Jason B Hack

Publications of Jason B Hack

• Levamisole exposure and hematologic indices in cocaine users.

  Authors: Peter R Chai, William Bastan, Jason Machan, Jason B Hack, Kavita M Babu

  Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 11/2011; 18(11):1141-7.

  Levamisole is an antihelminthic agent found in nearly 70% of seized U.S. cocaine. Sporadic case literature describes a life-threatening agranulocytosis associated with levamisole exposure secondaryLevamisole is an antihelminthic agent found in nearly 70% of seized U.S. cocaine. Sporadic case literature describes a life-threatening agranulocytosis associated with levamisole exposure secondary to cocaine use. The authors compared the distribution of hematologic indices in a population of cocaine users with and without a confirmed exposure to levamisole. The records of all patients in the Lifespan hospital system who underwent comprehensive toxicologic testing between September 2009 and December 2009 (n = 799) were reviewed. Of these, 95 patients were eligible for inclusion (cocaine-positive with a simultaneous complete blood count). Patients were grouped into levamisole-positive (n = 47) and -negative (n = 48) groups. The primary outcome measures were total white blood cell count (WBC), absolute neutrophil count (ANC), and absolute lymphocyte count (ALC); secondary outcome measures included percent neutrophils, lymphocytes, eosinophils, monocytes, and basophils, as well as identified co-ingestants. Both groups had a similar makeup of age, sex, and race. The total WBC count, ANC, and ALC were not significantly different between the two groups. There was no significant difference in relative proportion of neutrophils, eosinophils, basophils, or monocytes between the groups. There was one neutropenic patient in the levamisole-positive group, while three patients were neutropenic in the negative group. Additionally, a literature review of case reports describing levamisole-induced agranulocytosis (n = 33) was conducted. In 52% of these cases, patients presented with an oropharyngeal chief complaint; in an additional 27%, patients presented with soft tissue infections or purpura. The overall incidence of neutropenia was 4.2% in all cocaine users and 2.1% in the levamisole-positive group. A striking number of the reported patients with levamisole-associated neutropenia have presented to care with oropharyngeal complaints, vasculitis, or fever. A clinical algorithm for identifying levamisole toxicity in the emergency department setting is provided. Further research is necessary to determine the circumstances required for levamisole-associated neutropenia.

• A localizing circumferential compression device increases survival after coral snake envenomation to the torso of an animal model.

  Authors: Jason B Hack, Jocelyn M Deguzman, Kori L Brewer, William J Meggs, Dorcas O'Rourke

  The Journal of emergency medicine. 07/2011; 41(1):102-7.

  Pressure immobilization bandages have been shown to delay onset of systemic toxicity after Eastern coral snake (Micrurus fulvius) envenomation to the distal extremity. To assess the efficacy of aPressure immobilization bandages have been shown to delay onset of systemic toxicity after Eastern coral snake (Micrurus fulvius) envenomation to the distal extremity. To assess the efficacy of a novel compression device in delaying onset of systemic toxicity after truncal envenomations with Eastern coral snake (Micrurus fulvius) venom in a porcine model. With University approval, nine juvenile pigs (11 kg to 22 kg) were sedated, anesthetized, and intubated but not paralyzed to ensure continuous spontaneous respirations in a university animal laboratory. Each animal was injected subcutaneously with 10 mg of M. fulvius venom in a pre-selected area of the trunk. After 1 min, six animals had the application of a novel, localizing circumferential compression (LoCC) device applied to the bite site (treatment group) and three animals had no treatment (control group). The device was composed of a rigid polymer clay form molded into a hollow fusiform shape with an internal dimension of 8 × 5 × 3 cm and an elastic belt wrapped around the animal securing the device in place. Vital signs were recorded at 30-min intervals. End points included a respiratory rate below 3 breaths/min, oxygen saturation < 80%, or survival to 8 h. Survival to 8 h was analyzed using Fisher's exact test, with p < 0.05 indicating significance. Survival analysis was performed using the Mantel-Cox test to assess time to death with outcomes represented in a Kaplan-Meier Cumulative survival plot. Five of the six pigs in the treatment group survived 8 h (293-480 min). None of the control pigs survived to 8 h (Fisher's exact p = 0.04), with mean time of respiratory failure 322 min (272-382 min). Survival analysis showed a significant delay in time to event in the treatment group compared to the control group (p = 0.04). The LoCC device used in this study delayed the onset of systemic toxicity and significantly increased survival time after artificial truncal envenomation by Eastern coral snake venom.

