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Chambers A, Patton J, Wills BK. Precipitated opioid withdrawal in a patient started on olanzapine/samidorphan. Am J Emerg Med 2024; 79:230.e1-230.e2. [PMID: 38556414 DOI: 10.1016/j.ajem.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/13/2024] [Accepted: 03/20/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Olanzapine/Samidorphan (Lybalvi®) is a novel oral agent for the treatment of schizophrenia and bipolar I disorder. It was designed to reduce weight gain associated with olanzapine. Samidorphan is an analog of naltrexone, initially intended to treat substance use disorders by antagonizing mu, delta, and kappa opioid receptors. CASE REPORT We present the case of a 36-year-old who took their first dose of olanzapine/samidorphan shortly before calling for emergency services. The patient took diphenhydramine and an epinephrine autoinjector for what they thought was an allergic reaction but continued to have symptoms. EMS reported involuntary muscle movements thought to be due to dystonia from olanzapine. In the ED, they experienced generalized muscle spasms lasting for several seconds and diaphoresis. Initially, the staff treated for a presumed dystonic reaction to olanzapine and administered diphenhydramine 25 mg IV, diazepam 2 mg IV, midazolam 5 mg IV, and benztropine 1 mg IV without improvement. It was later determined that the patient took 16 mg of buprenorphine SL daily. With this information, precipitated opioid withdrawal was felt to be the likely cause of symptoms. The patient received 16 mg of buprenorphine for an initial Clinical Opiate Withdrawal Scale (COWS) score of 11 with repeat COWS of 6. Why should an emergency physician be aware of this? Initiating olanzapine/samidorphan in the setting of chronic opioid therapy may result in precipitated opioid withdrawal. Additional SL buprenorphine may be a reasonable treatment modality.
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Affiliation(s)
- Andrew Chambers
- Virginia Poison Center, Division of Clinical Toxicology, United States of America; Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Jessica Patton
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, United States of America.
| | - Brandon K Wills
- Virginia Poison Center, Division of Clinical Toxicology, United States of America; Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, United States of America
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Wilson LM, Dong C, Chambers A, Whitty S, Troendle M, Wills BK. Prolonged venom-induced consumptive coagulopathy following Mangshan pit viper (Protobothrops mangshanensis) envenomation despite Hemato Polyvalent antivenom administration. Toxicon 2024; 238:107563. [PMID: 38141969 DOI: 10.1016/j.toxicon.2023.107563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/26/2023] [Accepted: 12/11/2023] [Indexed: 12/25/2023]
Abstract
This case report summarizes an envenomation by the Mangshan pit viper (Protobothrops mangshanensis), a rare, endangered, venomous snake endemic to Mount Mang of China, and the first reported use of Hemato Polyvalent antivenom (HPAV) for this species. The snakebite occurred in a United States zoo to a 46-year-old male zookeeper. He presented via emergency medical services to a tertiary center after sustaining a single P. mangshanensis bite to the abdomen and was transported with antivenom from the zoo. Within 2 hours of envenomation, he developed oozing of sanguineous fluid and ecchymosis at the puncture site, and about 4 hours post-bite, was treated with HPAV. His coagulation profile fluctuated with the following pertinent peak/nadir laboratory values and corresponding hospital day (HD): undetectable fibrinogen levels, d-dimer 8.89 mg/L and 7.43 mg/L, and INR 2.97 and 1.46 on HD zero and three, respectively. Other peak/nadir values included hemoglobin 9.7 g/dL and creatinine phosphokinase 2410 U/L on HD four and platelets 81 × 109/L on HD seven. The patient received a total of 30 vials of HPAV over 5 days and 1 unit of cryoprecipitate on HD six. Upon discharge on HD eight, laboratory studies were normalizing, except for platelets, and edema stabilized. This case describes an acute, recurrent, and prolonged venom-induced consumptive coagulopathy despite prompt administration and repeated doses of HPAV.
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Affiliation(s)
- Lt Mallori Wilson
- Department of Emergency Medicine, Naval Medical Center, Portsmouth, VA, USA
| | - Catherine Dong
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA; Virginia Poison Center, Richmond, VA, USA.
| | | | - Sean Whitty
- Eastern Virginia Medical School, Norfolk, VA, USA
| | - Michelle Troendle
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA; Virginia Poison Center, Richmond, VA, USA
| | - Brandon K Wills
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA; Virginia Poison Center, Richmond, VA, USA
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Wills BK, Ringwood KJ, Davis TT, Provost R, Bachireddy C, Wang J, Keyser-Marcus L, Moeller FG. Outcomes of Emergency Department Patients With Opioid Use Disorder Utilizing a Virtual Addiction Bridge Clinic: A Case Series. J Addict Med 2023; 17:729-731. [PMID: 37934546 DOI: 10.1097/adm.0000000000001222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
OBJECTIVES Within the last decade, there has been a dramatic increase in the rate of emergency department (ED) visits and death from opioid overdose. Those who present to the ED are at high risk for subsequent morbidity and mortality. Despite effective treatment, many patients do not get rapidly connected to outpatient care. The aim of this investigation was to describe outpatient treatment engagement after ED discharge among patients with opioid use disorder (OUD) enrolled in a virtual Addiction Bridge Clinic (ABC). METHODS This was a retrospective case series describing an ED-initiated referral for rapid telehealth follow-up among patients with OUD. The primary outcome was addiction treatment engagement among those who completed the initial virtual ABC visit (engaged in ABC) vs. those who did not complete an ABC visit (Not engaged in ABC) at 1 week, 1 month, and 3 and 6 months timepoint intervals after the initial ED presentation. RESULTS Of the N = 201 patients referred to the ABC between March and December 2021, a majority were Black (71%) and male (77%). Of the 201 referrals, 85 (42%) completed an initial ABC telehealth visit. Subsequent treatment engagement was 26% at 1 week, 26% at 1 month, 22% at 3 months, and 18% at 6 months after the index ED visit. CONCLUSIONS A telehealth-enabled virtual addiction bridge clinic is one potential approach to reduce barriers to rapid treatment access. Strategies are needed to improve subsequent addiction treatment engagement after a virtual addiction bridge clinic visit.
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Affiliation(s)
- Brandon K Wills
- From the Department of Psychiatry (BKW, KJR, TTD, LK-M, FGM), Department of Emergency Medicine (BKW), School of Medicine (RP, JW), Virginia Commonwealth University; Department of Medical Assistance Services, Commonwealth of Virginia (CB), Richmond, VA
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Williams GR, Downs JW, Wolf CE, Cumpston KL, Tobarran N, Wills BK, Bachmann LM. Evaluation of Strontium Interference in Calcium Measurement Procedures and Content in Supplements as Measured by ICP-MS. J Appl Lab Med 2023; 8:307-318. [PMID: 36705074 DOI: 10.1093/jalm/jfac092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/19/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Bone health supplements containing strontium are available without prescription, however, the effects of strontium interference on clinical laboratory calcium measurement procedures are unknown. METHODS To evaluate strontium interference on total calcium measurements, plasma pools with exogenously added strontium were measured by 3 total calcium measurement procedures. For ionized calcium measurements, whole blood pools prepared with exogenously added strontium were measured by 2 ionized calcium measurement procedures. An inductively coupled plasma mass spectrometry assay (ICP-MS) was validated for research measurements of strontium content in commercially available supplements. RESULTS Exogenous strontium addition to plasma caused positive bias for total calcium measurements. Strontium concentrations of 1.0 mg/dL (0.114 mmol/L), 2.5 mg/dL (0.284 mmol/L), and 5.0 mg/Dl (0.568 mmol/L) resulted in mean biases of 1.9% to 3.5%, 4.9% to 9.0%, and 10.8% to 19.2%, respectively, for total calcium measurement procedures. Biases for ionized calcium measurements were less than 4.5% for a strontium concentration of 5.0 mg/dL (0.568 mmol/L). An in-house-developed ICP-MS assay for strontium in commercially available supplements exhibited within-laboratory and within-run coefficients of variation of less than 3%, and a linear response was obtained over the assay analytical measurement range of 10 to 100 000 ng/mL (0.0001 to 1.141 mmol/L). Strontium recovery for the ICP-MS assay was 97.1% to 105.3%. The largest amount of strontium measured in dietary supplements was 395 mg in a 1054 mg tablet. CONCLUSIONS Some dietary supplements contain larger amounts of strontium than indicated on the product label. High concentrations of strontium may cause significant interference for total calcium measurement procedures, but ionized calcium measurement procedures are not significantly affected.
