Outcomes after supratherapeutic escitalopram ingestions

Escitalopram (ESC) is a new selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. There are limited data regarding accidental and intentional ESC exposure. We conducted a retrospective chart review of isolated ESC ingestions reported to our regional poison center during 2003-2004. Twenty-eight patients met inclusion criteria. The average patient age was 28.1 years (range 2-75 years) and the average amount of ESC ingested was 62.5 mg (range 5-300 mg from 19 cases). The most common formulation ingested was the 20-mg tablet. There were eight accidental ingestions and 20 intentional overdoses. Six of the eight accidental ingestions were observed at home with follow-up in 24 h, and no adverse outcomes were reported. The other two accidental overdoses were observed in the Emergency Department (ED) and discharged home with no adverse events reported. Nineteen of the intentional overdoses were observed in the ED for approximately 4-6 h and discharged home or to an inpatient psychiatry ward. One of the intentional overdose patients was admitted for persistent lethargy, but had a good outcome. ESC toxicity can theoretically be life threatening, but no patients in our series had adverse sequealae after accidental or intentional overdose.     

运动性横纹肌溶解症并发急性肾功能不全及透析管相关性血栓1例并文献复习

目的 探讨多学科联合治疗运动性横纹肌溶解症并发急性肾功能不全及透析管相关性血栓的临床效果。方法 选取河北医科大学第三医院急诊科与血管外科联合治疗的运动性横纹肌溶解症并发急性肾功能不全及透析管相关性血栓的患者1例,对其临床资料、治疗方案进行回顾性分析,评价临床治疗效果。结果 急诊科采用血液透析治疗急性肾功能不全,血管外科采用清除血栓术治疗透析管相关性血栓形成,患者痊愈出院。结论 本例患者经多学科联合治疗取得了良好的临床效果。     

Iron Bezoar Retained in Colon Despite 3 Days of Whole Bowel Irrigation

Concretion formation is a documented complication of large iron ingestions. The generally accepted treatment is supportive care, whole bowel irrigation, and intravenous deferoxamine for systemic toxicity. Laparotomy and gastrotomy have also been used in patients with a high iron burden and bezoar formation. Though experiments suggest that iron is poorly absorbed in the colon, there are no case reports of iron overdose without systemic toxicity, despite a retained colonic bezoar. We report the case of a 16‐month‐old who presented to an Emergency Department 19 h after an iron ingestion. Initial laboratory studies revealed an anion gap of 14 mEq/L, and a 20 h serum iron concentration of 429 mcg/dL. An abdominal radiograph revealed multiple pills throughout the stomach and small bowel; whole bowel irrigation was initiated. Deferoxamine was administered at 10 mg/kg/h and then stopped when the serum iron level reached 27 mcg/dL, 36 h later. At this time, the abdominal radiograph showed an iron bezoar remaining in the ascending colon despite a clear rectal effluent from whole bowel irrigation. Despite whole bowel irrigation over the next 36 h, the iron bezoar was not removed and actually migrated proximally in the colon. Treatment was stopped on the third day and a normal diet was instituted with prompt passage of the bezoar.     

Combined ingestion and subcutaneous injection of elemental mercury

A 40-year-old man with a history of schizophrenia and inflammatory soft tissue lesions after self-injection of elemental mercury presented to the Emergency Department. Multiple skin abscesses associated with fever required operative debridement. An incidental finding of oral mercury ingestion was followed clinically and did not result in complications. Exposure to elemental mercury through injection or ingestion is an uncommon event, but one the Emergency Physician may encounter. Subcutaneous mercury injection should be managed with local wound debridement, whereas ingestions are rarely of clinical significance.     

经纤维胃镜取出食管内刀片方法的初步实践

目的：为了在运用胃镜从食管中取出刀片之手术中，探讨有效的操作方法，以提高胃镜取异物的成功率。方法：观察6例从食管中取出单刃刀片及金属异物的技术操作过程。结果：3例单刃刀片取出术和1例铝片取出术获得成功，2例失败。结论：选用鳄嘴状异物钳作为手术器械是最有效的手段，因力可防止刀片滑脱；选用安全保护套管可以防止食管损伤。刀片体积相对过大、食管生理狭窄发生痉挛水肿时不宜施行此类手术。     

