Surgical issues in the poisoned patient

Toxic Exposures Among Young Children One Year into the COVID-19 Pandemic: A Retrospective Review of Three San Francisco Bay Area Emergency Departments

BACKGROUND

Daycare and school closures prompted by shelter-in-place orders may have increased opportunities for unintentional ingestions among young children.

OBJECTIVES

We examined emergency department (ED) presentations for toxic exposures among young children during the COVID-19 pandemic in the San Francisco Bay Area, which had some of the strictest and most prolonged shelter-in-place policies in the United States.

METHODS

We performed a retrospective cross-sectional study of children 0 to 5 years of age who presented with an ED International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of toxic exposure within a tertiary care hospital system between March 16, 2016 and March 15, 2021. We considered the period after March 16, 2020 to represent the pandemic.

RESULTS

During the pandemic, the absolute number of poisonings among young children remained stable. Overall, ED encounters within this cohort decreased by 55%, which doubled the relative toxic exposure rate per 1000 ED encounters from 4.99 (95% confidence interval [CI] 3.19-5.90) to 9.79 (95% CI 8.09-11.49). Rates of admission, severe medical complications, operating room case requests, and length of stay were not significantly different. Shelter-in-place was associated with significantly higher odds of cannabis ingestion (odds ratio = 2.70, 95% CI 1.60-4.49).

CONCLUSION

Despite dramatic decreases in overall ED patient volumes, the absolute number and severity of toxic exposures were similar during the pandemic compared with previous years. © 2022 Elsevier Inc.

A case of methyl ethyl ketone peroxide poisoning and a review of complications and their management

Methyl Ethyl Ketone Peroxide (MEKP) is a highly toxic clear liquid used as a solvent. It is a strong oxidizing agent and a corrosive. Acute and chronic toxicity can occur as an occupational hazard. Ingestion is associated with corrosive burns leading to stricture formation, inhalational pneumonitis, acidosis, liver failure and renal failure. In this paper we present a case of a young patient who intentionally ingested MEKP. The patient developed multiple complications including proximal intestinal obstruction, acidosis and acute kidney injury. He was managed conservatively and recovered after a prolonged hospital stay. He had multiple inflammatory strictures on esophageal endoscopy, which improved over 3–6 moths.

Caustic ingestion in children

Caustic ingestion continues to be a significant problem worldwide especially in developing countries. In 2008 over 200,000 exposures to caustic substances were reported to the National Poison Data System. The presence or absence of symptoms or oral lesions does not predict the existence or severity of lesions. The best predictor of morbidity and mortality is the extent of injury as assessed during initial evaluation. Upper endoscopy remains the mainstay diagnostic modality for the evaluation of patients with caustic ingestion. There is a pressing need for noninvasive diagnostic modalities and effective therapeutic options to evaluate and treat the complications associated with caustic ingestion.

Is there a role for fasciotomy in Crotalinae envenomations in North America?

CONTEXT

The local effects of Crotalinae envenomation can cause significant tissue destruction, pain, paresthesias, and deformity of the limb, which mimic findings of compartment syndrome, despite rare subfascial penetration of the fangs. Complicating this are the various techniques and ideas about what determines compartment syndrome combined with the fact that elevated intracompartmental pressures have been documented after Crotalinae envenomation, without clear evidence of compartment syndrome or tissue hypoperfusion.

OBJECTIVE

The purpose of this review is to evaluate the North American literature to provide an evidenced-based conclusion about the indications for fasciotomy in Crotalinae envenomations.

METHODS

The search was conducted with studies published only in the English language. The search included all human and animal publications, regardless of the format of study. The Cochrane Central Register, MEDLINE/ Pub Med, Scopus, and Biological Science databases were searched. Citations from all the articles were also cross-referenced if they were pertinent to the review. Major toxicology and emergency medicine and surgical textbooks were also referenced. Abstracts from the North American Congress of Clinical Toxicology, Poisonidex®, and personal articles were also scanned to complete the process, resulting in a total of 640 sources. Papers were excluded if they were duplicates, non-North American, involved excisional therapy, or did not discuss fasciotomy. This left 99 publications applicable to our study.

FINDINGS

No randomized controlled trials, 8 animal experiments, 1 human prospective observational study, 24 retrospective reviews, 32 review articles, 10 case reports, 15 textbooks references, 2 abstracts, and 7 editorials were included in the analysis. Controlled animal experiments show that crotaline Fab antivenin reduces intracompartmental pressure and increases tissue perfusion, while fasciotomy either has no beneficial effect or worsens myonecrosis. The case reports and opinions supporting fasciotomy come from the surgical literature and precede the modern crotaline Fab antivenin.

CONCLUSION

The current evidence does not support the use of fasciotomy or dermotomy following Crotalinae envenomation with elevated intracompartmental pressures. At present, early and adequate administration of crotaline Fab antivenin is the treatment of choice. Fasciotomy cannot be recommended until further well-designed investigations are completed.

Updates on the Evaluation and Management of Caustic Exposures

In 2004, the American Association of Poison Control Centers' Toxic Exposure Surveillance System documented over 200,000 exposures to caustic substances, in both household and industrial products. Although the most commonly affected body areas are the face, eyes, and extremities, all reported fatalities were as a result of ingestion. Little controversy exists in patient management following dermal or ocular caustic exposure. Immediate water irrigation of the site of caustic exposure, followed by routine burn care, analgesia, intravenous fluids, and electrolyte replacement are standards of care. In this manuscript, a thorough review of the management of gastrointestinal caustic exposure is explored, not only because of the high rates of morbidity and mortality associated with these exposures, but also because there remains controversy regarding appropriate management of such exposures. Hydrofluoric acid, a weak acid in its aqueous form, requires special consideration and specific antidotes, and as such, is addressed separately.