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Affiliation(s)
- Grace R Williams
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, USA
| | - John W Downs
- Division of Clinical Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Carl E Wolf
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, USA
| | - Kirk L Cumpston
- Division of Clinical Toxicology, Virginia Commonwealth University, Richmond, VA, USA.,Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Natasha Tobarran
- Division of Clinical Toxicology, Virginia Commonwealth University, Richmond, VA, USA.,Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Brandon K Wills
- Division of Clinical Toxicology, Virginia Commonwealth University, Richmond, VA, USA.,Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Lorin M Bachmann
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, USA
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Kershner E, Tobarran N, Chambers A, Jenkins Z, Wills BK, Cumpston KL. Clinical characteristics and outcomes using dexmedetomidine in nonintubated patients: A poison center observational study. Am J Health Syst Pharm 2022; 80:526-531. [PMID: 36546397 DOI: 10.1093/ajhp/zxac378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Abstract
Disclaimer
In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
Purpose
Dexmedetomidine is a central alpha-2 agonist commonly used on intubated patients. It is increasingly being used off-label in non-intubated agitated patients. We sought to determine the overall clinical course, adverse effects, and need for subsequent mechanical ventilation in toxicology patients after treatment with dexmedetomidine.
Methods
This was a retrospective cohort study conducted by chart review of electronic records from the Virginia Poison Control Center from January 1, 2019 to February 4, 2022. Inclusion criteria consisted of all poison center cases where dexmedetomidine was used. The primary outcome was the presence or absence of clinical improvement following dexmedetomidine use. Secondary outcomes included adverse effects, subsequent intubation, or death.
Results
During this study period, there were 220 cases in which dexmedetomidine was used to treat agitation. After exclusions, 70 cases were analyzed. The categories included antimuscarinic (n= 19), polysubstance (n= 16), sedative withdrawal (n = 10), unknown agitation (n= 7), sympathomimetic (n =5), baclofen withdrawal (n= 3), unknown ingestion (n = 3), sedative/hypnotic (n= 2), antipsychotic (n = 2), hallucinogenic (n= 2), and opioid withdrawal (n= 1). Clinical improvement occurred in 62 of 70 patients (89%). There were no deaths. A total of four patients were intubated after starting dexmedetomidine, two for refractory agitation and two for hypoxia after aspiration.
Conclusion
Global clinical improvement was observed in the agitated toxicology patients administered dexmedetomidine. There was one case of intubation secondary to oversedation. Dexmedetomidine could be a useful adjunctive treatment for agitated toxicologic patients but should be studied further before routinely used.
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Affiliation(s)
- Emily Kershner
- Virginia Poison Center, Division of Clinical Toxicology; and Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond , VA, USA
| | - Natasha Tobarran
- Virginia Poison Center, Division of Clinical Toxicology; and Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond , VA, USA
| | - Andrew Chambers
- Virginia Poison Center, Division of Clinical Toxicology; and Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond , VA, USA
| | - Zach Jenkins
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond , VA, USA
| | - Brandon K Wills
- Virginia Poison Center, Division of Clinical Toxicology; and Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond , VA, USA
| | - Kirk L Cumpston
- Virginia Poison Center, Division of Clinical Toxicology; and Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond , VA, USA
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Kershner EK, Tobarran N, Chambers A, Wills BK, Cumpston KL. Retained bullets and lead toxicity: a systematic review. Clin Toxicol (Phila) 2022; 60:1176-1186. [PMID: 36074021 DOI: 10.1080/15563650.2022.2116336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Lead toxicity secondary to retained bullet(s) (RB) after a penetrating gunshot wound is a rare but likely underdiagnosed condition, given the substantial number of firearm injuries in the United States. There is currently no consensus on the indications for surveillance, chelation, or surgical intervention. OBJECTIVE The purpose of our review is to summarize the literature on systemic lead toxicity secondary to RBs to help guide clinicians in the management of these patients. METHODOLOGY The primary literature search was conducted in Medline (PubMed), EMBASE, Cochrane, and CENTRAL using the following MESH terms: "chelation" and "lead poisoning" or "lead toxicity" or "lead" and "bullet" or "missile" or "gunshot", or "bullet". RESULTS The search identified 1,082 articles. After exclusions, a total of 142 articles were included in our final review, the majority of which were case reports. Several factors appear to increase the risk of developing lead toxicity including the location of the RB, the presence of a fracture or recent trauma, number of fragments, hypermetabolic states, and bullet retention duration. Particularly, RBs located within a body fluid compartment like an intra-articular space appear to be at a substantially higher risk of developing lead toxicity. Even though patients with lead toxicity from RBs will have similar symptoms to patients with lead toxicity from other sources, the diagnosis of lead poisoning may occur months or years after a gunshot wound. Symptomatic patients with high blood lead levels (BLLs) tended to improve with a combination of chelation and surgical removal of RBs. CONCLUSIONS We suggest surveillance with serial BLLs should be performed. Patients with intra-articular RBs appear to be at increased risk of lead toxicity and if possible, early surgical removal of the RBs is warranted, especially given that signs of toxicity are vague, and patients may not have access to follow-up. Long-term chelation should not be used as a surgical alternative and management should be multidisciplinary.
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Affiliation(s)
- Emily K Kershner
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA.,Virginia Poison Center, Richmond, VA, USA
| | - Natasha Tobarran
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA.,Virginia Poison Center, Richmond, VA, USA
| | - Andrew Chambers
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA.,Virginia Poison Center, Richmond, VA, USA
| | - Brandon K Wills
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA.,Virginia Poison Center, Richmond, VA, USA
| | - Kirk L Cumpston
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA.,Virginia Poison Center, Richmond, VA, USA
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Tobarran N, Kershner E, Chambers A, Cumpston KL, Wills BK. Systemic toxicity from subcutaneous brimonidine injection successfully treated with naloxone: A case report. Am J Emerg Med 2022; 59:218.e5-218.e6. [PMID: 35835657 DOI: 10.1016/j.ajem.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/22/2022] [Accepted: 07/04/2022] [Indexed: 10/17/2022] Open
Abstract
Brimonidine is a topical ophthalmic alpha-2 adrenergic agonist solution used to treat glaucoma. The toxidrome includes drowsiness, lethargy, hypotension, bradycardia, and respiratory depression when ingested in infants. We report a case of intentional subcutaneous injection of brimonidine in an elderly patient resulting in hypotension and CNS depression that responded to naloxone. A 73-year-old female with a past medical history significant for glaucoma, hypertension, and indwelling pacemaker presented to the emergency department after injecting her brimonidine tartrate ophthalmic solution subcutaneously (SQ). The patient was not taking any antihypertensive medications or opioids. Initial presentation consisted of lethargy, a paced rhythm of 60 bpm, and blood pressure of 91/24 mmHg with a MAP of 46. Due to central nervous system depression, 3 mg of intranasal naloxone was administered. The patient was treated with intravenous fluids and escalating doses of naloxone and required a continuous infusion. Mental status and vital signs subsequently improved. The patient was admitted to the ICU and naloxone was subsequently weaned over 12 h. Systemic central alpha-2 adrenergic agonist toxicity resulted from SQ brimonidine injection. Central alpha-2 adrenergic agonist overdoses present as sympatholytic effects including CNS depression, bradycardia, hypotension, and may mimic the opioid toxidrome. Brimonidine SQ injection has not previously been reported and this case has similar findings to other central alpha-2 adrenergic agonist poisonings. Naloxone has previously shown variable reversal of CNS depression in central alpha-2 overdose. In this case, high-dose naloxone was useful for reversing CNS depression and hemodynamic instability.