Hypothermia: An Unusual Indication for Gastric Lavage

Background: Previous reports suggest that gastric lavage holds many risks and is not routinely indicated for decontamination of the overdose patient. Objective: To present a case of overdose with concurrent accidental hypothermia where gastric decontamination was utilized. Case Report: A 50-year-old hypothermic, comatose patient was transported to the Emergency Department with a concurrent, massive medication ingestion diagnosed incidentally on a routine abdominal computed tomography scan. Both active and passive rewarming measures, in conjunction with gastric lavage and retrieval of multiple pill fragments, were performed, and the patient survived to hospital discharge without sequelae. Interestingly, the patient admitted to an intentional ingestion of both labetalol and lorazepam. Conclusion: Due to hypothermia-mediated changes in metabolism, including gastric atony and decreased hepatic metabolism, gastric lavage may provide additional benefit in the management of severely hypothermic patients with potentially lethal, massive pill ingestions.     

Etiologic and Demographic Characteristics of Poisoning: A Prospective Hospital-Based Study in Oman

Background: The health care system in Oman is characterized by its rapid development and free medical services for all its nationals although traditional medicine still plays a major role in daily life. Epidemiological data on poisoning are scanty. Objective: To determine the annual rate of poisoning-related Accident & Emergency Department visits at Sultan Qaboos University Hospital in Oman and to evaluate, in both children and adults, the etiologic and demographic characteristics of poisoning cases. The poisoning pattern is contrasted to that of other countries. Methods: A prospective observational study included all symptomatic and asymptomatic poisoning-related Accident & Emergency Department visits over 4 years (1996–1999). Data were recorded on a specifically designed poison reporting form. Results: Two hundred and four poisoning-related Accidennt & Emergency Department visits were recorded corresponding to an average annual rate of 1.8/1000 Accident & Emergency Department visits. Therapeutic agents were most commonly involved (50% of all cases). Accidental poisoning in toddlers was most commonly caused by drugs. Intentional poisoning in adults involved mainly therapeutic agents (50%), particularly analgesics, followed by industrial and environmental agents (25%). Animal poisoning (14%) was most commonly encountered in adult males. Traditional remedies constituted 7% of all poisoning cases. A total of 148 patients (73%) were admitted for 1 to 175 days. Conclusions: Compared to studies performed in urban hospitals in other countries, (1) the annual rate of poisoning-related Accident & Emergency Department visits was substantially lower, (2) psychoactive drugs were less frequently incriminated in intentional ingestions, and (3) we found a significantly higher frequency of poisoning by animals and traditional remedies than reported by urban hospitals in other Middle Eastern countries. The limitations of our study (Accident & Emergency Department-based data collection in an urban hospital) do not permit extrapolation to the rest of the country.     

The evaluation and treatment of the sexually assaulted patient

There are several significant problems encountered in treating the assault victim in the Emergency Department setting. In a busy Emergency Department, the patient who has been assaulted may be prioritized behind other patients with more significant life-threatening illnesses or injuries. The delay in treatment that ensues may aggravate the emotional trauma already experienced. Additionally, the legal and technical aspects involved in the evaluation and subsequent testimony may erect a psychological barrier on the part of the physician or nurse. This article provides guidelines and handling all of the above problems with regard to the sexually assaulted patient.     

Is the Intra-Aortic Balloon Pump a Method of Brain Protection During Cardiogenic Shock After Drug Intoxication?

Cardiovascular medications are ubiquitous and are frequently implicated in accidental or intentional overdose. It is common that combined use of these drugs may lead to hypotension and even shock, followed by metabolic derangements. We report a case in which an intra-aortic balloon pump (IABP) was used in the management of self-poisoning with verapamil, amlodipine, metoprolol, and ibuprofen. In presenting this case of combined massive drug ingestion, we outline early strategy in the Emergency Department and some alternative treatment options. Beyond pharmacological and conservative procedures, we implemented an invasive approach that included temporary pacing, mechanical ventilation, and intra-aortic balloon counterpulsation (IABP). Such intense treatment was necessary due to the critical state of the patient. In our opinion, the use of the IABP contributed to the final recovery of our adolescent patient. Combined mechanical and pharmacological treatment may protect from multi-organ insufficiency, including permanent central nervous system injury. It is hoped that reporting our experience will raise awareness of alternative treatment options for ingestions of cardiovascular medications.     