• First-Onset Seizure After Use of an Energy Drink [corrected].

  Authors: Kavita M Babu, Matthew D Zuckerman, Joseph K Cherkes, Jason B Hack

  Pediatric emergency care. 06/2011; 27(6):539-40.

  The health consequences of energy drink use in adolescents are unknown. We discuss an adverse event in an adolescent who presented to the emergency department with his first-ever seizure afterThe health consequences of energy drink use in adolescents are unknown. We discuss an adverse event in an adolescent who presented to the emergency department with his first-ever seizure after consumption of 5-Hour Energy. We review the typical presentation of caffeine toxicity, as well as the importance of screening for energy drink use in adolescents with appropriate clinical findings. We pay particular attention to the identification of energy drink-related adverse events in the emergency department and the need for subsequent reporting to the Food and Drug Administration. To our knowledge, this is the first reported case of an adolescent presenting with a new-onset seizure associated with energy drink use.

• Cevimeline (Evoxac ®) overdose.

  Authors: Berenika Voskoboynik, Kavita Babu, Jason B Hack

  Journal of medical toxicology : official journal of the American College of Medical Toxicology. 03/2011; 7(1):57-9.

  Cevimeline (Evoxac ®) is an oral muscarinic agent that has been recently approved for the treatment of xerostomia in the setting of Sjogren's syndrome. Its toxicity in overdose has not been reportedCevimeline (Evoxac ®) is an oral muscarinic agent that has been recently approved for the treatment of xerostomia in the setting of Sjogren's syndrome. Its toxicity in overdose has not been reported in the medical literature to date. We report a previously healthy patient who intentionally ingested approximately 10 mg/kg of cevimeline and presented with symptoms of muscarinic excess and mental status depression. The patient recovered uneventfully after receiving activated charcoal and supportive care. This report describes the first documented cevimeline overdose.

• Methadone, another cause of opioid-associated hearing loss: a case report.

  Authors: Kathryn A Shaw, Kavita M Babu, Jason B Hack

  The Journal of emergency medicine. 12/2010; 41(6):635-9.

  Methadone has been used for many years in the clinical setting and has many well-described side effects. In recent years, the use of methadone and other opioids have been increasing throughout theMethadone has been used for many years in the clinical setting and has many well-described side effects. In recent years, the use of methadone and other opioids have been increasing throughout the United States (US), and presentations to US Emergency Departments (EDs) due to opioid use and abuse are increasing as well. As methadone and opioid use increases, ED physicians should be aware of infrequently seen side effects and toxicities associated with the use of these drugs. We report the case of a previously healthy 20-year-old man who presented with acute onset of bilateral hearing loss secondary to an unintentional methadone overdose. At follow-up, the patient's hearing had returned to normal, with the only intervention being abstinence from methadone. Although bilateral hearing loss is a rare toxic finding of opioid ingestion, given the prevalence of opioid use, this etiology should be considered in any patient presenting with this chief complaint.

• Efficacy of North American crotalid antivenom against the African viper Bitis gabonica (Gaboon viper).

  Authors: William J Meggs, Christopher N Wiley, Kori L Brewer, Jason B Hack

  Journal of medical toxicology : official journal of the American College of Medical Toxicology. 03/2010; 6(1):12-4.

