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ABSTRACT: BACKGROUND: Methamphetamine, a stimulant of abuse, is associated with a significant number of Emergency Department (ED) visits. Methamphetamine use may produce psychiatric symptoms including acute psychosis, depression, and anxiety disorders. STUDY OBJECTIVES: To characterize psychiatric emergencies either directly or indirectly attributable to methamphetamine use in an urban academic ED. METHODS: We analyzed a database of patients determined to have an ED visit that was either methamphetamine related or non-methamphetamine related. We retrospectively reviewed the records of the subset of ED visits from this database with psychiatric diagnoses. We compared the characteristics of patients with methamphetamine-related psychiatric visits (MRPVs) and non-methamphetamine-related psychiatric visits (non-MRPVs). RESULTS: We identified 130 patients with MRPVs. This represented 7.6% (130 of 1709) of all psychiatric visits. Patients with MRPV, compared to non-MRPV patients, were younger (34.4 years vs. 39.1 years, respectively, p = 0.0005), more likely to be uninsured (55% vs. 37%, respectively, p = 0.001), and less likely to have a past history of depression (10% vs. 19%, respectively, p = 0.011). Many characteristics between the two groups (MRPV vs. non-MRPV) were similar: likelihood of patient being placed on a psychiatric hold; hospital charges; previous histories of psychiatric visits; and history of anxiety, bipolar disorder, or schizophrenia. CONCLUSIONS: Methamphetamine may be related to a significant proportion (7.6%) of psychiatric ED visits. Furthermore, patients with methamphetamine-associated psychiatric visits are younger, have lower rates of depression, are more likely to be uninsured, and are less likely to have a substance abuse-related chief complaint than patients with non-methamphetamine-associated ED psychiatric visits.
Journal of Emergency Medicine 04/2013; · 1.31 Impact Factor
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ABSTRACT: Introduction. We present a case of envenomation by a Great Lakes Bush Viper, Atheris nitschei. Atheris species are a group of snakes that are indigenous to the forested areas of Central Africa. Prior reports of envenomation by Great Lakes Bush Vipers were not found in a Medline search. However, reports of other Atheris species envenomations describe coagulopathy and acute renal failure. Case details. A 30-year-old male was bitten by a Great Lakes Bush Viper on his left hand. His left upper extremity was edematous with ecchymoses in the left axilla. There was bleeding from the bite site and from the patient's oral mucosa. Initial laboratory studies demonstrated significant derangement of hematologic parameters including anemia, thrombocytopenia, coagulopathy, and hypofibrinoginemia. There is no antivenom for this species. The patient was treated with blood products. Mucosal bleeding ceased within 12 h of admission. Discussion. Atheris nitschei is an African snake with no available antivenom. In this case, the patient developed coagulopathy with hemolytic anemia, thrombocytopenia, and low fibrinogen. Renal function remained unaffected. Despite the lack of specific antivenom or the use of plasmapheresis, our patient was successfully treated with transfusion of multiple blood products.
Clinical Toxicology 01/2013; · 2.22 Impact Factor
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American family physician 08/2012; 86(3):222. · 1.70 Impact Factor
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Pediatric emergency care 06/2012; 28(6):581-3. · 0.92 Impact Factor
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ABSTRACT: Over the last few decades, the rate of breastfeeding has increased steadily in the developed countries of the world. During this time, opioid use in the general population has steadily increased as well. Despite this, clinicians remain unclear whether opioid use is safe during breastfeeding. While the vast majority of medications used during breastfeeding occur without incident, case reports and studies have reported possible opioid toxicity in breast-fed infants. Multiple enzymes are involved in the metabolism of opioids. CYP2D6 catabolizes O-demethylation of codeine, tramadol, oxycodone, and hydrocodone to more potent metabolites. CYP3A4 inactivates methadone, meperidine, and buprenorphine. Glucoronide conjugation by the UGT enzyme family inactivates morphine and hydromorphone. Genetic polymorphisms and interfering medications affect the maternal metabolism, which in turn determines the exposure and risk to the breast-fed neonate. We review the production of breast milk, the transfer of xenobiotics from blood to milk, the characteristics that alter xenobiotic breast-milk concentrations, and we review the evidence of specific common opioids and infant toxicity. The short-term maternal use of prescription opioids is usually safe and infrequently presents a hazard to the newborn.