Are one or two dangerous? Opioid exposure in toddlers

Ingestions of opioid analgesics by children may lead to significant toxicity as a result of depression of the respiratory and central nervous systems. A review of the medical literature was performed to determine whether low doses of opioids are dangerous in the pediatric population under 6 years old. Methadone was found to be the most toxic of the opioids; doses as low as a single tablet can lead to death. All children who have ingested any amount of methadone need to be observed in an Emergency Department (ED) for at least 6 h and considered for hospital admission. Most other opioids are better tolerated in ingestions as small as one or two tablets. Based on the limited data available for these opioids, we conclude that equianalgesic doses of 5 mg/kg of codeine or greater require 4 to 6 h of observation in the ED. Data for propoxyphene and all extended-release preparations are limited; their prolonged half-lives would suggest the need for longer observation periods. All opioid ingestions leading to respiratory depression or significant central nervous system depression require admission to an intensive care unit.     

Cardiac Arrest With Residual Blindness After Overdose of Tessalon® (Benzonatate) Perles

Background: The extent to which benzonatate (Tessalon®), a structurally similar agent to other local anesthetics including tetracaine and procaine, poses a risk to the public is not fully appreciated as it is still one of the most widely prescribed antitussives available. Objectives: To report a case of cardiac arrest with residual blindness after Tessalon® overdose, review its clinical manifestations, toxicology and management considerations, and describe the need for rational prescribing. Case Report: A 17-year-old woman with no previous medical history presented to the Emergency Department (ED) status post cardiac arrest. One to two hours prior, the patient had ingested at least 10 200-mg Tessalon® capsules as part of a suicide attempt. The patient was sedated, intubated, and given magnesium as prophylaxis against recurrent dysrhythmias. Emergent gastric lavage was performed and well tolerated. A 24-h hypothermia protocol with 6-h cooling period was initiated. Toxicological studies, chest radiograph, and a computed tomography scan of the head were all unremarkable. The patient was admitted to the Pediatric Intensive Care Unit for further work-up and supportive care. The patient was extubated and able to follow some commands 1 week post-admission. The patient developed blindness and experienced generalized confabulations, which did not resolve. Conclusion: Ingestion of Tessalon®, a seemingly innocuous and widely prescribed antitussive, may pose a risk to patients due to its potential for the rapid development of life-threatening adverse events and limited treatment options in the overdose setting. Rational prescribing and patient education is needed.     

Baclofen and ethanol ingestion: a case report

The number of reported cases of skeletal muscle relaxant ingestion has been increasing in the United States, although fatalities are rare. A 30-year-old women ingested 300 mg of baclofen and ethanol. She was able to ambulate into the Emergency Department (ED) 50 min later, but within 30 min post-arrival had a Glasgow Coma Score of 3. She was treated with supportive care including mechanical ventilation for 36 h. Her neurologic status returned to her previous state. Coma may occur rapidly after baclofen overdose, and the respiratory depression may be exacerbated by the co-ingestion of ethanol. Primary importance in the treatment of such ingestions should be placed on maintenance of an airway and respiratory support.     

Are one or two dangerous? Quinine and quinidine exposure in toddlers

Quinine and quinidine have been cited as drugs that may cause significant morbidity and mortality in toddlers who ingest one or two pills. The use of both of these drugs has declined in the United States since the 1980s. A review of the literature and Poison Control data reveals that large quinine and quinidine ingestions, although rare in this country, may lead to severe toxicity and death related to cardiovascular and neurological effects in both children and adults. Although the majority of cases of quinine and quinidine toxicity in toddlers occur after ingestions of more than two pills, a single report each of severe toxicity after the equivalent of an ingestion of two pills or less by a toddler exists for both quinine and quinidine. Although the risk to the toddler exposed to one or two tablets seems to be small, triage to an Emergency Department is warranted after quinidine ingestion of any amount and after quinine ingestion that exceeds the age-appropriate therapeutic dose.     

Survival of Acute Hypernatremia Due to Massive Soy Sauce Ingestion

Background

Intentional massive sodium chloride ingestions are rare occurrences and are often fatal.

Objectives

There are a variety of treatment recommendations for hypernatremia, ranging from dialysis to varying rates of correction. We report a case of acute severe hypernatremia corrected with rapid free-water infusions that, to our knowledge, has not been previously reported.

Case Report

A 19-year-old man presented to the Emergency Department in a comatose state with seizure-like activity 2 hours after ingesting a quart of soy sauce. He was administered 6 L of free water over 30 min and survived neurologically intact without clinical sequelae. Corrected for hyperglycemia, the patient's peak serum sodium was 196 mmol/L, which, to our knowledge, is the highest documented level in an adult patient to survive an acute sodium ingestion without neurologic deficits.

