(6):593-602.

It’s not just heroin anymore

We read with interest the recent review entitled “Do heroin overdose patients require observation after receiving naloxone?” by Willman et al. [1]. We congratulate the authors on their extensive review of this important and timely topic. We write, however, to express our concern regarding the timeliness and relevance of the conclusions drawn by the authors in the current clinical environment. These recommendations are ill-advised at a time when heroin is increasingly adulterated with synthetic opioids that have unpredictable or unknown pharmacoand toxicokinetics. In this era of protean heroin adulterants, as toxicologists we are obliged to admit the only thing that we do know about the current heroin epidemic is that heroin is no longer just heroin. We believe the conclusions drawn by the authors may result in an unsafe approach to the management of presumed heroin intoxication. In recent years, there have been multiple reports of heroin adulterated with synthetic opioids, such as fentanyl, as well as synthetic opioids masquerading as other pharmaceuticals resulting in fatalities [2,3]. Willman et al. [1] draw the conclusion that prehospital transport is not required after naloxone administration for heroin overdose in patients with normal mental status and normal vital signs. This is problematic, as the exact exposure can rarely, if ever, be accurately identified in the prehospital setting. In addition, the maximum prehospital naloxone dose administered to patients declining transport is not well described. Thus, patients requiring larger doses of naloxone, such as those exposed to synthetic opioids [4], are not adequately represented in this review. Alleged heroin users aroused with prehospital naloxone may be under the influence of an opioid whose duration of action will persist after naloxone has been metabolized. Willman et al. [1] also concluded that patients who are able to ambulate, have a Glasgow coma scale (GCS) of 15, normal vital signs, without clinical evidence of opioid intoxication may be safely discharged from the Emergency Department (ED) after 1 h of observation. However, in one study cited by the authors [5], 12 patients exhibited recrudescence of opioid toxicity requiring repeat doses of naloxone up to 187min after prehospital naloxone making only an hour of observation insufficient. Furthermore, the composition of an illicit opioid cannot be guaranteed, and often users are unaware of counterfeit or adulterated products. Discharge after an hour of observation may not be sufficient to predict delayed opioid toxidrome or other complications in the absence of sound toxicokinetic data on a known adulterant. With the increased incidence of heroin adulterated with synthetic opioids such as fentanyl, counterfeit products, and the advent of novel opioids with unknown pharmacoand toxicokinetics, we can no longer safely predict a patient’s naloxone requirement or the safest duration of observation. Until more data exist regarding pharmacokinetics, toxicokinetics, and expected clinical effects following exposure to synthetic opioids, it is prudent to ensure both hospital transport after naloxone reversal and a period of observation in the Emergency Department of at least 4 h.

High dose insulin for beta-blocker and calcium channel-blocker poisoning: 17 years of experience from a single poison center

Background/objectives High dose insulin (HDI) is a standard therapy for beta‐blocker (BB) and calcium channel‐blocker (CCB) poisoning, however human case experience is rare. Our poison center routinely recommends HDI for shock from BBs or CCBs started at 1 U/kg/h and titrated to 10 U/kg/h. The study objective was to describe clinical characteristics and adverse events associated with HDI. Methods This was a structured chart review of patients receiving HDI for BB or CCB poisoning with HDI defined as insulin infusion of ≥0.5 U/kg/h. Results In total 199 patients met final inclusion criteria. Median age was 48 years (range 14–89); 50% were male. Eighty‐eight patients (44%) were poisoned by BBs, 66 (33%) by CCBs, and 45 (23%) by both. Median nadir pulse was 54 beats/min (range 12–121); median nadir systolic blood pressure was 70 mm Hg (range, 30–167). Forty‐one patients (21%) experienced cardiac arrest; 31 (16%) died. Median insulin bolus was 1 U/kg (range, 0.5–10). Median starting insulin infusion was 1 U/kg/h (range 0.22–10); median peak infusion was 8 U/kg/h (range 0.5–18). Hypokalemia occurred in 29% of patients. Hypoglycemia occurred in 31% of patients; 50% (29/50) experienced hypoglycemia when dextrose infusion concentration ≤10%, and 30% (31/105) experienced hypoglycemia when dextrose infusion concentration ≥20%. Conclusions HDI, initiated by emergency physicians in consultation with a poison center, was feasible and safe in this large series. Metabolic abnormalities were common, highlighting the need for close monitoring. Hypoglycemia was more common when less concentrated dextrose maintenance infusions were utilized.