Clinical Toxicology 12/2011; 50(1):1-14. · 2.22 Impact Factor
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ABSTRACT: A 13-month-old male who ingested 20 diphenhydramine (25 mg) tablets presented with seizures and ultimately progressed to status epilepticus and wide-complex tachycardia. Due to worsening clinical course, hemodialysis was performed with temporal resolution of his symptoms. Hemodialysis may be considered in critically ill diphenhydramine overdoses not responsive to conventional supportive care.
Journal of medical toxicology: official journal of the American College of Medical Toxicology 06/2011; 7(2):147-50.
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ABSTRACT: CONTEXT. Lamotrigine is used for both seizure and psychiatric disorders. Overdoses typically follow a benign course. CASE DETAILS. A 19-year-old male with bipolar disorder ingested 4 g of lamotrigine. The patient suffered from multiple seizures, charcoal aspiration, respiratory arrest, prolongation of the QRS interval on electrocardiogram, complete heart block, multiorgan failure and ultimately death. DISCUSSION. We describe the emergency department (ED) and ICU course for this patient and briefly review the toxic effects of lamotrigine and the pharmacokinetics with and without hemodialysis.
Clinical Toxicology 04/2011; 49(4):330-3. · 2.22 Impact Factor
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Pediatric emergency care 03/2011; 27(3):239-41. · 0.92 Impact Factor
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ABSTRACT: A Vietnamese family living in the Pacific Northwest harvested several wild mushrooms grown in their front lawn. All three in the family suffered from delayed GI symptoms starting approximately 12 h after ingestion. One patient died and two developed hepatic injury. We provide photography and describe common characteristics of Amanita phalloides mushroom.
Clinical Toxicology 02/2011; 49(2):128-9. · 2.22 Impact Factor
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ABSTRACT: Envenomation by a large number of hymenopterans can cause significant morbidity and mortality due to venom load. We present the first case of massive Hymenoptera envenomation by native US Hymenoptera.
A 3-year-old boy and his family were hiking in Oregon and were attacked by yellow jackets. On emergency department arrival, the child was uncomfortable and vomiting. Vital signs were normal; physical examination showed more than 90 punctate lesions on the head and neck, and 30 below the neck without urticaria. Initial laboratory values were normal except for a white blood cell count of 37,500/μL and mild hypokalemia, including a normal creatinine kinase. Intravenously administered fluids, ondansetron, midazolam, and morphine were given for symptom control.Generalized edema developed 12 hours later and was treated with intravenously administered dexamethasone and diphenhydramine. His creatinine kinase peaked at 2085 U/L after 32 hours. Forty-eight hours after the incident, the child began to take oral fluids with laboratory values returning to normal.
Delayed toxic effects of mass envenomation are due to direct toxic effects from the large venom load, with several cases of death reported. All prior cases of mass Hymenoptera envenomation in the United States have involved Africanized "killer" honeybees. Guidelines recommend admitting all pediatric patients sustaining more than 50 stings for 24 hours for laboratory evaluations.
Delayed toxic reaction may be caused by native US species of Hymenoptera. Physicians should be aware that endemic US species can cause this reaction and should have a low threshold to admit pediatric patients with more than 50 stings for 24 hours.
Pediatric emergency care 01/2011; 27(1):46-8. · 0.92 Impact Factor
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Pediatric emergency care 12/2010; 26(12):938-41. · 0.92 Impact Factor
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ABSTRACT: Methamphetamine is a drug of abuse that has been manufactured locally by chemical conversion from the decongestant pseudoephedrine. In July 2006, an Oregon state law was enacted to establish pseudoephedrine as a schedule III drug and make it available by prescription only. This study sought to determine if this legislation altered the number of emergency department (ED) visits that are related to methamphetamine use.
