Emergency department presentation of opioid use disorder and alcohol use disorder

Mixing alcohol and opioid prescription medications can have serious health consequences. This study examines demographic and geographic differences in opioid use disorders (OUD) and alcohol use disorders (AUD) in emergency department (ED) presentations in the state of Texas. Using all diagnosis codes, the study examined discharge records for ED visits related to AUD and OUD in Texas for 2017. The study classified visits into three mutually exclusive groups (AUD-only, OUD-only, and AUD/OUD) and reported the number of visits, fatalities, total charges, proportions, and rates per 100,000 population by patient demographic characteristics. Chi square statistics assessed the association between patient characteristics and ED visit type, and the study used analysis of variance to compare ED visit rates by patient demographics. The study also fitted a multinomial logistic regression w to predict ED visit type by patient demographic and geographic characteristics. There were 221,363 OUD and AUD ED visits from Texans in 2017. Among them, 3863 had both AUD and OUD. There were 2443 fatalities related to AUD-only ED visits, whereas this rate was 292 for OUD-only ED visits. The majority of these patients had Medicare and Medicaid. AUD-only ED visits were more prevalent (680.7 vs 112.5 per 100,000 population) and resulted in higher overall charges than OUD-only ED visits ($6.1 billion vs $1 billion in total charges). However, AUD/OUD ED visits resulted in higher total charges on average than either OUD-only or AUD-only ED visits. Compared to patients with outpatient discharge, patients with inpatient admissions were more likely to belong to the OUD-only visit group (OR = 1.20, 95% CI: 1.17-1.23) or the AUD/OUD visit group (OR = 2.44, 95% CI: 2.28-2.61) than to the AUD-only visit group. Compared to urban patients, rural patients were less likely to belong to OUD-related visit groups than the AUD-only visit group. In conclusions, AUD was more prevalent than OUD among ED visits and resulted in a higher number of fatalities and higher medical charges. Current health policy regarding substance use that is heavily tilted toward curbing the opioid crisis remains woefully tolerant to AUDs. While efforts to curb opioid misuse should continue, future efforts should raise awareness among ED providers of the disease burden of and social harms caused by alcoholism and alcohol addiction.

Acute Elemental Mercury Poisoning Masquerading as Fever and Rash

This is a case series of 3 children from a single family who developed symptomatic elemental mercury poisoning requiring hospitalization and chelation. The mercury exposure primarily occurred in the home but the mercury was also tracked to one of their schools requiring environmental cleanup at both the home and school. The clinical assessment and management, as well as public health investigation and response, are discussed. There are many lessons learned in this difficult, often delayed, diagnosis. Early recognition of this environmental toxic exposure is essential. Communication between the clinicians and public health officials played a critical role. Public education prevented panic. Proper environmental sampling, and assessment and management of those exposed, were a few of the many challenges faced in this complicated case series.

Adverse Events in the Efficacy of Crotalidae Polyvalent Immune Fab Antivenom vs Placebo in Recovery from Copperhead Snakebite Trial

OBJECTIVE

To compare the incidence of hypersensitivity reactions following copperhead envenomation treated with Fab antivenom (FabAV) or placebo.

METHODS

Patients with copperhead snakebites received treatment and follow-up in a prospective, randomized, double-blind, placebo-controlled trial of FabAV or placebo. The treatment allocation ratio was 2:1 (FabAV:placebo). All of the included patients received at least one dose of study treatment. We reviewed all treatment-emergent adverse events (AEs) using a previously published scale to classify likely hypersensitivity reactions as mild, moderate, or severe.

RESULTS

We enrolled 74 patients at 13 sites. Forty-five patients received FabAV, and 29 patients received placebo. Five FabAV patients and 4 placebo patients had moderate envenomations; the rest were mild. Twenty-five FabAV patients and 8 placebo patients had at least 1 AE. Mild skin reactions occurred in 11 (24%) FabAV patients (pruritis, urticaria, rash, ecchymosis, erythema) and 1 (3%) placebo patient (pruritis). Moderate gastrointestinal AEs occurred in 7 (16%) FabAV patients (nausea, vomiting, constipation, diarrhea, oral paresthesia) and in 2 (7%) placebo patients (nausea). Respiratory AEs occurred in 3 (7%) FabAV patients (dyspnea, pulmonary embolism, nasal congestion, sneezing) and no placebo patients. Hypotension occurred in 1 patient in each group.

CONCLUSIONS

In a randomized controlled trial of FabAV for copperhead bites, the incidence of hypersensitivity reactions was low. Most reactions were mild skin reactions.

