"Spice" girls: synthetic cannabinoid intoxication

Background

“Spice” refers to various synthetic cannabinoid-containing products that seem to have rapidly become popular recreational drugs of abuse. Very little medical literature currently exists detailing the adverse effects and emergency department (ED) presentations associated with “spice” use.

Objectives

To describe the presentation of 2 patients who recreationally used a “spice” product and to briefly summarize what is known about “spice” and synthetic cannabinoids.

Case Report

Two patients presented to the ED with, predominantly, anxiety after recreationally using a “spice” product that we subsequently confirmed to contain the synthetic cannabinoids, JWH-018 and JWH-073.

Conclusion

We suspect that use of “spice” products may increase. Although anxiety was a prominent presentation in both of the patients described here, undoubtedly, future studies will describe the manifestations of intoxication and toxicity with the various synthetic cannabinoids.     

Accidental poisoning after ingestion of "aphrodisiac" berries: diagnosis by analytical toxicology

Background

A large number of plants, seeds, and berries have been used for medicinal, psychotropic, or aphrodisiac purposes for a thousand years. Mandragora officinarum belongs to the family of Solanaceae and is traditionally known as an aphrodisiac and is closely associated with witchcraft.

Objectives

In this study we report a case of an accidental poisoning after ingestion of some “aphrodisiac” berries and the contribution of the toxicological analysis in the case investigation.

Case Report

A 35-year-old man was admitted to the hospital with clinical signs and symptoms of an anticholinergic syndrome. The diagnosis of the poisoning was made by the toxicological analysis of the patient’s urine. The cause of the poisoning was revealed by his girlfriend’s disclosure that the patient had intentionally consumed some “aphrodisiac” berries to enhance his sexual performance. Subsequently, berries similar to the ones consumed were sent to the laboratory. The analysis of the urine and the berries revealed the presence of hyoscyamine and scopolamine; the berries were identified as Mandragora officinarum berries. Decontamination and symptomatic treatment were proven effective for the control of this poisoning. The patient recovered completely after hospitalization for 4 days.

Conclusion

This case report indicates the importance of analytical toxicology in diagnosis of intoxications after the consumption of unknown plants or plant products and presents the clinical aspects of Mandragora intoxication.     

"Code STEMI" protocol helps in achieving reduced door-to-balloon times in patients presenting with acute ST-segment elevation myocardial infarction during off-hours

Background

Door-to-balloon (D2B) time is conceived as a crucial parameter for evaluating the quality of acute ST-segment elevation myocardial infarction (STEMI) care. Ideally, primary percutaneous intervention should be performed within 90 min of hospital arrival.

Objectives

We sought to determine the impact of emergency physician-activated “Code STEMI” protocol on door-to-balloon times during off-hours.

Methods

Patients were divided into two study groups: one group consisted of 27 STEMI patients who presented during off-hours in the pre-Code STEMI period (January to December 2006) and the second group consisted of 60 STEMI patients admitted during off-hours when Code STEMI was fully operational (January 2007 to December 2008). The primary objective was to compare median D2B times in both the study groups. Secondary parameters of interest included the individual components of D2B time, peak serum troponin levels, peak creatine kinase total levels, all-cause in-hospital mortality, 6-month all-cause mortality, and 12-month all-cause mortality.

Results

With the implementation of “Code STEMI” protocol, the median D2B time during off-hours dropped to 77 min (interquartile range [IQR] 67–95), representing a 52-min improvement (p = 0.0001). ECG-to-catheterization laboratory time demonstrated absolute reduction of 16 min. Median peak troponin-I levels dropped from 62 ng/mL (IQR 23–142) to 25 ng/mL (IQR 7–43; p < 0.002). No statistically significant differences were perceived in all-cause mortality among the study groups.

Conclusions

Implementation of “Code STEMI” protocol at our institution significantly reduced D2B times for STEMI during off-hours.     

Synthetic Cannabinoid Intoxication: A Case Series and Review

Background

Synthetic cannabinoid receptor agonists are becoming increasingly popular with adolescents as an abused substance. Chronic use of these drugs can lead to addiction syndrome and withdrawal symptoms similar to cannabis abuse. Due to their potential health risk, several countries have banned these substances.