This was a retrospective analysis of a database created during a prospective study aimed at determining the effect of methamphetamine on ED visits. That prospective study was 1 year in duration and required ED clinicians to determine whether a patient's visit was related to methamphetamine and if the patient had confirmed use of methamphetamine. The clinicians received initial and continued education and training on methamphetamine during the study period. The questions were asked at every ED visit during the study period and were electronically linked to the patient's disposition and could not be circumvented. The study period was divided into prelegislation (February 5, 2006, to June 30, 2006) and postlegislation periods (July 1, 2006, to February 5, 2007).
Over the 1-year study period, 37,625 patients were enrolled, 1.90% (n = 714) of patients had methamphetamine-related ED visits (MREDVs), and 1.65% (n = 620) had confirmed methamphetamine use. Patients with MREDVs were more likely than patients with non-MREDVs to be white and uninsured. The number and proportion of weekly MREDVs significantly decreased from the prelegislation period to the postlegislation period (mean number of weekly visits, 18.0 vs. 11.3, p = 0.001; mean proportion of weekly visits, 2.3% vs. 1.6%, p = 0.003). The number and proportion of weekly confirmed users of methamphetamine also significantly decreased during the study period (mean number of weekly users, 14.6 vs. 10.3, p = 0.004; mean proportion of weekly users, 1.9% vs. 1.4%, p = 0.017). There were no significant differences in the diagnoses of MREDVS between the pre- and postlegislation periods.
This study found an association between the enactment of legislation that limits pseudoephedrine availability and a decrease in MREDVs and confirmed users of methamphetamine in the study ED.
Academic Emergency Medicine 11/2010; 17(11):1216-22. · 1.86 Impact Factor
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Annals of emergency medicine 07/2010; 56(1):72-3; author reply 73. · 4.23 Impact Factor
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ABSTRACT: The objective was to evaluate the applicability of a previously studied multifactorial nausea scale in the emergency department (ED) setting via exploratory factor analysis (EFA).
Two studies evaluated the validity and factor structure of 18 nausea descriptors scored on 11-point Likert scales. Trained research volunteers administered the scale to 83 men and 123 women in the first sample and to 100 men and 230 women in the second sample. All patients were assessed at enrollment and again at 90 minutes to detect changes in symptom severity. An EFA in the first study used a maximum likelihood estimation method with a principal factor analysis. The second study narrowed the descriptors and evaluated the factor structure with a confirmatory factor analysis (CFA).
Two factors were retained in the solution; one contained five items with descriptors of physical symptoms, and a second contained five items with psychological symptoms. CFA determined that the two five-item scales were stable and reliable measures of patient nausea experience.
The scales measure both physical and psychological symptoms of nausea, indicating that the experience is multidimensional.
Academic Emergency Medicine 06/2010; 17(6):e33-9. · 1.86 Impact Factor
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ABSTRACT: After acute ingestion, acetaminophen (APAP) is generally absorbed within 4 h and the APAP concentration ([APAP]) slowly decreases with a predictable half-life. Alterations in these pharmacokinetic principles have been rarely reported. We report here three cases of an unusual double hump, or Bactrian, pattern of [APAP]. We review the literature to describe the case characteristics of these rare cases. A 38-year-old woman ingested 2 g hydrocodone/65 g acetaminophen. Her [APAP] peaked at 289 mcg/mL (8 h), decreased to 167 mcg/mL (31 h), then increased to 240 mcg/mL (39 h). She developed liver injury (peak AST 1603 IU/L; INR1.6). A 25-year-old man ingested 2 g diphenhydramine/26 g APAP. His [APAP] peaked at 211 mcg/mL (15 h), decreased to 185 mcg/mL (20 h), and increased again to 313 mcg/mL (37 h). He developed liver injury (peak AST 1153; INR 2.1). A 16-year-old boy ingested 5 g diphenhydramine and 100 g APAP. His [APAP] peaked at 470 mcg/mL (25 h), decreased to 313 mcg/mL (36 h), then increased to 354 mcg/mL (42 h). He developed liver injury (peak AST 8,686 IU/L; peak INR 5.9). We report three cases of Bactrian ("double hump") pharmacokinetics after massive APAP overdoses. Cases with double hump pharmacokinetics may be associated with large ingestions (26-100 g APAP) and are often coingested with antimuscarinics or opioids. Several factors may contribute to these altered kinetics including the insolubility of acetaminophen, APAP-induced delays in gastric emptying, opioid or antimuscarinic effects, or enterohepatic circulation. Patients with double hump APAP concentrations may be at risk for liver injury, with AST elevations and peaks occurring later than what is typical for acute APAP overdoses.