Cottonmouth snake bites reported to the ToxIC North American snakebite registry 2013-2017

Introduction: The majority of venomous snake exposures in the United States are due to snakes from the subfamily Crotalinae (pit vipers). There are three types of US pit vipers: rattlesnakes (Crotalus and Sisturus spp.) copperheads (Agkistrodon contortrix), and cottonmouths (Agkistrodon piscivorus) also known as water moccasins. Cottonmouth bites are reported less frequently than other pit viper envenomations, and data on cottonmouth envenomation are limited. Our objective was to describe the epidemiology, clinical manifestations, and management of cottonmouth envenomations using prospective data reported to the Toxicology Investigators Consortium's (ToxIC) North American Snakebite Registry (NASBR)Methods: Cottonmouth envenomation cases reported to NASBR for the period from January 1, 2013, through December 31, 2017 were reviewed. Variables collected included patient demographics, bite location, clinical manifestations, and management.Results: Thirty-one cottonmouth envenomations were reported. Most bites occurred in children aged 7-12 (39%). Most bites involved the lower extremity (72%). Intentional interaction with the snake occurred in three cases (10%). Swelling was the most reported clinical effect and occurred in all patients. Gastrointestinal symptoms were reported in 19% of patients, and 19% developed coagulopathy. Antivenom treatment was used in 84% of patients. Nineteen patients (61%) required hospital stays of >24 hours.Discussion: Our study represents the first systematic prospective data collection on cottonmouth bites. Our data demonstrate that cottonmouth envenomations cause primarily local effects and, occasionally, systemic toxicity. Our study also demonstrates that antivenom is often indicated for these envenomations per published guidelines and recommendations.Conclusions: Cottonmouth envenomations are relatively infrequent. However, they can cause significant local and systemic toxicity. Most cottonmouth envenomations in this series were treated with antivenom and were hospitalized beyond 24 hours.

Antivenom Treatment Is Associated with Fewer Patients using Opioids after Copperhead Envenomation

Introduction

Copperhead envenomation causes local tissue destruction, leading people to seek treatment for the pain and swelling. First-line treatment for the pain is opioid medications. There is rising concern that an initial opioid prescription from the emergency department (ED) can lead to long-term addiction. This analysis sought to determine whether use of Fab antivenom (FabAV) for copperhead envenomation affected opioid use.

Methods

We performed a secondary analysis using data from a randomized clinical trial designed to determine the effect of FabAV on limb injury recovery following mild to moderate copperhead envenomation. Opioid use was a defined secondary outcome in the parent trial. Patients were contacted after discharge, and data were obtained regarding medications used for pain and the patients’ functional status. This analysis describes the proportion of patients in each treatment group reporting opioid use at each time point. It also assesses the interaction between functional status and use of opioids.

Results

We enrolled 74 patients in the parent trial (45 received FabAV, 29 placebo), of whom 72 were included in this secondary analysis. Thirty-five reported use of any opioids after hospital discharge. A smaller proportion of patients treated with FabAV reported opioid use: 40.9% vs 60.7% of those in the placebo group. The proportion of patients using opioids remained smaller in the FabAV group at each follow-up time point. Controlling for confounders and interactions between variables, the model estimated that the odds ratio of using opioids after hospital discharge among those who received placebo was 5.67 times that of those who received FabAV. Patients who reported higher baseline pain, those with moderate as opposed to mild envenomation, and females were more likely to report opioid use at follow-up. Patients with ongoing limitations to functional status had an increased probability of opioid use, with a stronger association over time. Opioid use corresponded with the trial’s predefined criteria for full recovery, with only two patients reporting opioid use in the 24 hours prior to achieving full limb recovery and no patients in either group reporting opioid use after full limb recovery.

Conclusion

In this study population, the proportion of patients using opioids for pain related to envenomation was smaller in the FabAV treatment group at all follow-up time points.

Early administration of Fab antivenom resulted in faster limb recovery in copperhead snake envenomation patients

BACKGROUND

No previous research has studied whether early snake antivenom administration leads to better clinical outcomes than late antivenom administration in North American pit viper envenomation.

METHODS

A secondary analysis of data from a clinical trial of Fab antivenom (FabAV) versus placebo for copperhead snake envenomation was conducted. Patients treated before the median time to FabAV administration were classified as receiving early treatment and those treated after the median time were defined as the late treatment group. A Cox proportional hazards model was used to compare time to full recovery on the Patient-Specific Functional Scale (PSFS) instrument between groups. Secondary analyses compared estimated mean PSFS scores using a generalized linear model and the estimated proportion of patients with full recovery at each time point using logistic regression. To evaluate for confounding, the main analysis was repeated using data from placebo-treated subjects.