  Envenomations by exotic snakes occur from zoological collections and private individual collectors. Antivenoms to these snakes may not be readily available. The objective of this study is toEnvenomations by exotic snakes occur from zoological collections and private individual collectors. Antivenoms to these snakes may not be readily available. The objective of this study is to determine the efficacy of North American crotalid antivenin in treating mice envenomated with venom of the African viper Bitis gabonica (Gaboon viper). The subjects of the study were Swiss Webster mice weighing approximately 30 g. The study was conducted in the University research laboratory. B. gabonica venom was obtained from Venom Supplies Pty Ltd (Tanunda, South Australia) and reconstituted in sterile water. North American Crotalid Fab2 antivenin (Anavyp, Instituto Bioclon, Mexico) was donated by the manufacturer. The experimental groups were: Group I received two times an intraperitoneal LD(50) dose of venom, 2.58 mg/kg. Group II received the same dose after incubation for 1 h with 10 mg of antivenin. Time to onset of toxicity defined as respiratory rate <10/min or absence of response to prodding. t test and Chi square with p < 0.05 considered significant. Time to onset of toxicity was 7.040 +/- 4.334 h in group I, and 20.665 +/- 2.074 in group II (p = 0.0064, 95% confidence interval of difference of means -22.694 to -4.556). Antivenin was efficacious to statistical significance at 4, 8, 12, and 16 h (p values of 0.062, 0.0067, 0.0067, and 0.0253, respectively). Improvement at 20 and 24 h (p values of 0.0673 and 0.0673, respectively) did not achieve statistical significance. North American Crotalid antivenin (Anavyp, Instituto Bioclon, Mexico) demonstrated efficacy in increasing time to onset of distress in mice poisoned with B. gabonica (Gaboon viper) venom. Based on this result, treatment of humans envenomated with B. gabonica with North American Croatlid antivenin could be considered for severe envenomations if specific B. gabonica antivenin is unavailable.

• A localizing circumferential compression device delayed death after artificial eastern diamondback rattlesnake envenomation to the torso of an animal model in a pilot study.

  Authors: Jason B Hack, Babatunde Orogbemi, Jocelyn M Deguzman, Kori L Brewer, William J Meggs, Dorcas O'Rourke

  Journal of medical toxicology : official journal of the American College of Medical Toxicology. 03/2010; 6(2):207-11.

  Nearly all prior studies to delay onset of systemic toxicity and death after snake bite use a model of distal extremity envenomation. In the first of a series of planned studies using snake venomsNearly all prior studies to delay onset of systemic toxicity and death after snake bite use a model of distal extremity envenomation. In the first of a series of planned studies using snake venoms with different toxicity profiles, the application of a novel device in a new model of torso envenomation in the setting of Eastern Coral Snake (Micrurus fulvius) venom (a potent neurotoxin) envenomation showed promise by delaying systemic intoxication. In this pilot study, we investigated this novel localizing circumferential compression (LoCC) device's ability to delay onset of life threatening systemic toxicity after Eastern Diamondback Rattlesnake (Crotalus adamanteus) envenomation, a potent hemotoxic and myotoxic venom. With university approval, four juvenile female pigs (22-25 kg) were anesthetized, sedated, and intubated but not paralyzed to allow for spontaneous respirations. Each animal was injected subcutaneously with 50 mg of C. adamanteus venom in identical preselected areas of the trunk. After 1 min, two treatment animals had the LoCC device applied; two control animals had no intervention. Vital signs were recorded every 10 min for the first 2 h and every 30 min thereafter. Endpoints included cardiovascular collapse (fatal arrhythmia, loss of mean arterial pressure, or pulse) or respiratory arrest (<3 breaths/min, saturation < 80%) or survival to 7 h. The pigs in the treatment group reached an endpoint at an average time of 355 (+/-65) min compared with control 32 (+/-3.5) min (p < 0.04). In this pilot study, the LoCC device significantly delayed onset of systemic symptoms and death after torso envenomation with Eastern Diamondback Rattlesnake venom in this model.

• Drunk Spell.

  Authors: Jason B Hack

  Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 07/2009;

• An alcohol oxidase dipstick rapidly detects methanol in the serum of mice.