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Affiliation(s)
- Natasha Tobarran
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, United States of America.
| | - Emily Kershner
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Andrew Chambers
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Kirk L Cumpston
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Brandon K Wills
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, United States of America
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Cumpston KL, Rodriguez V, Nguyen T, Maclasco A, Zin C, Rose SR, Ferguson J, Wills BK. In response to: Evaluation of prehospital hydroxocobalamin use in the setting of smoke inhalation. Am J Emerg Med 2022; 58:323-324. [PMID: 35361517 DOI: 10.1016/j.ajem.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Kirk L Cumpston
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America; Virginia Poison Center, Richmond, VA, United States of America; Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America
| | - Viviana Rodriguez
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Tammy Nguyen
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America
| | - Adam Maclasco
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America
| | - Carolyn Zin
- School of Medicine, Virginia Commonwealth University, Richmond, VA, United States of America
| | - S Rutherfoord Rose
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America; Virginia Poison Center, Richmond, VA, United States of America; Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America
| | - Jeffrey Ferguson
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America
| | - Brandon K Wills
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America; Virginia Poison Center, Richmond, VA, United States of America; Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America.
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Crouse E, Haught J, Tobarran N, Nichols C, Cumpston KL, Wills BK. Skin Necrosis Following Inadvertent Dermal Injection of Extended-release Buprenorphine. J Addict Med 2022; 16:242-245. [PMID: 33795578 DOI: 10.1097/adm.0000000000000846] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Extended-release subcutaneous buprenorphine injection is a relatively new formulation and clinicians are still gaining experience with its use. There is sparse literature available on adverse events. We describe a case of skin necrosis associated with the injection site of extended-release buprenorphine. CASE REPORT A 35-year-old reported immediate swelling and eventual skin breakdown near his buprenorphine injection site. He was found to have ulceration down to the subcutis with no evidence of infection. The patient followed up with dermatology and underwent debridement of the site. The injection site healed with scar formation. DISCUSSION Although mild to moderate adverse events related to the injection site have been reported in Phase 3 studies of extended-release buprenorphine injection, this is a rare case of skin necrosis requiring surgical intervention and excision of the depot. CONCLUSIONS This case highlights the potential complication of skin necrosis after inadvertent dermal of extended-release buprenorphine and reviews proper administration techniques.
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Affiliation(s)
- Ericka Crouse
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia (EC), Department of Dermatology, Virginia Commonwealth University Health System, Richmond, Virginia (JH, CN), Virginia Poison Center, Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, Virginia (NT, KC, BW), Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, Virginia (NT, KC, BW)
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Abstract
INTRODUCTION Kratom (Mitragyna speciosa) is a popular plant-based extract that has dose-dependent stimulatory and sedative effects. It has been used for self-treatment of opioid withdrawal and can result in seizures, hepatotoxicity, and infectious complications from bacterial contamination. Reports of morbidity and mortality associated with Kratom may be confounded by coingestants. We report a case of severe rhabdomyolysis and pressure necrosis leading to fasciotomy in a patient who was using Kratom. CASE REPORT A 31-year-old male with substance use presented to the emergency department after loss of consciousness for 6 hours after smoking Kratom. He was found to have rhabdomyolysis, acute renal and hepatic injury, and electrolyte disturbances. No ethanol was detected, and urine drug screen was negative. Over the next 3 hours, the patient developed signs of compartment syndrome and he was transferred to the operating room for fasciotomy. He required continuous renal replacement therapy for 48 hours and his labs and clinical status improved. He was discharged 18 days later. A serum and urine sample from the first day of presentation were analyzed for mitragynine and 7-hydroxymitragynine using an Ultra Performance Liquid Chromatography-Tandem Mass Spectrometer (UPLC-MSMS) method. The serum mitragynine was 5 ng/mL and the urine mitragynine 6 ng/mL. CONCLUSIONS Although there are numerous reports of opioids resulting in prolonged periods of immobilization and rhabdomyolysis, this is not commonly reported in Kratom overdoses.This case report highlights the profound sedative effect of Kratom and the potential of pressure necrosis injury resulting in rhabdomyolysis and compartment syndrome requiring fasciotomy.
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Affiliation(s)
- Natasha Tobarran
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA (NT, KLC, BKW); Forensic Toxicology and Specialty Testing, Department of Pathology, Virginia Commonwealth University Health System, Richmond, VA (CW)
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Cumpston KL, Rodriguez V, Nguyen T, Maclasco A, Zin C, Rose SR, Ferguson J, Wills BK. In response to: Evaluation of prehospital hydroxocobalamin use in the setting of smoke inhalation. Am J Emerg Med 2022; 54:300-301. [PMID: 35183400 DOI: 10.1016/j.ajem.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 02/02/2022] [Indexed: 10/19/2022] Open
Affiliation(s)
- Kirk L Cumpston
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA; Virginia Poison Center, Richmond, VA, USA; Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
| | - Viviana Rodriguez
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Tammy Nguyen
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
| | - Adam Maclasco
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
| | - Carolyn Zin
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - S Rutherfoord Rose
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA; Virginia Poison Center, Richmond, VA, USA; Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
| | - Jeffrey Ferguson
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
| | - Brandon K Wills
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA; Virginia Poison Center, Richmond, VA, USA; Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA.
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Tobarran N, Kershner EK, Cumpston KL, Rose SR, Wills BK. Homicide with intramuscular cyanide injection: a case report. Toxicology Communications 2022. [DOI: 10.1080/24734306.2021.2015550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Natasha Tobarran
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
- Virginia Poison Center, Richmond, VA, USA
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
| | - Emily K. Kershner
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
- Virginia Poison Center, Richmond, VA, USA
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
| | - Kirk L. Cumpston
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
- Virginia Poison Center, Richmond, VA, USA
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
| | - S. Rutherfoord Rose
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
- Virginia Poison Center, Richmond, VA, USA
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
| | - Brandon K. Wills
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
- Virginia Poison Center, Richmond, VA, USA
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
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Cumpston KL, Rodriguez V, Nguyen T, MacLasco A, Zin C, Rose SR, Ferguson J, Wills BK. Evaluation of prehospital hydroxocobalamin use in the setting of smoke inhalation. Am J Emerg Med 2021; 50:365-368. [PMID: 34461397 DOI: 10.1016/j.ajem.2021.08.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/15/2021] [Accepted: 08/22/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND The indications for prehospital hydroxocobalamin are not well defined. The aim of this study was to evaluate prehospital signs and symptoms in patients who received hydroxocobalamin to improve future use. METHODS In this retrospective study, all patients who received prehospital Hydroxocobalamin at a tertiary care burn center from December 2012 to March 2018 were reviewed. Each case was evaluated for evidence of suspected cyanide toxicity: hypotension, syncope, CNS depression/altered mentation, seizures, respiratory or cardiac arrest. A determination was made whether or not hydroxocobalamin was indicated. RESULTS In this study, EMS providers administered hydroxocobalamin to 42 patients between December 2012 and March 2018. The majority (71%) of suspected cyanide exposures were from house fires. The most common prehospital findings were coma or depressed CNS (36%), followed by hypotension (16%) and cardiac arrest (12%). Sixty percent of patients treated with hydroxocobalamin had none of the six clinical indicators for potential cyanide toxicity. Carboxyhemoglobin and serum lactate were significantly different in patients that had a clinical indication for hydroxocobalamin compared to those who did not. CONCLUSIONS Prehospital hydroxocobalamin was used empirically however, indications are unclear. Using defined clinical indications may provide greater clarity for providers and reduce unnecessary use of hydroxocobalamin.