Objectives

To report the clinical presentation and legislation status of synthetic cannabinoids in “Spice” products and alert the health care community about the identification and risk assessment problems of these compounds.

Case Reports

We retrospectively reviewed cases presenting to our Emergency Department (ED) during a 3-month period with chief complaints of Spice drug use before arrival. Six cases presented to our ED after using Spice drugs. Two patients were admitted after reporting seizures. All but one presented with tachycardia. Two patients had hallucinations. The average length of ED observation was 2.8 h. No patient with seizures had recurrent episodes.

Conclusion

Spice drugs can cause potentially serious health care conditions that necessitate ED evaluation. Most cases can be discharged from the ED after a period of observation. Legal issues surrounding these drugs are yet to be finalized in the United States.     

Excited Delirium Syndrome (ExDS): Defining Based on a Review of the Literature

Background

Patients present to police, Emergency Medical Services, and the emergency department with aggressive behavior, altered sensorium, and a host of other signs that may include hyperthermia, “superhuman” strength, diaphoresis, and lack of willingness to yield to overwhelming force. A certain percentage of these individuals will go on to expire from a sudden cardiac arrest and death, despite optimal therapy. Traditionally, the forensic community would often classify these as “Excited Delirium” deaths.

Objectives

This article will review selected examples of the literature on this topic to determine if it is definable as a discrete medical entity, has a recognizable history, epidemiology, clinical presentation, pathophysiology, and treatment recommendations.

Discussion

Excited delirium syndrome is characterized by delirium, agitation, acidosis, and hyperadrenergic autonomic dysfunction, typically in the setting of acute-on-chronic drug abuse or serious mental illness or a combination of both.

Conclusions

Based upon available evidence, it is the consensus of an American College of Emergency Physicians Task Force that Excited Delirium Syndrome is a real syndrome with uncertain, likely multiple, etiologies.     

The bougie: an inexpensive lifesaving airway device

Background

“Bougies,” otherwise known as endotracheal tube introducers, remain preferred devices for the emergency physician when faced with a difficult airway. Bougies have high success rates for the prehospital provider and the first-time emergency department (ED) user, with few reported complications. Inexpensive, disposable models provide simple yet valuable tools in the challenging patient with an anterior airway or limited neck mobility.

Objectives

Use of the bougie is similar to standard endotracheal intubation. Correct placement is determined by feeling “clicks” as the device passes over the tracheal rings and a “hold up” when entering the distal airways.

Case Reports

Three recent cases from our ED are briefly reported, in which the bougie was invaluable in the management of the difficult airway. All patients had limited visualization of the glottis but were intubated successfully.

Conclusion

This article discusses three example cases, and then reviews the history of the bougie, placement technique, and current evidence for use.     

The effect of prehospital nebulized naloxone on suspected heroin-induced bronchospasm

Background

Snorting or smoking heroin is a known trigger of acute asthma exacerbation. Heroin abuse may be a risk factor for more severe asthma exacerbations and intubation. Heroin and other opioids provoke pulmonary bronchoconstriction. Naloxone may play a role in decreasing opioid-induced bronchospasm. There are no known clinical cases describing the effect of naloxone on opioid-induced bronchospasm.

Methods

This is an observational study in which nebulized naloxone was administered to patients with suspected heroin-induced bronchospasm. Patients with spontaneous respirations were administered 2 mg of naloxone with 3 mL of normal saline by nebulization. We describe a case series of administrations for suspected heroin-induced bronchospasm.

Results

We reviewed 21 administrations of nebulized naloxone to patients with suspected heroin-induced bronchospasm. Of these, 19 patients had a clinical response to treatment documented. Thirteen patients displayed clinical improvement (68%), 4 patients had no improvement (21%), and 2 patients worsened (10%). Of the 2 patients who had clinical decline, none required intubation. Of the patients who improved, 1 patient received only nebulized naloxone and 1 patient received naloxone and albuterol together. Seven patients showed clinical improvement after the administration of albuterol, atrovent, and naloxone together as a combination. Four patients showed additional improvement when the naloxone was administered after the albuterol and atrovent combination.

Conclusion

Naloxone may play a role in reducing acute opioid-induced bronchoconstriction, either alone or in combination with albuterol. Future controlled studies should be conducted to determine if the addition of naloxone to standard treatment improves bronchospasm without causing adverse effects.     