  Authors: Jason B Hack, Jacqueline Early, Kori L Brewer

  Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 01/2008; 14(12):1130-4.

  BACKGROUND: Patients presenting with ingestions of methanol and ethylene glycol pose a significant challenge to emergency physicians. The decision to initiate antidotal therapy must be made quicklyBACKGROUND: Patients presenting with ingestions of methanol and ethylene glycol pose a significant challenge to emergency physicians. The decision to initiate antidotal therapy must be made quickly and is currently based on the presence of indirect signs, symptoms, and laboratory tests, because no real-time diagnostic test exists to measure these substances. OBJECTIVES: To determine whether a commercially available ethanol-in-saliva detecting dipstick (ALCO-Screen) would be a reliable and rapid indicator of toxic alcohol presence in the serum of an animal model. METHODS: Fifty mice randomly received intraperitoneal doses of methanol, ethylene glycol, or ethanol to induce serum concentrations of approximately 5-400 mg/dL. Thirty minutes after injection, serum was obtained. Serum was both applied to the dipstick and frozen for definitive concentration determination by gas chromatography. After 2 minutes, dipsticks were evaluated for color change by a blinded observer and photographed to be evaluated by other blinded observers at a later time. RESULTS: All concentrations of methanol > or =5 mg/dL consistently caused a color change on the ALCO-Screen. Ethylene glycol reliably caused a color change at > or =300 mg/dL. There was significant agreement among multiple observers whether or not color change had occurred using the ALCO-Screen. CONCLUSIONS: A commercially available dipstick that uses an alcohol oxidase colorimetric reaction reliably and rapidly detects very low serum concentrations of methanol but not ethylene glycol in this animal model. This color change is easily detected by most observers.

• Emergency Physicians' Patterns of Treatment for Presumed Gonorrhea and Chlamydia in Women: One Center's Practice.

  Authors: Jason B Hack, Claus Hecht

  The Journal of emergency medicine. 01/2008;

  No indicator reliably predicts if a woman has gonorrhea or chlamydia (sexually transmitted diseases [STDs]) during an Emergency Department (ED) visit. Before culture results return, emergencyNo indicator reliably predicts if a woman has gonorrhea or chlamydia (sexually transmitted diseases [STDs]) during an Emergency Department (ED) visit. Before culture results return, emergency physicians (EPs) must choose whom to treat. We evaluated EP treatment of STDs within our institution. EPs voluntarily completed anonymous surveys while evaluating women requiring both a pelvic examination and STD cultures, except for sexual assault victims. The questionnaires asked for patients' demographics, history, physical examination, and in-ED laboratory tests, and whether any particular section of the encounter caused treatment. The treated and untreated groups' characteristics, as reported by the examining physicians, were compared. There were 145 questionnaires returned over a 6-month period; 41/145 patients (28%) were treated for presumed STD-28 (68%) based on physical examination, 8 (19.5%) on history, and 5 (12.5%) on in-ED laboratory tests. Comparison of treated vs. untreated groups revealed no difference in patient demographics. The treated group had more historical positives (3.92 vs. 2.84, respectively; p < 0.001) and physical examination findings (3.39 vs. 1.24, respectively; p < 0.001) compared to the untreated group. Eleven patients (7.58%) had positive STD cultures, 4 (9.75%) in the treated group and 7 (6.73%) in the untreated group (p > 0.05). In our institution, EPs chose to treat patients with more historical and physical examination findings, not based on demographics. Our EPs' presumptive STD treatment paradigms do not accurately distinguish patients with positive pelvic culture results from those with negative results, supporting the available literature that describes the difficulty of this diagnosis. Individual EDs must recognize this infection identification problem and, after assessment of their treatment population, institute either a liberal presumptive STD treatment regimen for all comers, or establish reliable and timely follow-up for women left untreated.

• Emergency Medicine Residents and Statistics: What is the Confidence?