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Affiliation(s)
- Kirk L Cumpston
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America; Virginia Poison Center, Richmond, VA, United States of America; Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America
| | - Viviana Rodriguez
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, United States of America
| | - Tammy Nguyen
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America
| | - Adam MacLasco
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America
| | - Carolyn Zin
- School of Medicine, Virginia Commonwealth University, Richmond, VA, United States of America
| | - S Rutherfoord Rose
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America; Virginia Poison Center, Richmond, VA, United States of America; Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America
| | - Jeffrey Ferguson
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America
| | - Brandon K Wills
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America; Virginia Poison Center, Richmond, VA, United States of America; Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States of America.
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14
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Downs J, Wolf CE, Williams G, Cumpston KL, Kershner E, Wills BK. Negligible Nux Vomica: Homeopathic Nux Vomica remedies don't contain strychnine? Toxicon 2021; 200:1-2. [PMID: 34181973 DOI: 10.1016/j.toxicon.2021.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/14/2021] [Accepted: 06/16/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The St. Ignatius bean of the Strychnos ignatii tree and Nux Vomica homeopathic products presumably could contain the toxic alkaloids strychnine and brucine. This study aimed to determine the amount of these toxic alkaloids in some commercially available Nux Vomica products and the St. Ignatius bean and to determine if overdose of these products could result in clinically significant toxicity. METHODS Using ultra-performance liquid chromatography-tandem mass spectrometry, various formulations of Nux Vomica products and St. Ignatius beans were analyzed for strychnine, and brucine with detection limits set at 0.1 ng/g. RESULTS None of the analyzed Nux Vomica products contained any detectable strychnine or brucine, while the expected strychnine dose from a St. Ignatius bean would be < 0.001 mg. CONCLUSIONS Overall, our study reveals that the amount of strychnine in homeopathic Nux Vomica products or St. Ignatius beans are not likely to result in clinically significant strychnine toxicity.
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Affiliation(s)
- John Downs
- Department of Emergency Medicine, Division of Medical Toxicology Virginia Commonwealth University Health System, USA.
| | - Carl E Wolf
- Division of Medical Toxicology Virginia Commonwealth University Health System, Richmond, VA, USA.
| | - Grace Williams
- Department of Pathology, Virginia Commonwealth University Health System, Richmond, VA, USA.
| | - Kirk L Cumpston
- Department of Emergency Medicine, Division of Medical Toxicology Virginia Commonwealth University Health System, USA.
| | - Emily Kershner
- Department of Emergency Medicine, Division of Medical Toxicology Virginia Commonwealth University Health System, USA.
| | - Brandon K Wills
- Department of Emergency Medicine, Division of Medical Toxicology Virginia Commonwealth University Health System, USA.
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15
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Downs JW, Wills BK, Cumpston KL, Rose SR. Descriptive epidemiology of clinically significant occupational poisonings, United States, 2008-2018. Clin Toxicol (Phila) 2021; 59:1259-1263. [PMID: 33703981 DOI: 10.1080/15563650.2021.1892717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION References listing common occupational poisons often include agents that were observed decades prior to the introduction of worker protective laws and regulations. Current causes of work-related acute poisonings have not been characterized. This study's primary objective was to describe the most common poisons and routes of exposure responsible for clinically significant occupational poisonings. A secondary objective was to determine the crude rate of clinically significant occupational poisonings and occupational poisoning-related deaths over the study period. METHODS This was a retrospective cohort study using electronic data from the American Association of Poison Control Centers' (AAPCC) National Poison Data System (NPDS), and open source data from the United States Bureau of Labor Statistics (BLS). The NPDS was queried for all cases with exposure reason coded as "Unintentional-Occupational" for the period 1 January 2008 to 31 December 2018. A case of clinically significant occupational poisoning (CSOP) was defined as a case with moderate or severe clinical effects reported, to include fatal cases. A descriptive analysis was conducted using unadjusted odds ratios to assess the strength of association between main variables of interest and CSOP. RESULTS 329,437 exposure cases were available for analysis. Of these, 54,254 were considered CSOP and included 196 deaths. The top five poisons responsible for occupational fatalities were hydrogen sulfide, ammonia, carbon monoxide, simple asphyxiants, and chlorines. Fatalities were 3.7 times (OR: 3.7; 95% CI: 2.2-6.4) more likely to be men and 5.7 times (OR: 5.7; 95% CI: 4.0-8.1) more likely to have had an inhalational exposure, compared to those workers with CSOP without fatality. The crude rate of occupational fatal poisoning reported to US poison centers was 11.3 deaths per 100,000,000 worker-years during the study period. The crude rate of clinically significant occupational poisoning was 3.1 per 100,000 worker-years. These rates remained generally stable over the study period. CONCLUSION Occupational poisonings continue to be a significant cause of morbidity and mortality in the workplace despite significant improvements in workplace chemical safety over the last four decades. Workplace education and proper preventive measures devoted to inhalational toxicants and respiratory protection are opportunities for improvement.
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Affiliation(s)
- John W Downs
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Brandon K Wills
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Kirk L Cumpston
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - S Rutherfoord Rose
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA, USA
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16
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Downs JW, Cumpston KL, Kershner EK, Troendle MM, Rose SR, Wills BK. Clinical outcome of massive acetaminophen overdose treated with standard-dose N-acetylcysteine. Clin Toxicol (Phila) 2021; 59:932-936. [PMID: 33620007 DOI: 10.1080/15563650.2021.1887493] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Recent recognition of "massive" acetaminophen (APAP) overdoses has led to the question of whether standard dosing of N-acetylcysteine (NAC) is adequate to prevent hepatoxicity in these patients. The primary aim of this study was to evaluate the clinical outcome for patients with massive APAP overdose who received standard intravenous NAC dosing of 300 mg/kg over 21 h. METHODS This was a single-center retrospective cohort study conducted by chart review of APAP overdoses reported to a regional poison center from 1 January 2010 to 31 December 2019. Massive APAP overdose was defined by single, acute overdose resulting in an APAP concentration exceeding 300 mcg/mL at 4 h post-ingestion. Standard univariate statistical analysis was conducted to describe the cohort, and a multivariate logistic model was utilized to calculate adjusted odds ratios for risk of hepatoxicity. RESULTS 1425 cases of APAP overdose were reviewed. 104 cases met the inclusion criteria of massive APAP overdose. Overall, 79 cases (76%) had no acute liver injury or hepatotoxicity, and 25 (24%) developed hepatoxicity. Nine percent (n = 4) of cases receiving NAC within 8 h developed hepatotoxicity. Crude odds for hepatoxicity was 5.5-fold higher for cases who received NAC after 8 h. CONCLUSIONS Standard NAC dosing received within 8 h prevented hepatoxicity in 91% (n = 40) of cases in our series of massive APAP overdoses. Additional data is needed to determine the clinical outcomes of massive APAP overdose using current intravenous NAC dosing.
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Affiliation(s)
- John W Downs
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Kirk L Cumpston
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Emily K Kershner
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Michelle M Troendle
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - S Rutherfoord Rose
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Brandon K Wills
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
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17
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Cumpston KL, Tobarran N, Taylor L, Wills BK. Sonographic extremity assessment of crotalinae envenomation. Toxicology Communications 2021. [DOI: 10.1080/24734306.2020.1864967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Kirk L. Cumpston
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Natasha Tobarran
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Lindsay Taylor
- Department of Emergency Medicine, Division of Clinical Ultrasound, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Brandon K. Wills
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, USA
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18
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Abstract
This study compares the numbers of nonfatal, unintentional opioid-related opioid overdoses presenting to a US urban emergency department during the early months of the coronavirus disease 2019 (COVID-19) pandemic (March-June 2020) vs 2019, overall and by age, race/ethnicity, and insurance status.