TRIAD III: nationwide assessment of living wills and do not resuscitate orders

Background

Concern exists that living wills are misinterpreted and may result in compromised patient safety.

Objective

To determine whether adding code status to a living will improves understanding and treatment decisions.

Methods

An Internet survey was conducted of General Surgery, and Family, Internal, and Emergency Medicine residencies between May and December 2009. The survey posed a fictitious living will with and without additional clarification in the form of code status. An emergent patient care scenario was then presented that included medical history and signs/symptoms. Respondents were asked to assign a code status and choose appropriate intervention. Questions were formatted as dichotomous responses. Correct response rate was based on legal statute. Significance of changes in response due to the addition of either clinical context (past medical history/signs/symptoms) or code status was assessed by contingency table analysis.

Results

Seven hundred sixty-eight faculty and residents at accredited training centers in 34 states responded. At baseline, 22% denoted “full code” as the code status for a typical living will, and 36% equated “full care” with a code status DNR. Adding clinical context improved correct responses by 21%. Specifying code status further improved correct interpretation by 28% to 34%. Treatment decisions were either improved 12–17% by adding code status (“Full Code,” “Hospice Care”) or worsened 22% (“DNR”).

Conclusion

Misunderstanding of advance directives is a nationwide problem. Addition of code status may help to resolve the problem. Further research is required to ensure safety, understanding, and appropriate care to patients.     

Prepubertal Girl with Vaginal Bleeding

Background

Prepubertal children with vaginal bleeding are frequently brought in to the Emergency Department (ED) for evaluation with the primary concern of sexual abuse. Appropriate history and physical examination can help recognize the specific cause and allay anxiety of parents and reduce unnecessary work-up.

Objective

The purpose of this report is to describe a frequently unrecognized cause of vaginal bleeding that is unrelated to sexual abuse.

Case Report

We report the case of a 6-year-old African-American girl referred to our ED as a case of vaginal bleeding with suspicion of sexual abuse. She was clinically diagnosed to have urethral prolapse.

Conclusion

In prepubertal girls with vaginal bleeding, urethral prolapse should be strongly considered as a diagnostic possibility. Increased physician awareness and early recognition of urethral prolapse avoids unnecessary examinations and patient anxiety and prevents misdiagnosis as sexual abuse.     

A rare cause of poisoning in childhood: yellow phosphorus

Background

Yellow phosphorus poisoning is rare, but when it occurs, it may result in pathological changes in almost all organs of the body, especially the liver, heart, kidney, spleen, and brain, and it has a significant mortality rate.

Objectives

This report presents two cases of poisoning by yellow phosphorus in children. Yellow phosphorus ingestion rarely has been reported among the pediatric population.

Case Report

This report presents two cases of yellow phosphorus poisoning in children. The patients were admitted with upper abdominal pain, vomiting, lethargy, and respiratory distress. Laboratory testing revealed hepatotoxicity and coagulation disorder. Yellow phosphorus poisoning was treated with conservative therapy in both patients, and one patient died.

Conclusion

Yellow phosphorus poisoning is a rare clinical entity and should be considered a dangerous toxic ingestion in children.     

Toxic CO-ingestions in Intentional Carbon Monoxide Poisoning

Background

Intentional carbon monoxide (CO) poisoning is responsible for two-thirds of the deaths from CO poisoning in this country and an estimated 15,000 Emergency Department visits annually.

Objectives

In an attempt to optimize medical management of such patients, this study was conducted to examine the frequency and types of toxic co-ingestions that may accompany CO inhalation.

Methods

Records of all patients treated with hyperbaric oxygen for acute, intentional CO poisoning at a regional referral center for hyperbaric medicine in Seattle from 1980 to 2005 were reviewed. For those where co-ingestions were identified, information about type of poison(s) and results of toxicology screens was recorded and analyzed.

Results

Over the 25-year period examined, 433 patients were treated for intentional CO poisoning and records were available for 426. Of those, 188 (42%) had ingested one or more poisons in addition to CO. Ethanol was most common, but a wide variety of other drug classes were also identified. Toxicology screening studies of some type were performed in 49 patients.