RESULTS

Forty-five subjects were treated with FabAV at a median of 5.47 h after envenomation. Patients in the early treatment group had a significantly shorter time to full recovery than those treated late (median time: 17 versus 28 days, p = .025). Model-estimated PSFS scores were numerically higher at each time point in the early group. No difference was found between patients treated early versus late with placebo.

CONCLUSIONS

In this secondary analysis of trial data, recovery of limb function was faster when Fab antivenom was administered soon after envenomation, as opposed to late administration.

Differences Between Snakebites with Concomitant Use of Alcohol or Drugs and Single Snakebites

OBJECTIVES

Published reports have suggested that the concurrent use of alcohol or drugs occurs among some snakebite victims, but no national assessment of such data exists.

METHODS

We used data from US poison control centers collected during telephone calls in calendar years 2000-2013 to compare snake envenomations with concomitant use of drugs, alcohol, or both to snakebites lacking such use.

RESULTS

A total of 608 snakebites with 659 instances of concomitant alcohol/drug use were reported, which represent approximately 1% of 92,751 snakebites reported to US poison control centers. An annual mean of 48 snakebites with concomitant use of alcohol/drugs was reported, compared with a mean of 6625 snakebites per year with no concomitant use of alcohol/drugs. Most cases involved men, peaked during the summer months, and involved copperheads or rattlesnakes, which mirrored overall trends. Snakebite victims who also used alcohol/drugs were more likely than victims with only a snakebite reported to be bitten by rattlesnakes, to be admitted to the hospital, and die. Alcohol was the most common reported concomitant substance, but other substances were reported.

CONCLUSIONS

Snakebites with concomitant use of alcohol/drugs are uncommon, accounting for approximately 1% of the snakebite envenomations reported annually to US poison control centers; however, snakebite victims also reporting alcohol/drug use are more likely to be bitten by rattlesnakes, be admitted to a healthcare facility, and die.

The Epidemiology, Clinical Course, and Management of Snakebites in the North American Snakebite Registry

The American College of Medical Toxicology established the North American Snakebite Registry (NASBR), a national database of detailed, prospectively collected information regarding snake envenomation in the United States, in 2013. This report describes the epidemiology, clinical course, and management of snakebites in the NASBR. All cases entered into the NASBR between January 1, 2013 and December 31, 2015 were identified. Descriptive statistics are used to report results. Fourteen sites in 10 states entered 450 snakebites. Native species comprised 99% of cases, almost all of which were pit viper bites. 56.3% were identified as rattlesnakes and 29.4% as copperheads. 69.3% were male and 28.2% were children age 12 and under. Fifty-four percent of bites were on the lower extremity. Twenty-seven percent of patients with lower extremity bites were not wearing shoes. Common tissue findings associated with envenomation were swelling, ecchymosis, and erythema. Systemic effects and hematologic toxicity were more common in rattlesnake than copperhead or cottonmouth envenomations. Crotalidae Polyvalent Immune Fab antivenom was given to 84% of patients. Twelve patients (4.3%) were re-admitted to the hospital after completion of treatment. Eight were re-treated with antivenom. The NASBR gathers detailed data on venomous snakebites across the US. In its initial years, useful information has already been gained. Data regarding footwear will inform public health interventions and education, and information regarding the clinical presentation may help physicians better anticipate effects and manage snakebite. As the number of cases in the NASBR grows, associations between patient-related factors and outcomes may be studied.

Childhood Victims of Snakebites: 2000-2013

BACKGROUND

Snakebites are not a reportable condition (to state health departments), and 1 major assessment of US children with snakebites was published 50 years ago. Increasing urbanization, population shifts south and west, newer antivenom therapy, and the importation of exotic snakes may have changed snakebites. Poison control centers are often consulted on treatment and collect surveillance data.

METHODS

Generic codes for venomous, nonvenomous, and unknown snakebites were used to characterize victims aged ≤18 years reported to US poison control centers between 2000 and 2013. Data included demographic characteristics, snake types, and outcomes.

RESULTS

Callers reported 18 721 pediatric snakebites (annual mean, 1337). Two-thirds were male (n = 12 688 [68%]), with a mean age of 10.7 years. One-half of the snakebites were venomous (n = 9183 [49%]), with copperheads (n = 3602 [39%]) and rattlesnakes (n = 2859 [31%]) the most frequently identified. Reported copperhead bites increased 137% and unknown crotalids (venomous) increased 107%. Exotic (nonnative) exposures were reported in 2% of cases. All 50 states reported snakebites, but one-quarter occurred in Texas and Florida. Rates for total snakebites and venomous snakebites were highest in West Virginia, Oklahoma, and Louisiana. One-fifth required ICU admission. Limited data for 28% of bites for antivenom treatment suggests increasing use. Four victims died.