  Authors: Jason B Hack, Poopak Bakhtiari, Kevin O'Brien

  The Journal of emergency medicine. 01/2008;

  The objective of this study was to assess whether residents have the essential tools and a sense of competency when evaluating published studies, especially the statistics. Questionnaires were mailedThe objective of this study was to assess whether residents have the essential tools and a sense of competency when evaluating published studies, especially the statistics. Questionnaires were mailed to emergency medicine (EM) residency programs in the United States querying residents' demographics and training in statistics as well as their impressions and use of statistics in the current literature; a five-question statistical quiz was also included. Possible responses of-almost always, more than (1/2) time, (1/2) time, less than (1/2) time, almost never-were tallied individually as well as compared in groups of polarized answers: over 1/2 time (almost always + more than (1/2) time) vs. under (1/2) time (less than (1/2) time + almost never). There were 495 questionnaires returned from 42 centers. No significant difference was found when comparing quiz performance with participants' self-reported statistical knowledge. There were considerable differences in the polarized answers (Over vs. Under), whether statistics: were used appropriately (40% vs. 15%, respectively); were used to enhance weak data (54% vs. 13%, respectively); enhanced their understanding of information (38% vs. 24%, respectively); simplified complex data (26% vs. 41%, respectively); were understood by them (23% vs. 38%, respectively); confused them (37% vs. 24%, respectively); were skipped (52% vs. 23%, respectively). Participants felt there should be more statistical training (49% vs. 22%, Over vs. Under, respectively). There was no difference in respondents who did or did not read the statistics (39% vs. 34%, Over vs. Under, respectively). Many EM residents surveyed do not trust, read, or understand statistics presented in current journal articles. Residency programs may want to consider enhanced training in statistics.

• Images in emergency medicine. Activated charcoal aspiration.

  Authors: Jason B Hack, M G F Gilliland, William J Meggs

  Annals of emergency medicine. 12/2006; 48(5):522, 531.

• Heparin reverses anaphylactoid shock in a porcine model.

  Authors: Charles R Heflin, Kori L Brewer, Jason B Hack, William J Meggs

  Annals of emergency medicine. 08/2006; 48(2):190-3.

  STUDY OBJECTIVE: Heparin binds histamine and has been advocated as a therapy for anaphylactic and anaphylactoid shock. The efficacy of heparin in treating anaphylactoid shock is compared with therapySTUDY OBJECTIVE: Heparin binds histamine and has been advocated as a therapy for anaphylactic and anaphylactoid shock. The efficacy of heparin in treating anaphylactoid shock is compared with therapy with diphenhydramine and epinephrine, as well as sham treatment with saline. METHODS: This controlled study of 9 anesthetized, intubated pigs induced shock with intravenous calcium ionophore A23187 (5 mg/kg), which is known to degranulate mast cells in vitro. Serum histamine levels were measured using an enzyme-linked immunosorbent assay. Shock, defined as a greater than 20% decrease in mean arterial blood pressure, was treated with intravenous saline, epinephrine with diphenhydramine, or heparin. Data were analyzed using Wilcoxon rank sum and analysis of variance, as appropriate. RESULTS: All pigs developed anaphylactoid shock after injection with A23187, as evidenced by hypotension, flushing, and an increase in plasma histamine. Mean arterial blood pressure fell from a mean of 73 (SD 10) mm Hg to 28 (SD 16) mm Hg after injection (P<.001; 95% confidence interval [CI] of the difference in pressures 34 to 57 mm Hg). Mean serum histamine levels increased from 712 micromol/dL (SD 731) to 1,154 micromol/dL (SD 799) after injection (Z value -2.201; P=.0277; 95% CI of the difference -610 to -99). Both epinephrine with diphenhydramine and heparin but not saline reversed shock. CONCLUSION: A23187 induced anaphylactoid shock in all subjects. Therapy with intravenous epinephrine combined with diphenhydramine reversed shock. Heparin also rapidly reversed shock.

• Resistant alcohol withdrawal: does an unexpectedly large sedative requirement identify these patients early?