Conclusions

Toxic co-ingestions seem to be relatively common in patients treated for intentional CO poisoning. For this reason, providers should be vigilant and open to clinical signs that can’t be explained with CO exposure alone, and ready to treat clinical issues that arise from co-ingestions.     

Unexpected late rise in plasma acetaminophen concentrations with change in risk stratification in acute acetaminophen overdoses

Background

The acetaminophen risk analysis nomogram is used to predict hepatotoxicity risk in acute acetaminophen overdose based on a single plasma acetaminophen concentration (PAC) measured between 4 and 24 h after ingestion. There are case reports of patients with acute overdoses of acetaminophen combination products in whom a toxic PAC occurred later after an initial non-toxic PAC at approximately 4 h.

Objectives

The objective was to describe patients who had an initial non-toxic PAC and a subsequent toxic PAC.

Methods

A poison center’s database was searched for records in which patients were administered N-acetylcysteine. Cases were included if they involved an acute overdose of an acetaminophen-containing product with at least 2 plottable PACs, the first of which was obtained at least 4 h after ingestion and was below the treatment line on the nomogram with a subsequent toxic PAC. Data were analyzed for doses, timed PACs, specific acetaminophen preparation, coingestants, activated charcoal administration, and clinical effects.

Results

Twenty patients were included. Thirteen patients ingested combination products. All patients experienced vomiting, neurologic, or cardiovascular effects at presentation or before obtaining the second PAC. Two patients developed hepatotoxicity, one of which died from the complications of acetaminophen-induced hepatotoxicity.

Conclusion

The nomogram fails to predict toxicity based on a single PAC in a small subset of patients.     

The use of cephalosporins in penicillin-allergic patients: a literature review

Background

The practice of avoiding cephalosporin administration to penicillin-allergic patients persists despite the low rate of cross reactions between both groups of antibiotics.

Objective

The purpose of this literature review is to evaluate the published evidence regarding the commonly held belief that patients with a history of an allergic reaction to penicillin have a significantly increased risk of an allergic reaction to cephalosporins.

Materials and Methods

Articles were identified through a computerized search of MEDLINE from 1950 to the present using the search terms “penicillin$,” “cephalosporin$,” “allerg$,” “hypersensitivity,” and “cross-react$.” All articles were reviewed, and additional sources cited in them were added to the literature review.

Results

Penicillins have a cross allergy with first-generation cephalosporins (odds ratio 4.8; confidence interval 3.7–6.2) and a negligible cross allergy with second-generation cephalosporins (odds ratio 1.1; confidence interval 0.6–2.1). Laboratory and cohort studies confirm that the R1 side chain is responsible for this cross reactivity. Overall cross reactivity between penicillins and cephalosporins is lower than previously reported, though there is a strong association between amoxicillin and ampicillin with first- and second-generation cephalosporins that share a similar R1 side chain.

Conclusions

Although a myth persists that approximately 10% of patients with a history of penicillin allergy will have an allergic reaction if given a cephalosporin, the overall cross-reactivity rate is approximately 1% when using first-generation cephalosporins or cephalosporins with similar R1 side chains. However, a single study reported the prevalence of cross reactivity with cefadroxil as high as 27%. For penicillin-allergic patients, the use of third- or fourth-generation cephalosporins or cephalosporins with dissimilar side chains than the offending penicillin carries a negligible risk of cross allergy.     

Prognosis of emergency department patients with suspected infection and intermediate lactate levels: A systematic review

Purpose

Previous studies have shown a correlation between blood lactate greater than 4.0 mmol/L and mortality in patients with suspected infection in the emergency department (ED), but data are more limited regarding the prognosis of intermediate blood lactate (2.0-3.9 mmol/L), particularly in the absence of hemodynamic instability. We sought to quantify the prognostic significance of intermediate blood lactate levels in ED patients with suspected infection, emphasizing patients without hypotension.

Methods

A systematic review of 4 databases was conducted to identify studies using a comprehensive search strategy. All studies performed on adult ED patients with suspected infection and available data on hemodynamics, intermediate lactate levels, and mortality rates were included.

Results

We identified 20 potential publications, 8 of which were included. Intermediate lactate elevation was found in 11062 patients with suspected or confirmed infection, 1672 (15.1%) of whom died. Subgroup analysis of normotensive patients demonstrated a mortality of 1561 (14.9%) of 10?442, with rates from individual studies between 3.2% and 16.4%.

