Prospective evaluation of "crack-vial" ingestions

The "crack" (cocaine alkaloid) epidemic has resulted in an increasing number of hospitalizations of "crack-vial body-stuffers," or patients who ingest "crack-vials" in an attempt to avoid prosecution. Management strategies for this type of ingestion are lacking because of the paucity of data. This report discusses the demographics and symptomatology of 23 patients with "crack-vial" ingestions, as well as the value of abdominal radiographs and the utility of varied strategies for decontamination in this patient population.

Comparison of titratable acid/alkaline reserve and pH in potentially caustic household products

Exposure to caustic agents is a common problem, affecting thousands of individuals annually. Despite this incidence, the factors responsible for the production of injury remain poorly defined. Although extremes of pH seem to correlate well with the production of esophageal lesions, pH alone fails to explain the damage resulting from exposure to agents with near neutral pH, such as soldering flux containing zinc chloride. We determined titratable acid/alkaline reserve (TAR) in 38 potentially caustic household agents. A subset of these products was evaluated in an in-vitro canine esophageal model to determine whether TAR correlated with esophageal injury. The results indicate that for the products evaluated TAR correlated better than pH with the production of caustic esophageal injury.

Ethanol-associated metabolic disorders

The ingestion of alcohol, both intermittently and habitually, results in significant patient morbidity and mortality and stresses an already compromised socioeconomic system. Ethanol can interact with normal metabolic pathways to produce a variety of life-threatening abnormalities, particularly in those with underlying poor nutritional status, as is found in many alcohol users. Once identified, the metabolic derangements associated with alcohol use generally respond well to therapeutic interventions. The recurrence rate, however, is extremely high. Any attempt at long-term solutions must involve extensive rehabilitative services. Current research is directed largely toward improving survival from alcohol-related illnesses such as cirrhosis and cardiac disease. We must focus our efforts on the social implications of alcoholism, providing medical support, counseling, and rehabilitation to affected persons. Since alcohol-related problems present most frequently to the Emergency Department, it is appropriate that the emergency physician take the first step in attacking this disease, a step that may be as simple as a referral for detoxification or social services support.

Physical illness encountered in patients with eating disorders

Careful evaluation for medical illness with a severity rating scale of 276 eating-disorder patients admitted to hospital revealed that patients with anorexia and bulimia were at risk for developing medical complications. Severe cardiovascular complications were most likely to occur in eating-disorder patients who were also diuretic and/or laxative abusers. Forty percent of patients with bulimia had significant medical complications. The findings suggest that a medical work-up should be carefully undertaken in both anorexic and bulimic patients admitted to hospital. A mixed history of severe anorexia nervosa alternating with periods of bulimia was most likely to lead to severe life-threatening illness. Seventy percent of the bulimic patients admitted required some medical treatment. Five percent were considered severely medically ill, while 34% suffered from a significant medical disorder. Ten percent of patients with restrictive anorexia or anorexia alternating with binge/purge required intensive care unit (ICU) placement. Most illnesses requiring medical treatment were unknown to the patient and the patient's physician at the time of admission.

Methemoglobinemia resulting from smoke inhalation

Methemoglobinemia following fire exposure is largely unrecognized. Fire related morbidity and mortality are customarily attributed to thermal injury, associated trauma, and carbon monoxide poisoning. More recently, cyanide poisoning has been described from the inhalation of hydrogen cyanide liberated from of burning plastics (1). Symptoms of tissue hypoxia and cyanosis resulting from methemoglobinemia may be difficult to diagnose in the presence of thermal injury, cyanide and/or carbon monoxide poisoning. Relatively low levels of methemoglobin could complicate concomitant carbon monoxide poisoning by additive or synergistic effects on oxygen binding and delivery. We report 3 cases of significant methemoglobinemia (levels of 19, 12, and 12%) in survivors of a dwelling fire and review the literature with regard to this phenomenon.

Comparison of titratable acid/alkaline reserve and pH in potentially caustic household products

Exposure to caustic agents is a common problem, affecting thousands of individuals annually. Despite this incidence, the factors responsible for the production of injury remain poorly defined. Although extremes of pH seem to correlate well with the production of esophageal lesions, pH alone fails to explain the damage resulting from exposure to agents with near neutral pH, such as soldering flux containing zinc chloride. We determined titratable acid/alkaline reserve (TAR) in 38 potentially caustic household agents. A subset of these products was evaluated in an in-vitro canine esophageal model to determine whether TAR correlated with esophageal injury. The results indicate that for the products evaluated TAR correlated better than pH with the production of caustic esophageal injury.

Evaluation of coagulation factor abnormalities in long-acting anticoagulant overdose

Newer Rodenticides of the long-acting anticoagulant or "superwarfarin" class are gaining popularity. Since few cases of severe, prolonged anticoagulation after ingestion have been reported, the course of toxicity is not precisely understood. In this case of an intentional ingestion of brodifacoum, a longitudinal analysis of specific coagulation factor derangements was carried out in an attempt to guide a future treatment strategy for this type of toxicity. Results of this analysis demonstrated a profound decrease in levels of factors II, VII, IX, and X, lasting at least 43 days post ingestion. Treatment with subcutaneous vitamin K1 in doses up to 100 milligrams per day was without complication and was effective in reversing the coagulopathy produced by brodifacoum.

Axillary lymph node dissection for intraductal breast carcinoma--is it indicated?

One hundred patients with intraductal breast carcinoma (DCIS) were treated with either mastectomy (49 patients) or radiation therapy (51 patients). All patients underwent axillary lymph node dissection (average number of nodes removed, 16) as part of their treatment. No patient had any positive axillary lymph nodes. There has been one recurrence in each treatment group (median follow-up, 27 months) and no deaths. Intraductal breast carcinoma has little potential for metastasis to axillary lymph nodes.

Hooked-wire-directed breast biopsy and overpenetrated mammography

Six hundred fifty-three biopsies were performed for clinically occult, mammographically detected breast abnormalities. One hundred forty-seven cancers (22.5%) were found. Eighty-nine of those cancers (60.5%) were noninvasive. None of the in situ lesions had involved axillary lymph nodes. Of the 58 invasive cancers, only six (10.3%) had metastases to axillary nodes. Fifty-four patients (36.7%) were treated by mastectomy while 93 patients (63.3%) were treated conservatively, 20 by biopsy only, and 73 by lumpectomy, axillary node dissection, and radiation therapy. Only four patients (0.7%) had significant complications.

Operation of a medical-psychiatric unit in a general hospital setting

Patients with coexistent medical and psychiatric disorders, when both require acute-level care, are managed only with considerable difficulty in traditional hospital settings. A unit designed to offer such patients comprehensive care is described, its clinical and educational advantages discussed, and the essential administrative features of its operation identified. Since very few comparable units exist at the present, our model is offered in the hope of encouraging and assisting their future development. In view of current trends in the evolution of our field, this type of unit may well represent the advancing edge of inpatient psychiatry.