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Affiliation(s)
- Taylor A. Ochalek
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond
| | - Kirk L. Cumpston
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond
| | - Brandon K. Wills
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond
| | - Tamas S. Gal
- Department of Biostatistics, Virginia Commonwealth University, Richmond
| | - F. Gerard Moeller
- Department of Psychiatry, Virginia Commonwealth University, Richmond
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19
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Downs JW, Wills BK, Cumpston KL, Wolf CE, Rose SR. Pediatric Guanfacine Toxicity with Severely Elevated Plasma Concentration. J Child Adolesc Psychopharmacol 2020; 30:473-474. [PMID: 32667829 DOI: 10.1089/cap.2020.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- John W Downs
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA.,Funding: The authors received no funding towards the creation of this article
| | - Brandon K Wills
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA.,Funding: The authors received no funding towards the creation of this article
| | - Kirk L Cumpston
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA.,Funding: The authors received no funding towards the creation of this article
| | - Carl E Wolf
- Toxicology Laboratory, Department of Pathology, Virginia Commonwealth University Health System, Richmond, Virginia, USA.,Funding: The authors received no funding towards the creation of this article
| | - S Rutherfoord Rose
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA.,Funding: The authors received no funding towards the creation of this article
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20
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Ross JA, Downs JW, Bazydlo LA, Bordwine PH, Gineste CE, Kopatic MC, Rege SV, Saady DM, Utah OF, Wyatt SA, Wills BK, Rose SR, Holstege C. Outbreak of Severe Hypoglycemia After Ingestion of a Male Enhancement Supplement - Virginia, August-November 2019. MMWR Morb Mortal Wkly Rep 2020; 69:740-743. [PMID: 32555139 PMCID: PMC7302474 DOI: 10.15585/mmwr.mm6924a3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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21
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Maskell KF, Powell SW, Willis D, Okhomina V, Sima AP, Wills BK. Patterns of transaminase elevation in rhabdomyolysis versus acetaminophen toxicity. Am J Emerg Med 2020; 44:362-365. [PMID: 32507476 DOI: 10.1016/j.ajem.2020.04.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/13/2020] [Accepted: 04/17/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Transaminase elevations can occur from liver injury or in the setting of rhabdomyolysis. The goal of this study is to evaluate indices that could differentiate acetaminophen toxicity from muscle injury in the setting of transaminase elevations. METHODS A retrospective chart review of consecutive cases reported to our regional poison center. Patients with transaminase (AST and ALT) elevation were grouped as those with acetaminophen exposure (AT) and those with elevated creatine phosphokinase (CPK) without evidence of acetaminophen exposure (RHB). RESULTS Of the 345 patients included in the study, elevated AST/ALT levels were attributed to rhabdomyolysis in 168 patients and attributed to acetaminophen toxicity in 177 patients. The median AST: ALT values also differed between groups, with patients in the RHB group had higher median ratios (p < 0.001). Using an AST: ALT value of 2.02 as a diagnostic cutoff produced a specificity of 0.52 (95% CI: 0.37, 0.64) and sensitivity of 0.84 (95% CI: 0.73, 0.94) for acetaminophen detection in the test dataset (N = 104). CONCLUSIONS Elevated transaminases due to liver injury from acetaminophen ingestion had a different pattern than elevated transaminases due to rhabdomyolysis. Lower AST:ALT ratios were found in acetaminophen cases, however, the specificity using a ratio threshold of ≤1 would be 83%.
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Affiliation(s)
- Kevin F Maskell
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Scott W Powell
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Deanna Willis
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Victoria Okhomina
- Department of Biostatistics, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Adam P Sima
- Department of Biostatistics, Virginia Commonwealth University Health System, Richmond, VA, United States of America
| | - Brandon K Wills
- Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, United States of America.
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22
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Wills BK, Willis D, Bullock A, Willis OG, Cumpston KL. Severe Anemia in a 14-Month-Old. Clin Pediatr (Phila) 2020; 59:716-718. [PMID: 32460604 DOI: 10.1177/0009922820920009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Brandon K Wills
- VCU Medical Center, Richmond, VA, USA.,Virginia Poison Center, Richmond, VA, USA
| | | | | | | | - Kirk L Cumpston
- VCU Medical Center, Richmond, VA, USA.,Virginia Poison Center, Richmond, VA, USA
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23
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Wills BK, Billet M, Rose SR, Cumpston KL, Counselman F, Shaw KJ, Cresswell KG, Charlton N. Prevalence of hematologic toxicity from copperhead envenomation: an observational study. Clin Toxicol (Phila) 2019; 58:262-265. [DOI: 10.1080/15563650.2019.1644346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Brandon K. Wills
- Department of Emergency Medicine, Division of Clinical Toxicology, VCU Medical Center, Richmond, VA, USA
- Virginia Poison Center, Richmond, VA, USA
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
| | - Michael Billet
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
| | - S. Rutherfoord Rose
- Department of Emergency Medicine, Division of Clinical Toxicology, VCU Medical Center, Richmond, VA, USA
- Virginia Poison Center, Richmond, VA, USA
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
| | - Kirk L. Cumpston
- Department of Emergency Medicine, Division of Clinical Toxicology, VCU Medical Center, Richmond, VA, USA
- Virginia Poison Center, Richmond, VA, USA
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, USA
| | - Francis Counselman
- Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Kendall J. Shaw
- Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Kellen G. Cresswell
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Nathan Charlton
- Division of Medical Toxicology, University of Virginia, Charlottesville, VA, USA
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Affiliation(s)
- Charles Schall
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA
| | - Kirk L Cumpston
- Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA; Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA
| | - Joi Lenczowski
- Department of Dermatology, Virginia Commonwealth University Health System, Richmond, VA
| | - Brandon K Wills
- Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA; Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA
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25
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Abstract
Extracorporeal membrane oxygenation (ECMO) use in poisoned patients is increasing, but is rare post cardiac arrest. We report a case of ECMO use with complete recovery in a patient who arrested twice after a cardiotoxicant overdose. A 17-year-old male presented after an unknown overdose. He rapidly became hypotensive and bradycardic and received aggressive supportive care without improvement. He was transferred to our institution and suffered a cardiac arrest shortly after arrival. Six minutes of advanced cardiac life support resulted in return of spontaneous circulation. High-dose insulin, lipid emulsion, and ECMO were initiated. While awaiting ECMO deployment, he again became pulseless. Compressions resumed, and after 30 min, ROSC was achieved, and he was cannulated for veno-arterial ECMO. Within 48 h, he was decannulated, and then weaned off epinephrine 2 days later. Upon extubation, he was neurologically intact. Amlodipine and metoprolol were later confirmed in serum. Adolescent poisoned patients represent an ideal population for ECMO due to lack of comorbidities. As experience with ECMO in overdose increases, additional research is needed to determine appropriate indications and timing for its use. ECMO is an option for patients poisoned with a cardiotoxicant drug, even following witnessed cardiac arrest.