  Authors: Jason B Hack, Robert S Hoffmann, Lewis S Nelson

  Journal of medical toxicology : official journal of the American College of Medical Toxicology. 07/2006; 2(2):55-60.

  INTRODUCTION: While most patients with alcohol withdrawal (AW) respond to standard treatment that includes doses of benzodiazepines, nutrition and good supportive care (non resistant alcoholINTRODUCTION: While most patients with alcohol withdrawal (AW) respond to standard treatment that includes doses of benzodiazepines, nutrition and good supportive care (non resistant alcohol withdrawal-NRAW), a subgroup may resist therapy (resistant alcohol withdrawal-RAW). This study describes a distinct group of AW patients, their sedative requirements, and hospital courses. METHODS: Over a period of 6 months, AW patients requiring 50 mg diazepam IV in the first hour were followed. We recorded admission indices and diazepam doses with vital signs at 1, 2, 3, 6, 12, and 24 hours. Patients were considered to have RAW if they required additional sedatives for control of symptoms and/or were having persistent abnormal vital signs despite the physicians' choices of therapy. RESULTS: Nineteen patients were enrolled; all had similar admission indices. While the 4 NRAW had normal vital signs within 3 hours, all 15 RAW patients had abnormal vital signs; 15 RAW patients required escalating diazepam doses--14 required barbiturates, 7 were intubated, and 5 had hypotension. Comparing groups: interval and total diazepam doses were not different at 1,2, and 3 hours; interval doses at 6 and 12 hours, and total doses at 6, 12, and 24 hours were significantly different. CONCLUSIONS: RAW patients require large doses of benzodiazepine administration, additional sedatives, and undergo complicated hospitalizations.

• Are the "life-support" courses updated? An evaluation of their literature base.

  Authors: Jason B Hack, Heather L Wilkinson

  Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 06/2006; 13(5):580-4.

  BACKGROUND: As a condition of employment, many physicians practicing in the United States are mandated to remain current in their certification of some or all of the life-support courses. TheseBACKGROUND: As a condition of employment, many physicians practicing in the United States are mandated to remain current in their certification of some or all of the life-support courses. These courses reputedly set the standard of care by establishing nationally recognized paradigms of resuscitation. These courses' textbooks are revised and re-released at regular intervals. OBJECTIVES: To determine whether the source data for these texts are vigorously updated with each revision and whether there is an obvious literature-based impetus to release a new version. METHODS: A comparison was made of the years of the references contained within the three most recent textbook editions of the advanced cardiac life support (ACLS), advanced trauma life support, basic life support, and pediatric advanced life support courses. The years of the references were tallied for each text, and these tallies were compared both within and between the courses. Data were divided into three groups: group 1, references published before the previous versions' release; group 2, references published after previous versions' release; group 3, references dated within three years of the texts' release. RESULTS: There appears to be a large amount of overlap of group 1 data throughout most of the course texts; the number of references in group 2 and 3 varies greatly between and within these courses. CONCLUSIONS: With one exception (ACLS in 2003), the life-support courses appear to be based on similar reference sets for the last 7 to 11 years. There may be a reason other than an availability of a critical mass of new information that prompts the release of a new edition of these life-support courses.

• Sustained oxygenation without ventilation in paralyzed pigs with high-flow tracheal oxygen.

  Authors: William J Meggs, Robert G Carroll, Kori L Brewer, Jason B Hack, Timothy J Reeder

  The American journal of emergency medicine. 12/2005; 23(7):864-7.