Journal of medical toxicology: official journal of the American College of Medical Toxicology 05/2010; 6(3):337-44.
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ABSTRACT: Cang Er Zi Wan (CEZW) is a herbal medication derived from Xanthium sibiricum that is used to treat allergies and upper respiratory problems. Its toxicity has been described in grazing animals, in experimental studies, and in human overdoses. We describe a case of muscular spasm that was associated with the therapeutic use of CEZW.
A 17-year-old female was prescribed CEZW for chronic allergies. Shortly after her second dose of 10 pills BID, she developed intermittent muscular spasms. She was seen in an Emergency Department and had normal vital signs and no significant laboratory abnormalities. Her physical exam was significant only for intermittent spasm of the muscles of the face, neck, and upper extremities. No tremor, fasciculation, dystonia, akisthisia, chorea, bradykinesia, or clonus was noted. She discontinued the CEZW and the symptoms slowly decreased over 4 days. Testing of the product did not detect any other medications or drugs.
CEZW is a herbal medication that contains X. sibiricum. X. sibiricum is a widespread weed that has caused muscular spasm, seizures, and death in animals that graze on it as well as animals experimentally exposed to it. Eleven cases of accidental human ingestion of Xanthium leading to spasm, somnolence, hypoglycemia, renal, and liver toxicity have been described. We describe a unique case of isolated muscular spasms because of the therapeutic use of a CEZW product.
Clinical Toxicology 05/2010; 48(4):380-4. · 2.22 Impact Factor
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ABSTRACT: Intralipid therapy has been used successfully as "rescue therapy" in several cases of overdose. We present a case of iatrogenic lipid emulsion overdose because of a dosing error.
A 71-year-old female overdosed on 27 tablets of 5 mg amlodipine. Although initially stable in the Emergency Department, she became hypotensive, oliguric, and respiratory failure developed despite medical therapy. The primary treating team felt that meaningful recovery was unlikely to occur without rapid improvement in clinical status, and 12.5 h after presentation, intralipid rescue therapy was initiated. A protocol for intralipid specifying a maximum infusion of 400 mL of 20% lipid emulsion was faxed, but the infusion was continued until 2 L of lipid emulsion was infused. There were no detectable adverse hemodynamic effects of the intralipid infusion. After this time, laboratory values were difficult to obtain. Three hours after the infusion, a metabolic panel was obtained from ultracentrifuged blood showing hyponatremia. A white blood cell (WBC) was obtained from a complete blood count (CBC) performed 22 h after the infusion, hemoglobin and hematocrit could not be obtained from this blood. A platelet count was obtained by smear estimate. Hematocrits were obtained from centrifuged blood and appeared elevated. No oxygenation could be obtained on blood gas. The patient's family chose to withdraw care on hospital day 2 and no further laboratory draws were obtained. Amlodipine was 1,500 ng/mL (ref. 3-11 ng/mL).
Lipid emulsion overdose caused no detectable acute adverse hemodynamic effects. The following laboratory values were unobtainable immediately after infusion: white blood cell count, hemoglobin, hematocrit, platelet count, and a metabolic panel of serum electrolytes. Ultracentrifugation of blood allowed for detection of a metabolic panel 3 h after the infusion. Centrifuged hematocrits appeared to be higher than expected.