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Affiliation(s)
- Kevin F Maskell
- Department of Emergency Medicine, Virginia Commonwealth University Health System, 830 E. Main St, STE 300, Richmond, VA, 23219, USA.
| | - Nikki Miller Ferguson
- Department of Pediatrics, Virginia Commonwealth University Health System, Richmond, VA, 23219, USA
| | - Jesse Bain
- Department of Pediatrics, Virginia Commonwealth University Health System, Richmond, VA, 23219, USA
| | - Brandon K Wills
- Department of Emergency Medicine, Virginia Commonwealth University Health System, 830 E. Main St, STE 300, Richmond, VA, 23219, USA
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26
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Cumpston KL, Carter M, Wills BK. Clinical outcomes after Kratom exposures: A poison center case series. Am J Emerg Med 2017; 36:166-168. [PMID: 28751041 DOI: 10.1016/j.ajem.2017.07.051] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 07/12/2017] [Accepted: 07/14/2017] [Indexed: 11/18/2022] Open
Affiliation(s)
- Kirk L Cumpston
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States; Virginia Poison Center, Richmond, VA, United States; Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States.
| | - Michael Carter
- Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States
| | - Brandon K Wills
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States; Virginia Poison Center, Richmond, VA, United States; Department of Emergency Medicine, VCU Medical Center, Richmond, VA, United States
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Abstract
INTRODUCTION Unintentional mothball ingestions may cause serious toxicity in small children. Camphor, naphthalene, and paradichlorobenzene mothballs are difficult to distinguish without packaging. Symptoms and management differ based on the ingested compound. Previous studies have used a variety of antiquated, impractical and potentially dangerous techniques to identify the mothballs. The goal of this study is to discover a simplified identification technique using materials readily available in an emergency department. METHODS Mothballs made of naphthalene and paradichlorobenzene along with camphor tablets were tested. Each material was tested both intact and after being fragmented to simulate a partially ingested mothball. Each of these six sample types were then immersed in 40 ml each of 11 fluids: water, 0.45% NaCl, 0.9% NaCl, lactated Ringer's, 5% dextrose in water, 5% dextrose in 0.9% NaCl, 50% dextrose in water, 8.4% NaHCO3, 3% H2O2, 70% isopropanol, and 91% isopropanol. All tests were conducted in standard urinalysis sample cups to replicate available materials. Three toxicologists blinded to the identities of samples and solutions visually evaluated each sample. Observations included assessing response to immersion: sink, float, or dissolve. RESULTS All evaluators agreed in their description of 62/66 (94%) of the samples, with all four disagreements being on sinking and dissolving versus sinking only. A two-fluid algorithm utilizing 50% dextrose and water was sufficient to distinguish the sample types. Camphor will float in water while both paradichlorobenzene and naphthalene will sink. In 50% dextrose, both naphthalene and camphor will float while paradichlorobenzene will sink. CONCLUSION Mothball materials can be distinguished by immersion in water and 50% dextrose. Limitations of this study include using camphor tablets as a substitute for mothballs given lack of availability.
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Affiliation(s)
- Michael J Moss
- a Department of Emergency Medicine , VCU Medical Center , Richmond , VA , USA
| | - Kevin F Maskell
- b Division of Clinical Toxicology, Department of Emergency Medicine , VCU Medical Center , Richmond , VA , USA.,c Virginia Poison Center , Richmond , VA , USA
| | - Michelle A Hieger
- b Division of Clinical Toxicology, Department of Emergency Medicine , VCU Medical Center , Richmond , VA , USA.,c Virginia Poison Center , Richmond , VA , USA
| | - Brandon K Wills
- a Department of Emergency Medicine , VCU Medical Center , Richmond , VA , USA.,b Division of Clinical Toxicology, Department of Emergency Medicine , VCU Medical Center , Richmond , VA , USA.,c Virginia Poison Center , Richmond , VA , USA
| | - Kirk L Cumpston
- a Department of Emergency Medicine , VCU Medical Center , Richmond , VA , USA.,b Division of Clinical Toxicology, Department of Emergency Medicine , VCU Medical Center , Richmond , VA , USA.,c Virginia Poison Center , Richmond , VA , USA
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Cumpston KL, Reynolds P, Stromberg PE, Wills BK, Rose SR. Variability of limb measurements performed by emergency medicine nurses in a simulated Crotalinae envenomation. Am J Emerg Med 2016; 34:1683-5. [DOI: 10.1016/j.ajem.2016.04.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 04/28/2016] [Accepted: 04/30/2016] [Indexed: 11/28/2022] Open
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Hieger MA, Emswiler MP, Maskell KF, Sentz JT, Miller KB, Wolf CE, Cumpston KL, Wills BK. A Case Series of Clenbuterol Toxicity Caused by Adulterated Heroin. J Emerg Med 2016; 51:259-61. [PMID: 27431866 DOI: 10.1016/j.jemermed.2016.05.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/03/2016] [Accepted: 05/17/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Adulteration of drugs of abuse may be done to increase profits. Some adulterants are relatively innocuous and others result in significant toxicity. Clenbuterol is a β2-adrenergic agonist with veterinary uses that has not been approved by the U.S. Food and Drug Administration for human use. It is an infrequently reported heroin adulterant. We describe a cluster of hospitalized patients with laboratory-confirmed clenbuterol exposure resulting in serious clinical effects. CASE SERIES Ten patients presented with unexpected symptoms shortly after heroin use. Seven evaluated by our medical toxicology service are summarized. Presenting symptoms included chest pain, dyspnea, palpitations, and nausea/vomiting. All patients were male, with a median age of 40 years (interquartile range [IQR] 38-46 years). Initial vital signs included a heart rate of 120 beats/min (IQR 91-137 beats/min), a respiratory rate of 20 breaths/min (IQR 18-22 breaths/min), a temperature of 36.8°C (IQR 36.7-37.0°C), a systolic blood pressure of 107 mm Hg (IQR 91-131 mm Hg), and a diastolic blood pressure of 49 mm Hg (IQR 40-70 mm Hg). Serum potassium nadir was 2.5 mEq/L (IQR 2.2-2.6 mEq/L), initial glucose was 179 mg/dL (IQR 125-231 mg/dL), initial lactate was 9.4 mmol/L (IQR 4.7-10.5 mmol/L), and peak creatine phosphokinase was 953 units/L (IQR 367-10,363 units/L). The median peak troponin level in six patients was 0.7 ng/mL (IQR 0.3-2.4 ng/mL). Three patients underwent cardiac catheterization and none had significant coronary artery disease. Clenbuterol was detected in all patients after comprehensive testing. All patients survived with supportive care. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Atypical presentations of illicit drug intoxication may raise concern for drug adulteration. In the case of heroin use, the presence of adrenergic symptoms or chest pain with hypokalemia, lactic acidosis, and hyperglycemia suggests adulteration with a β-agonist, such as clenbuterol, and patients presenting with these symptoms often require hospitalization.