Physostigmine is superior to non-antidote therapy in the management of antimuscarinic delirium: a prospective study from a regional poison center

Abstract Context: Poison centers (PCs) frequently manage patients with antimuscarinic delirium. However, controversy surrounds the antidotal use of physostigmine for its treatment. The aim of this study was to prospectively investigate physostigmine versus non-antidote therapy for the management of antimuscarinic delirium in a single regional PC. Methods: This was a prospective observational analysis of patients diagnosed with antimuscarinic delirium and treated in consultation with a regional PC. Certified Specialists in Poison Information (CSPIs) use a clinical guideline to recommend the use of physostigmine. Using a previously derived altered mental status score, we quantified the rate of delirium improvement with physostigmine compared to non-antidote therapy two hours after initial patient identification. We also recorded adverse events (defined a priori as bradycardia, vomiting, seizures) and resource utilization (intubation and physical restraint). Results: We identified 245 patients and included 154 in the analysis. The most common exposure classes were antihistamines (68%), analgesics (19%), and antipsychotics (19%). CSPIs recommended physostigmine in 81% (125) of cases and the treatment team administered it in 37% (57) of these. We observed delirium control in 79% of patients who received physostigmine versus 36% of those who did not. The odds of delirium control were six times greater for patients receiving physostigmine than for patients treated with non-antidote therapy (OR 6.6). Adverse events were rare and did not differ significantly between the groups. Physostigmine was not associated with changes in the incidence of intubation or restraint. Conclusions: This study provides further evidence of both the safety and efficacy of physostigmine in the treatment of antimuscarinic delirium.

A 15-year retrospective review of brake fluid exposures in children from a single poison center

ABSTRACT Brake fluid frequently contains diethylene glycol, a poison known to cause kidney failure, metabolic acidosis, coma and death. No consensus exists regarding management of accidental pediatric brake fluid exposures. We sought to better characterize small-volume brake fluid exposures in children less than 6 years old. We retrospectively reviewed a single poison centers database from 2000 to 2014 for all small-volume, oral, unintentional exposures to brake fluid in children less than 6 years of age. We included cases followed to a known outcome. In all cases, we attempted to confirm the clinical outcome via telephone call between October and December of 2014. Data collected included gender, age, month and year of exposure, caller site, exposure site, management site, National Poison Data System (NPDS) medical outcome, estimated quantity of brake fluid ingested, clinical effects, therapies, and laboratory data. Initial database query yielded 121 cases. We excluded 69 cases, leaving 52 for analysis. Forty cases resulted in no effect; 12 resulted in a minor effect. No cases resulted in a moderate effect, major effect, or death. These retrospective observational data suggest acute exposures to small or unknown amounts of brake fluid in children result in minor effects. These children likely can be managed expectantly.

Unexpected Complication of Cocaine-associated Anti-neutrophil Cytoplasmic Antibody Vasculitis Related to Persistent In-hospital Cocaine Use