  OBJECTIVES: It is generally assumed that ventilation is necessary for oxygenation. This study tested if paralyzed animals without respirations can maintain arterial oxygenation when administeredOBJECTIVES: It is generally assumed that ventilation is necessary for oxygenation. This study tested if paralyzed animals without respirations can maintain arterial oxygenation when administered high-flow oxygen delivered by a catheter in the trachea. METHODS: DESIGN: Prospective observational study. SETTING: University research laboratory. PARTICIPANTS: 3 anesthetized/paralyzed swine weighing 29.5 +/- 4.2 kg. INTERVENTIONS/OBSERVATIONS: Pigs were intubated, anesthetized with intravenous tiletamine and a pentobarbital drip. A femoral arterial line was placed to record arterial blood gases and vital signs every 5 minutes. Respiratory paralysis was obtained with vecuronium 150 microg/kg and repeated at any sign of movement. A catheter was placed in the trachea to deliver oxygen at 15 L/min. Outflow gas from the endotracheal tube was analyzed for O2 and CO2. O2 was discontinued at 75 minutes. The institutional animal care and use committee approved the protocol. RESULTS: All pigs survived to 75 minutes. PaO2 was more than 100 mm Hg throughout the study period. Mean PaCO2 was 37.4 +/- 2.8 mm Hg at baseline, 146 +/- 59 at 30 minutes, then rose above 200 mm Hg in all pigs by 45 minutes. Mean arterial pH fell from 7.47 +/- 0.04 at onset to 6.75 +/- 0.06 at 75 minutes. When oxygen was terminated at 75 minutes, PaO2 fell to 16.5 +/- 7.6 mm Hg within 5 minutes, and all pigs were sacrificed within 10 minutes. For outflow gas, O2 was more than 98% and expired CO2 less than 1% throughout the study period. CONCLUSIONS: Paralyzed, unventilated pigs receiving high-flow oxygen via a tracheal catheter remained alive after 75 minutes, although a profound respiratory acidosis developed.

• Use of CroFab antivenin in the management of a very young pediatric copperhead envenomation.

  Authors: Hai H Trinh, Jason B Hack

  The Journal of emergency medicine. 09/2005; 29(2):159-62.

  The use of crotalid Fab antivenin (CroFab) in the treatment of snake envenomations in the pediatric population is still an underexplored area. There are very limited data to confirm the efficacy andThe use of crotalid Fab antivenin (CroFab) in the treatment of snake envenomations in the pediatric population is still an underexplored area. There are very limited data to confirm the efficacy and safety of dosing children the same as adults and even less information available to evaluate this antivenin use in copperhead snake bites in children. We report the first use of crotalid Fab antivenin in an adult dose for a copperhead snake envenomation in a 2-year-old child. She had rapid resolution of symptoms with no adverse effects. The report serves to increase the literature supporting the current dosing recommendations of crotalid Fab antivenin in very young pediatric patients evidenced by its effectiveness in this patient.

• Pressure-immobilization bandages delay toxicity in a porcine model of eastern coral snake (Micrurus fulvius fulvius) envenomation.

  Authors: Benjamin T German, Jason B Hack, Kori Brewer, William J Meggs

  Annals of emergency medicine. 07/2005; 45(6):603-8.

  STUDY OBJECTIVES: Pressure-immobilization bandages are used in countries where neurotoxic snake envenomations are common. They impede lymphatic egress from the bite site and delay systemic venomSTUDY OBJECTIVES: Pressure-immobilization bandages are used in countries where neurotoxic snake envenomations are common. They impede lymphatic egress from the bite site and delay systemic venom toxicity. The effectiveness of these devices has not been evaluated in coral snake envenomations. We investigated the efficacy of pressure-immobilization bandages in delaying the onset of systemic toxicity in a porcine model of coral snake envenomation. METHODS: A randomized controlled trial of pressure-immobilization bandages was conducted in a university animal care center. Subjects were 12 anesthetized, spontaneously breathing pigs, ranging from 9.1 to 11.4 kg. After injection with 10 mg of Micrurus fulvius fulvius venom in the subcutaneous tissue of the distal foreleg, subjects were randomized to receive no treatment or application of a pressure-immobilization bandage at 1 minute after injection. Treated animals had elastic bandages applied to the extremity and splinting for immobilization. Vital signs and quality of respirations were recorded. Outcome was the onset of respiratory failure or survival to 8 hours. Necropsies and histologic analysis of the envenomation site was performed. RESULTS: One animal from each group was removed because of the discovery of pre-existing respiratory pathology. Four of 5 pigs in the treatment group survived to 8 hours, but none in the control group survived. Mean time to onset of respiratory compromise was 170.4 +/- 33.3 minutes in the control group. None of the pigs had histologic changes at the envenomation site consistent with ischemia or pressure-related injury. CONCLUSION: Pressure-immobilization bandages delayed the onset of systemic toxicity in our porcine model of M fulvius envenomation.