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Affiliation(s)
- Michelle A Hieger
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia; Virginia Poison Center, Richmond, Virginia
| | - Michael P Emswiler
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia; Virginia Poison Center, Richmond, Virginia
| | - Kevin F Maskell
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia; Virginia Poison Center, Richmond, Virginia
| | - John T Sentz
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Kristin B Miller
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia
| | - Carl E Wolf
- Toxicology Laboratory, Departments of Pathology and Forensic Science, Virginia Commonwealth University, Richmond, Virginia
| | - Kirk L Cumpston
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia; Virginia Poison Center, Richmond, Virginia
| | - Brandon K Wills
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia; Virginia Poison Center, Richmond, Virginia
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Rose SR, Cumpston KL, Kim J, Difranco D, Wills BK. Absorption of salicylate powders versus tablets following overdose: a poison center observational study. Clin Toxicol (Phila) 2016; 54:857-861. [PMID: 27383649 DOI: 10.1080/15563650.2016.1204549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Salicylate absorption following overdose of aspirin (ASA) tablet formulations can be prolonged for greater than 24 h. Accordingly, serial serum concentrations are typically recommended to guide treatment. However, there are little published data on absorption following ingestion of powder ASA formulations, and it is not known if delayed ASA absorption occurs following overdose of powder formulations. The objective of this study is to compare the absorption characteristics of powder and tablet formulations of ASA in patients reported to a single poison center. METHODS Electronic records from an accredited poison center were searched for single substance acute or acute on chronic ingestions of ASA in powder form between 1 January 2002 and 31 January 2014. An identical search for ingestions of ASA tablet products between 1 January 2012 and 31 December 2013 was undertaken as the comparator group. Other inclusion criteria were age >12 years, documented time of ingestion, treatment in a health care facility within nine hours of ingestion and at least two detectable serum salicylate concentrations. RESULTS 16 of 25 powder and 22 of 49 tablet cases met inclusion criteria for analysis. Repeat serum salicylate concentrations following ingestion of tablets increased or insignificantly changed in 11 of 22 (50%) cases, and median serum salicylate concentrations in followed cases remained elevated for up to 12 h in some cases. In comparison, serum salicylate concentrations following powder ingestions declined in 15 of 16 (94%) cases. One patient, who ingested a powder product, underwent hemodialysis pursuant to an initial serum salicylate concentration of 96 mg/dL. CONCLUSIONS In contrast to persistent concentrations following overdose of tablets, the majority of serum salicylate concentrations declined following ingestion of powder formulations. In this small study population, these findings suggest that prolonged absorption is unlikely following ingestions of ASA powders.
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Affiliation(s)
- S Rutherfoord Rose
- a Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Poison Center , Virginia Commonwealth University , Richmond , VA , USA
| | - Kirk L Cumpston
- a Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Poison Center , Virginia Commonwealth University , Richmond , VA , USA
| | - Janice Kim
- a Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Poison Center , Virginia Commonwealth University , Richmond , VA , USA
| | - Danielle Difranco
- a Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Poison Center , Virginia Commonwealth University , Richmond , VA , USA
| | - Brandon K Wills
- a Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Poison Center , Virginia Commonwealth University , Richmond , VA , USA
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Nguyen TT, Troendle M, Cumpston K, Rose SR, Wills BK. Lack of adverse effects from flumazenil administration: an ED observational study. Am J Emerg Med 2015; 33:1677-9. [DOI: 10.1016/j.ajem.2015.07.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 07/09/2015] [Accepted: 07/10/2015] [Indexed: 10/23/2022] Open
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Stromberg P, Wills BK, Rose SR. Gout exacerbation, weakness, hypotension--Dx? J Fam Pract 2014; 63:455-456. [PMID: 25350260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Paul Stromberg
- Department of Emergency Medicine, Carilion Clinic, Roanoke, VA, USA.
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Abstract
This article is intended for clinicians treating neurotoxic emergencies. Presented are causative agents of neurotoxic emergencies, many of which are easily mistaken for acute psychiatric disorders. Understanding the wide variety of agents responsible for neurotoxic emergencies and the neurotransmitter interactions involved will help the psychiatrist identify and treat this challenging population.
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Affiliation(s)
- J Dave Barry
- Emergency Medicine Residency Program, Naval Medical Center Portsmouth, Portsmouth, VA, USA.
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Abstract
A 20-year-old woman presented to the emergency department for evaluation of a wound to left hand (Fig. 1). She admitted having a history of chronic severe headaches requiring daily use of analgesics. She first noted the ulcer approximately 10 months prior to presentation. Her examination was remarkable for a 10-cm by 8-cm ulceration to the dorsum of her left hand with exposed and necrotic metacarpals. Fibrous exudate was present in the wound-bed, and the ulcer was associated with a foul odor. She was afebrile on presentation with a peripheral white blood cell count of 6.4 x109/L, CRP 1.9 mg/dL, and ESR 15 mm/h.
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Affiliation(s)
- Paul E Stromberg
- Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Richmond, VA 23298-0522, USA.
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Simmons JR, Skinner CG, Williams J, Kang CS, Schwartz MD, Wills BK. Intoxication from smoking "spice". Ann Emerg Med 2011; 57:187-8. [PMID: 21251535 DOI: 10.1016/j.annemergmed.2010.08.039] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 08/27/2010] [Accepted: 08/27/2010] [Indexed: 02/07/2023]
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Wills BK, Bryant SM, Buckley P, Seo B. Can acute overdose of metformin lead to lactic acidosis? Am J Emerg Med 2010; 28:857-61. [PMID: 20887905 DOI: 10.1016/j.ajem.2009.04.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 04/13/2009] [Accepted: 04/14/2009] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Metformin-associated lactic acidosis (MALA) is well described in patients taking therapeutic metformin who develop renal failure or other serious comorbid conditions. Metformin-associated lactic acidosis from acute overdose has also been described in case series but is debated by some clinicians, arguing that metformin overdose does not cause lactic acidosis. Our aim was to perform a multicenter poison control database review to determine if MALA can occur in mono-overdose patients with no comorbid conditions. METHODS This was a retrospective chart review of the Illinois and Washington Poison Centers between the 2001-2006 and 1999-2006 periods, respectively. Metformin overdoses that were referred to health care facilities were categorized into mono-overdose with or with out MALA and polypharmacy overdose with or without MALA. RESULTS The overall prevalence of MALA was 14 (3.5%) of 398 cases referred to a health care facility. Metformin-associated lactic acidosis occurred in 9.1% of mono-overdose and in 0.7% of polypharmacy overdose patients referred to health care facilities and was 16% for intentional mono-overdoses. There was one death of 132 mono-overdoses referred to health care facilities. CONCLUSIONS Apparent metformin mono-overdose is associated with MALA. Dosages that place patients at risk for MALA will require additional study.
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Affiliation(s)
- Brandon K Wills
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA 98431, USA.
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Wills BK, Albinson C, Wahl M, Clifton J. Sildenafil citrate ingestion and prolonged priapism and tachycardia in a pediatric patient. Clin Toxicol (Phila) 2009; 45:798-800. [DOI: 10.1080/15563650701664483] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Johnson JN, Jones R, Wills BK. Spontaneous pneumomediastinum. West J Emerg Med 2008; 9:217-8. [PMID: 19561749 PMCID: PMC2672281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2007] [Revised: 03/25/2008] [Accepted: 03/27/2008] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jeremy N. Johnson
- Address for Correspondence: Jeremy N. Johnson, DO. Department of Emergency Medicine, Madigan Army Medical Center, Fort Lewis, WA.,
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Wills BK, Liu JM, Wahl M. Third-degree AV block from extended-release diltiazem ingestion in a nine-month-old. J Emerg Med 2008; 38:328-31. [PMID: 18403171 DOI: 10.1016/j.jemermed.2007.10.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2006] [Revised: 05/21/2007] [Accepted: 10/28/2007] [Indexed: 10/22/2022]
Abstract
Calcium channel blocker (CCB) overdose is associated with dysrhythmias and atrioventricular (AV) block, however, experience with infant CCB overdose is limited. A 9-month-old girl was found playing with tablets of extended-release diltiazem 120 mg. The patient had two episodes of emesis, which contained pill fragments, and was brought to the Emergency Department (ED) 4.5 h after being found. Vital signs were: rectal temperature 37.1 degrees C, pulse 87 beats/min, respiratory rate 30-40 breaths/min, blood pressure 72/48 mm Hg, and oxygen saturation (SpO(2)) 99% on room air. Otherwise, the patient was well-appearing, with normal skin color and examination. The electrocardiogram revealed third-degree atrioventricular block with a ventricular rate of 90 beats/min, QRS 68 ms, and QTc 411 ms. Atropine 0.1 mg i.v. was given, which increased the heart rate to 100-110 beats/min. Calcium gluconate 500 mg was also given intravenously. Laboratory evaluation revealed bicarbonate 17 mEq/L, anion gap 16, and glucose 129 mg/dL. On hospital day 1, the patient was noted to have a junctional rhythm with a rate of 90-100, and systolic blood pressure of 80-90 mm Hg. No additional medications were given. Early on day 2, the patient converted spontaneously to a normal sinus rhythm and was discharged approximately 42 h after presentation to the ED. In addition to bradycardia and hypotension, this 9-month-old patient manifested third-degree AV block after ingesting extended-release diltiazem.