Introduction: Levamisole-adulterated cocaine has been implicated in anti-neutrophil cytoplasmic antibody (ANCA) vasculitis. We present a case of spontaneous intraperitoneal hemorrhage, an unexpectedly severe complication of cocaine-related ANCA vasculitis, developing late during hospitalization. Case Report: An adult male with a history of hepatitis C, distant cocaine use, and limited health care presented to a local emergency department (ED) with volume overload, renal failure, hyperkalemia and non-anion gap metabolic acidosis. An extensive workup ensued, followed by pulse-dose methylprednisolone and plasma exchange for ANCA vasculitis with crescentic glomerulonephritis. Tachycardia and hypertension persisted throughout hospitalization despite treatment. On hospital day (HD) 13, his abdomen became distended and tender. Mental status and blood pressure declined, and he was emergently intubated. Paracentesis revealed frank blood; hemoglobin declined from 10.6 to 4.6u200ag/dL during 10u200ahours. Laparotomy revealed 3.5u200aL of intraperitoneal blood and a bleeding omental vessel. Histopathology revealed necrotic aneurysmal dilatation diagnostic of systemic vasculitis. Urine cocaine metabolite was positive on HD #13, consistent with the patients report of in-hospital cocaine use. He was discharged on HD #28 without further complications with plans for outpatient hemodialysis. Discussion: ANCA vasculitis is widely reported following levamisole-adulterated cocaine use. Catastrophic in-hospital hemorrhage due to ANCA vasculitis and vascular necrosis, though previously unreported, may occur with ongoing cocaine use.

Complete clinical course of envenomation by Protobothrops mangshanensis: delayed coagulopathy and response to Trimeresurus albolabris antivenom

ABSTRACT Introduction: Protobothrops mangshanensis, the Mangshan pit viper, is a rare pit viper native to the area surrounding Mount Mang in China’s Hunan province. Toxicity from envenomation is not well characterized. Case details: A 33-year-old male presented to an emergency department (ED) after being bitten on the forearm by his P. mangshanensis. He complained of mild swelling and pain at the bite site. He was admitted for observation and toxicology consultation. Following initially normal coagulation studies including platelets, prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and D-dimer, fibrinogen decreased to 121u2009mg/dL and D-dimer concurrently rose to 377u2009ng/mL over 24u2009h. On hospital day 2 fibrinogen stabilized at 109u2009mg/dL and he was discharged with outpatient laboratory monitoring. Three days later, he returned with bruising to the contralateral arm. Fibrinogen was undetectable (<40u2009mg/dL) and PT was 14.6u2009s. He declined admission but returned 2 d later with bruising to the nose. Bloodwork revealed immeasurably prolonged PT, aPTT, and thrombin time, but he eloped. Late that evening he returned and was treated with three vials of Green pit viper (Trimeresurus albolabris) antivenom. Within 24 h coagulopathy improved markedly; at five days, coagulation abnormalities resolved. Discussion: Mangshan pit viper envenomations may cause isolated hemotoxicity, despite molecular studies suggesting additional neurotoxicity and myotoxicity. T. albolabris antivenom appears effective in treating the resultant coagulopathy. Conclusion: We report the natural history of envenomation by the Mangshan pit viper. A delayed coagulopathy, apparently fibrinolytic in nature, is unaccompanied by local tissue destruction and responsive to Green pit viper antivenom.

An acutely altered toddler.

The mother of a 2-year-old boy contacted a regional poison control center to report that her child had ingested approximately 1 oz of liquid nail polish remover minutes before her call. She inquired whether to induce vomiting in her son. During the telephone interaction, she reassessed the well-being of her son and found that he had become unresponsive. Emergency medical services (EMS) were dispatched to the household, and the caller was advised not to induce vomiting while awaiting assistance. On arrival, an emergency responder verified the unresponsiveness of the child, characterizing him as having his eyes half-open and actively producing gurgling sounds with breathing. Discussion with the child’s mother revealed that the child had ingested a nail polish remover named Once REMOVED. When the EMS arrived, vital signs included a heart rate of 90 beats per minute and a blood pressure of 100/67 mmHg. No peripherally measured oxygen saturation of hemoglobin was reported. En route to the accepting health care facility, the EMS provided supportive care including oxygen delivery but did not place an advanced airway. On arrival to the emergency department, the boy had regained consciousness and was awake and alert. The consulting poison control center recommended ongoing observation of the child for further signs of toxicity. An Internet search of the implicated product revealed that the offending toxicant was widely known to be present in Once REMOVED.