• Pilot study: concordance of disposition for hypothetical medical patients in the emergency department.

  Authors: Jason B Hack, Kevin O'Brien, Nicholas Benson

  Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 06/2005; 12(6):562-7.

  OBJECTIVES: Emergency physicians (EPs) make dispositions for every patient in the emergency department (ED) and often require agreement from inpatient services to admit medical patients to theOBJECTIVES: Emergency physicians (EPs) make dispositions for every patient in the emergency department (ED) and often require agreement from inpatient services to admit medical patients to the hospital. Sometimes disagreements arise. The authors sought to determine in their institution disposition concordance between EPs and admitting medical services of hypothetical ED patients. A second objective was to describe additional information requested by each service. METHODS: Within a two-week period, physicians from emergency medicine (EM), family practice (FP), and internal medicine (IM) voluntarily completed anonymous questionnaires asking them to disposition hypothetical ED patients. Eleven case scenarios were followed by three disposition choices (admit, discharge, or cannot tell) from given information (followed by a free-text area). RESULTS: A total of 105 questionnaires were returned: 42 from EM (12 attending physicians/30 residents), 33 from FP (14 attending physicians/19 residents), and 30 from IM (4 attending physicians/26 residents). Admission rates were statistically different for EM (68% attending physicians/65% residents/66% total) when compared with FP (42% attending physicians/54% residents/49% total) (p < 0.01) and IM (36% attending physicians/53% residents/51% total) (p < 0.01). Discharge rates were also statistically different for EM (8% attending physicians/19% residents/16% total) versus FP (29% attending physicians/29% residents/28% total) (p < 0.01) and IM (27% attending physicians/28% residents/28% total) (p < 0.01). "Cannot tell" rates were not significantly different between groups (p > 0.05) for EM (23% attending physicians/16% residents/18% total) versus FP (25% attending physicians/14% residents/19% total) and IM (36% attending physicians/16% residents/18% total). The proportion of additional tests requested in the "cannot tell" disposition by attending EPs was about half that of the other groups. Dispositions between FP and IM were not different at any level (p > 0.05). CONCLUSIONS: In the authors' institution, when presented with identical hypothetical ED patients, EPs would admit more, discharge less, and ask for fewer additional tests than FP or IM physicians. The FP and IM physicians surveyed disposition patients in a similar manner.

• Pediatric ingestion of lamotrigine.

  Authors: Andrea G Zidd, Jason B Hack

  Pediatric neurology. 08/2004; 31(1):71-2.

  A 3-year-old female presented to the emergency department after ingesting forty-six 25-mg tablets of lamotrigine that resulted in sedation, rash, and transient elevation of liver function tests. HerA 3-year-old female presented to the emergency department after ingesting forty-six 25-mg tablets of lamotrigine that resulted in sedation, rash, and transient elevation of liver function tests. Her initial physical examination was significant for marked somnolence and a lacy reticular blanching rash. Laboratory studies were all within normal limits except for mildly elevated liver function tests. Initial plasma lamotrigine level was found to be elevated above adult therapeutic levels (25.3 microg/mL). Treatment consisted of gastric lavage followed by activated charcoal. The patient was subsequently observed in the pediatric intensive care unit where symptoms and laboratory abnormalities promptly resolved, and she was discharged 24 hours later without further complication. This case report describes the largest single ingestion of lamotrigine ever reported in a pediatric patient. The patient exhibited significant somnolence, rash, and liver function test abnormalities with only a slight elevation of serum level of lamotrigine above adult therapeutic levels. More research is required to investigate the toxic profile of lamotrigine in pediatric patients.