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Affiliation(s)
- Brandon K Wills
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, Washington 98431, USA
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Wills BK, Mycyk MB, Mazor S, Zell-Kanter M, Brace L, Erickson T. Factitious lithium toxicity secondary to lithium heparin-containing blood tubes. J Med Toxicol 2008; 2:61-3. [PMID: 18072115 DOI: 10.1007/bf03161172] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Lithium concentrations analyzed from blood collected in inappropriate tubes may lead to misdiagnosis and lead to unnecessary hospitalization and intervention. We sought to assess the magnitude of falsely elevated lithium levels in green top lithium heparin-containing blood tubes. METHODS Serum lithium concentrations from two types of commonly used standard green top tubes were evaluated against a control tube. Blood samples obtained from 5 healthy volunteers who have never ingested pharmaceuticals containing lithium were aliquoted into a control serum separator tube (SST), a light green heparin-containing tube, and a dark green heparin tube at the following volumes: full draw, 2cc, and 1cc. Serum lithium levels in lithium heparin blood tubes were compared to standard blood tubes. RESULTS All levels are reported as mmol/L. Mean serum lithium level for the control was 0.16 [range: 0.1-0.2]. Levels for the light-green tubes at full-draw, 2cc, and 1cc were 1.05 [1.0-1.1], 1.99 [1.68-2.3], and 3.31 [2.8-4.2] respectively. Levels for the darkgreen tubes at full-draw, 2cc, and 1cc were 1.07 [1.0-1.14], 2.35 [2.1-2.55], and 4.04 [3.8-4.4] respectively. CONCLUSIONS Falsely elevated lithium levels may occur when using green-top lithium containing blood tubes and may contribute as much as 4 mmol/L to the level in tubes not completely filled.
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Affiliation(s)
- Brandon K Wills
- Cook County Hospital, University of Illinois at Chicago Medical Center, Rush University Medical Center, Chicago, IL, USA.
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Abstract
BACKGROUND Coca tea, derived from the same plant that is used to synthesize cocaine, is commonly consumed in South America and easily obtained in the United States. OBJECTIVES To determine whether consumption of coca tea would result in a positive urine toxicology screen for cocaine metabolites. METHODS Five healthy adult volunteers consumed coca tea and underwent serial quantitative urine testing for cocaine metabolites by fluorescence polarization immunoassay. The cutoff for a positive assay was chosen at 300 ng/ml, the National Institute on Drug Abuse standard. RESULTS Each participant's urine cocaine assay was positive (level exceeding 300 ng/ml) by 2 h after ingestion. Three out of five participants' samples remained positive at 36 h. Mean urine benzoylecgonine concentrations in all postconsumption samples was 1777 ng/ml (95% confidence interval: 1060-2495). CONCLUSIONS Coca tea ingestion resulted in a positive urine assay for cocaine metabolite. Healthcare professionals should consider a history of coca tea ingestion when interpreting urine toxicology results.
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Affiliation(s)
- Suzan S Mazor
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital and Regional Medical Center, Seattle, Washington 98105, USA.
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Wills BK, Haller NA, Peter D, White LJ. Use of amifostine, a novel cytoprotective, in alpha-amanitin poisoning. Clin Toxicol (Phila) 2005; 43:261-7. [PMID: 16035202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Mortality from ingestions of the mushroom Amanita phalloides remains as high as 20-40% with many surviving patients requiring liver transplantation. A variety of treatments for Amanita ingestion have been evaluated, yet other than supportive measures, no effective therapy has been identified. In addition, an antidote for Amanita toxicity may not be practical due to delayed patient presentation. The drug amifostine was proposed to potentially improve survival from alpha-amanitin toxicity by conferring cytoprotective effects on hepatocytes at risk for cell death. Amifostine is used as a radio--and chemo-protective agent. It protects against lipoperoxidation, interferes with the cross-linking of DNA, and may act by other mechanisms yet to be identified, making it attractive for potentially attenuating ongoing hepatic necrosis. It has not previously been studied in a toxicologic model. STUDY OBJECTIVE To determine whether amifostine is an effective postexposure therapy for alpha-amanitin, the primary lethal toxin in Amanita phalloides. METHODS Swiss mice (n = 30 in all groups) were given an approximate LD75 dose of intraperitoneal (i.p.) alpha-amanitin. Amifostine was administered i.p. 6 h after poisoning in three cumulative dosing groups: 250 mg/kg; 500 mg/kg; and 1600 mg/kg. Controls received equal volumes of i.p. sterile 0.9% saline. Mice were monitored and time of death recorded. At day 7, survival was assumed and the remaining mice were euthanized. Qualitative histologic comparisons of hepatic and renal toxicity were performed. RESULTS At day 7, only 10% of the control mice survived. Survival in the amifostine 250, 500, and 1600 mg/kg groups was 20%, 20%, and 3%, respectively. No statistically significant differences were detected in Kaplan-Meier survival between the control group and those receiving 250 or 500 mg/kg; however, there was a statistically significant decrease in survival for the group receiving 1600 mg/kg (p = 0.0002). CONCLUSION No survival benefit was seen with cumulative doses between 250 and 500 mg/kg; however, higher doses may result in subsequent toxicity and decreased survival.
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Affiliation(s)
- Brandon K Wills
- Emergency Medicine Residency Program, Akron General Medical Center, Akron, Ohio, USA.
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Podolin DA, Wills BK, Wood IO, Lopez M, Mazzeo RS, Roth DA. Attenuation of age-related declines in glucagon-mediated signal transduction in rat liver by exercise training. Am J Physiol Endocrinol Metab 2001; 281:E516-23. [PMID: 11500307 DOI: 10.1152/ajpendo.2001.281.3.e516] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This study investigated alterations in glucagon receptor-mediated signal transduction in rat livers from 7- to 25-mo-old animals and examined the effects of exercise training on ameliorating these changes. Sixty-six young (4 mo), middle-aged (12 mo), and old (22 mo) male Fischer 344 rats were divided into sedentary and trained (treadmill running) groups. Isolated hepatic membranes were combined with [(125)I-Tyr(10)]monoiodoglucagon and nine concentrations of glucagon to determine maximal binding capacity (B(max)) and dissociation constant (K(d)). No alterations were found in B(max) among groups; however, middle-aged trained animals had significantly higher glucagon affinity (lower K(d); 21.1 +/- 1.8 nM) than did their untrained counterparts (50.2 +/- 7.1 nM). Second messenger studies were performed by measuring adenylyl cyclase (AC) specific activity under basal conditions and with four pharmacological stimulations to assess changes in receptor-dependent, G protein-dependent, and AC catalyst-dependent cAMP production. Age-related declines were observed in the old animals under all five conditions. Training resulted in increased cAMP production in the old animals when AC was directly stimulated by forskolin. Stimulatory G protein (G(s)) content was reduced with age in the sedentary group; however, training offset this decline. We conclude that age-related declines in glucagon signaling capacity and responsiveness may be attributed, in part, to declines in intrinsic AC activity and changes in G protein [inhibitory G protein (G(i))/G(s)] ratios. These age-related changes occur in the absence of alterations in glucagon receptor content and appear to involve both G protein- and AC-related changes. Endurance training was able to significantly offset these declines through restoration of the G(i)/G(s) ratio and AC activity.
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Affiliation(s)
- D A Podolin
- University of Colorado, Boulder, CO 80303, USA.
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