Conclusion

This systematic review found that among ED patients with suspected infection, intermediate lactate elevation is associated with a moderate to high risk of mortality, even among patients without hypotension. Physicians should consider close monitoring and aggressive treatment for such patients.     

Predicting difficult and traumatic lumbar punctures

Objective

The objective of this study is to determine if visual and tactile inspection of the spine is useful in the prediction of a difficult or traumatic lumbar puncture (LP).

Design

This was a prospective, observational, cohort study conducted in the emergency department (ED) on patients who were undergoing an LP. Physicians prospectively completed a structured data form that included information about the patient, number of prior LPs performed, their assessment of the LP difficulty, and the number of needlesticks required. A “difficult” LP and a “traumatic” tap were defined a priori. χ², t tests, and regression were used as appropriate; an independent statistician performed the statistical analysis.

Setting

The study was conducted at an urban university teaching hospital with an annual ED census of approximately 48 000 patients between November 1, 2002, and June 1, 2003.

Patients

The study population included a convenience sample of patients undergoing LP in the ED.

Results

Of the 148 patients enrolled, LP was difficult in 47 (32%) patients and traumatic in 23 (16%) patients. The percentage of patients that did not have a visible spine was significantly higher in the difficult and traumatic groups (P < .05). Among patients where the physician was unable to visualize the spine, there were significantly more difficult LPs (P < .05).

Conclusion

It may be possible to predict which patients will have difficult or traumatic LPs before performing the procedure. Simple bedside assessments of spine visibility and palpability may assist in planning the approach to an LP in patients.     

Transient Cardiac Effects in a Child with Acute Cholinergic Syndrome Due to Rivastigmine Poisoning

Background

We report a case of rivastigmine poisoning resulting in a full cholinergic syndrome with nicotinic, muscarinic, and central effects requiring supportive or intensive care in a pediatric patient.

Case Report

A 3-year-old girl was admitted to the Emergency Department suspected of having ingested one or two pills of rivastigmine. The child was hyporeactive, with symptoms of altered mental status, sialorrhea, sweating, and diarrhea. Subsequently, she started showing signs of respiratory failure, severe tracheobronchial involvement, and gastric and abdominal distension. An electrocardiogram recorded frequent monomorphic ventricular ectopic beats with bigeminy and trigeminy. Long-term follow-up showed a transient dysrhythmia.

Conclusion

Poisoning with rivastigmine can be a life-threatening condition. Timely identification and appropriate management of the toxic effects of this drug are essential and often life-saving. This is particularly true in cases of cholinergic syndrome subsequent to drug poisoning. Patients with cholinergic syndrome should also be assessed for possible cardiac complications such as dysrhythmias. The main factors predisposing to the development of such complications are autonomic disorder, hypoxemia, acidosis, and electrolyte imbalance.     

Usefulness of severity scores in patients with suspected infection in the emergency department: a systematic review

Background

Score systems for severity of illness and organ dysfunction have been validated and used as tools to predict the risk of death in intensive care unit (ICU) patients, but their usefulness in patients with suspected infection in the emergency department (ED) or hospital ward is unclear.

Objectives

The objective of this systematic review was to establish the accuracy of score systems in the prediction of mortality in patients with suspected infection in hospital settings compared to the ICU.

Methods

Three researchers independently performed a systematic search and a review of related articles and their references using the PubMed database. The articles were selected by consensus, based on previously defined inclusion and exclusion criteria.

Results

In total, 21 studies were included, 19 of which were carried out in the ED. The researchers found that the operative characteristics to evaluate the accuracy (calibration and discrimination) of the different scores were insufficiently assessed in most studies. Only two studies evaluated the calibration, using the Hosmer-Lemeshow goodness-of-fit test, and less than half of the studies evaluated the discrimination, using the area under the receiver operator characteristics curve.

Conclusions

The reviewed literature did not provide enough information to assess the accuracy of the prognostic models in patients with suspected infection admitted to the ED and hospital ward. Some reports suggest a better accuracy with new scores like the MEDS (Mortality in Emergency Department Sepsis score), but the results are not consistent.