Clinical Toxicology 04/2010; 48(4):393-6. · 2.22 Impact Factor
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Journal of Emergency Medicine 12/2009; 41(1):89. · 1.31 Impact Factor
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ABSTRACT: We describe the demographics, characteristics, treatment, and clinical course of methamphetamine body stuffers. We also determine the clinical characteristics of methamphetamine body stuffers who have severe outcomes.
A 6.5-year descriptive nonconcurrent observational case series evaluated methamphetamine body stuffers about whom the Oregon Poison Center was consulted by their primary physicians. Poison center charts were supplemented by completed hospital charts (for 95% of patients).
Six hundred forty-eight patients with methamphetamine exposure were identified and reviewed, and 55 charts met the criteria for "methamphetamine body stuffer." We found the following characteristics of methamphetamine body stuffers: mean age 29 years (range 16 to 57 years), men in 44 of 55 cases (80%), mean time to arrival 2.7 hours after ingestion, with a median of 1 hour after ingestion. Ninety-seven percent (53/55) stuffed methamphetamine orally (2/55 rectally). Methamphetamine was most frequently swallowed in baggies, but 25% were unpackaged. The median dose ingested was 3.5 g of methamphetamine in 1 package. Outcome-based analysis revealed 29% (16/55) of patients had severe outcomes, as defined by end-organ toxicity, with agitation requiring intubation the most common severe outcome. There was 1 death reported. Toxicity did not appear to be related to the amount of methamphetamine or number of packets. Patients with severe outcomes had higher mean initial pulse rates and temperatures. Eighty-eight percent (14/16) of patients with severe outcomes had a presenting pulse rate greater than 120 beats/min or a temperature greater than 38 degrees C versus 18% (7/39) patients with a benign outcome. Twenty-four radiographic studies were obtained; none detected packets.
Methamphetamine body stuffers have similar demographics to those of body stuffers of other stimulants, but tended to ingest fewer baggies with larger masses, and had a higher percentage of severe outcomes (29%) than previously reported with other stimulants. Increases in presenting pulse rate and temperature (pulse rate >120 beats/min or >38.0 degrees C) are common in patients who will develop end-organ damage.
Annals of emergency medicine 10/2009; 55(2):190-7. · 4.23 Impact Factor
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ABSTRACT: To quantify the frequency, cost, and characteristics associated with emergency department (ED) visits that are related to methamphetamine use.
This was a prospective observational study. The authors performed a training program for ED clinicians on the acute and chronic effects of methamphetamine and the signs of methamphetamine abuse. A standardized two question survey was administered to clinicians concerning the relationship between the ED visit and the patient's methamphetamine use. The survey was embedded in the patient tracking system and was required for all ED patients before disposition. Survey results were merged with administrative data on demographics, diagnosis, disposition, and charges. Univariate analyses were used to determine patient characteristics associated with methamphetamine-related ED visits.
The authors examined 15,038 ED visits over a 20-week period from February 2006 to June 2006. There were a total of 353 methamphetamine-related visits, for an average of 17.65 visits per week (2.4% of all visits). Hospital charges for methamphetamine-related ED visits averaged $133,181 per week, for an estimated total of $6.9 M in annual charges. Methamphetamine-related ED patients were more likely to be male (odds ratio [OR] 1.6, 95% confidence interval [CI] = 1.30 to 2.01), white (OR 1.8, 95% CI = 1.38 to 2.29), and uninsured (OR 3.2, 95% CI = 2.21 to 4.69). The top four medical conditions associated with methamphetamine-related visits were mental health (18.7%), trauma (18.4%), skin infections (11.1%), and dental diagnoses (9.6%).
Methamphetamine abuse accounts for a modest but substantial proportion of ED utilization and hospital cost. Methamphetamine-related ED visits are most commonly related to mental illness, trauma, skin, and dental-related problems.
Academic Emergency Medicine 02/2008; 15(1):23-31. · 1.86 Impact Factor