Conclusion

Emergency physicians should consider rapidly lowering serum sodium with hypotonic intravenous fluids as a potential management strategy for acute severe hypernatremia secondary to massive salt ingestion.     

急诊绿色通道在分检地震伤员中的作用

目的分析“5·12”汶川特大地震后不同时段地震伤员在我院急诊科停留时间,探讨急诊绿色通道在分检地震伤员中的作用,为救治特大灾害伤员积累经验。方法回顾性分析2008年5月12日14时28分至5月15日14时27分汶川地震伤员在四川大学华西医院急诊科救治停留的时间,并分为震后24h内、震后24～48h和48-72h三个时段进行比较。结果震后72h内我院收治伤员536例,其中24h内收治伤员207例,伤员在急诊科平均停留时间为129min;24—48h收治伤员104例,伤员在急诊科平均停留时间97min;48～72h内收治伤员226例,伤员在急诊科平均停留时间为86min。第一个24h与第二个24h和第三个24h比较,地震伤员在急诊科的停留时间差异有统计学意义（P〈0．05）,但第二个24h和第三个24h比较差异无统计学意义（P〉0．05）,表明建立建全急诊绿色通道,对加快应急状态下伤员救治处理有重要意义。结论应根据实际情况,及时更新绿色通道,使地震伤员在急诊科的停留时间不断缩短,保证伤员尽快得到专科处理,为抢救危重伤员赢得宝贵时间。     

The relative value of education of emergency physicians in patient outcome: A retrospective analysis at a single center in developing India

BACKGROUND: There is a considerable paucity with regards to the research available on the quality and quantity of clinical teaching in the national emergency department (ED) setups. With the onset of the age of modern medicine, the outlook towards to the time worn tradition of triage and detailed medical evaluation must be revoked. Despite the variety of programs being conducted in the country, a comparable entity common to all is patients’ clinical outcomes which can be measured using simple parameters which can be easily acquired compiling hospital registry entries.METHODS: A retrospective observational study was conducted in the emergency department of Max Hospital, Saket, New Delhi. A period of 22 months prior to the start of the program and like-wise 22 months after initiation of the program was collected from the hospital registry. The Emergency Medicine program in consideration was the Masters in emergency Medicine (MEM) Program affiliated with George Washington University, NY, USA. Patients of all age groups and gender registering in the Emergency Department and so were all the doctors working in the ED before and after initiation of the program.RESULTS: An improvement was noted in terms of total admissions through the ED per month, average length of stay of admitted as well as discharged patients; return to ED within 24 hours; leave against medical advice and patient complaints. A reduction was noted in number of discharges from the ED. Despite a numerical worsening on the patient’s death in ED a graphical improvement can be noted considering the month wise representation of data.CONCLUSION: We can make a coherent conclusion that there is an improvement in the outcome of the entire patient related aspects in the Emergency Department considering the all two time frames included in the study. The difference can be very well attributed to the integration of the structural Academic Program in the development of the Emergency Physicians. This leads us to make a conclusive analysis regarding a positive impact of the Relative Value of Education of Emergency Physicians not only in patient outcome but also in physicians and administrative outlook towards an overall better emergency care.     

Tangential gunshot wound to the chest causing venous air embolism: a case report and review

This is a case report of a 53-year-old woman who presented to the Emergency Department after sustaining a tangential gunshot wound to the left anterior chest wall. On arrival, the patient was somnolent, hypotensive, hypoxic, and had impaired speech. The patient's cardiopulmonary status stabilized quickly after fluid resuscitation and supplemental oxygen. Because the initial chest radiograph revealed only mild vascular congestion without traumatic injuries, a computed tomography angiogram of the chest was subsequently obtained, which showed air within the right ventricle and pulmonary arteries. Significant bilateral pulmonary infiltrates were also noted without evidence of pneumothorax, penetrating lung, or vascular injuries. There are numerous case reports of venous air embolism (VAE) after penetrating neck, chest, and abdominal injuries, surgical procedures, or secondary to unintentional air injection through venous catheters. Due to the wide range of neurological and cardiopulmonary clinical presentations, the non-specific signs and symptoms of VAE may frequently be attributed to other causes, especially in the setting of trauma. An overview of the pathophysiology, clinical presentation, diagnosis, and treatment of VAE is presented, with emphasis on diagnostic imaging modalities.