CONCLUSIONS

The epidemiology of pediatric snakebites is changing. One-half of the reported exposures were venomous, and copperhead bites and exotic species are being reported more frequently. Although snakebite-related deaths are rare, ICU admission is common. Antivenom treatment is incompletely reported, but its use is increasing.

Electronic cigarette exposures reported to Texas poison centers

INTRODUCTION

Exposure to the liquid nicotine solutions in electronic cigarettes (e-cigs) may be dangerous because they are highly concentrated. Little is known about the impact of exposure on public health. This study describes e-cig exposures reported to poison centers.

METHODS

All e-cig exposures reported to Texas poison centers during 2009 to February 2014 were identified. Exposures involving other substances in addition to e-cigs and exposures not followed to a final medical outcome were included. The distributions of exposures by demographic and clinical factors were determined.

RESULTS

Of 225 total exposures, 2 were reported in January 2009, 6 in 2010, 11 in 2011, 43 in 2012, 123 in 2013, and 40 through February 2014. Fifty-three percent (n = 119) occurred among individuals aged <5 years old, 41% (n = 93) occurred among individuals aged >20 years old, and 6% (n = 13) occurred among individuals aged 6-19 years. Fifty percent were female. The route of exposure was 78% ingestion. Eighty-seven percent of the exposures were unintentional, and 5% were intentional. The exposures occurred at patients' own residences in 95% of the cases. The clinical effects reported most often were vomiting (20%), nausea (10%), headache (4%), ocular irritation (5%), dizziness (5%), and lethargy (2%).

CONCLUSION

E-cig exposures reported to poison centers are increasing. Most of the patients are young children, and the exposures most frequently occur through ingestion. Reported exposures often do not have serious outcomes.

The Toxicology Investigators Consortium Case Registry-the 2010 experience

INTRODUCTION

The American College of Medical Toxicology Case Registry was established in 2010 as a method of identifying cases cared for by medical toxicologists at participating institutions. The Registry allows for the extraction of information from medical records making it the most robust multicenter database on chemical toxicities in existence. The current report is a summary of the data collected in 2010.

METHODS

All cases seen by medical toxicologists at participating institutions were entered on a database. Information characterizing patients entered in 2010 was tabulated.

RESULTS

Over the course of 2010, the number of institutions contributing cases grew from 4 to 50. Three thousand nine hundred forty-eight cases were entered. Emergency departments were the most common source of consultations, accounting for approximately 50% of the cases. The most common reason for consultations was for pharmaceutical overdoses, which occurred in 42% of the patients. The most common classes of agents were non-opioid analgesics (14%), sedative/hypnotics/muscle relaxants (10%), ethanol (8%), and opioids (8%). N-acetylcysteine was the most common antidote used, followed by opioid antagonists, sodium bicarbonate, and physostigmine. Anti-crotalidae Fab fragments were administered in 72% of the cases in which an antivenin was used. Signals were detected suggesting the possibility that amlodipine and metoprolol were associated with greater toxicity than had been previously recognized.

CONCLUSIONS

The Registry can identify and characterize patients who have sufficient toxicity to require a consultation by a medical toxicologist. Hypotheses for further investigation emerged from the data. The Registry appears to be a potentially powerful tool for toxicovigilance and research.

The Toxicology Investigators Consortium (ToxIC) Registry

Many medical toxicologists are interested in participating in a practice-based, multicenter research and toxicosurveillance network. In 2009, the American College of Medical Toxicology established the Toxicology Investigators Consortium (ToxIC). One facet of ToxIC is a registry that can be used for surveillance of new or old agents, assessment of treatment decisions, and the creation of new research questions. This paper describes the development of and the initial experiences with this registry of toxicology patients. In November 2009, ACMT invited members to participate in a new registry of cases evaluated and cared for by practicing medical toxicologists who provide direct hands-on clinical care. A password-protected, encrypted, online registry data site was created to upload a newly developed electronic case report form (CRF) on registry patients. The CRF includes demographics; encounter circumstances; agent; syndrome, symptoms, and signs; and treatment. A test version at four sites began in January 2010, seven additional sites were added in March 2010 for the beta phase, and the registry was opened to all interested US medical toxicology practices in April 2010. The CRF underwent continuous modifications based upon frequent feedback from and discussion among the participants. Thirty-three toxicology practice sites, encompassing 56 hospitals and clinics, have entered data into the ToxIC Registry. During the first 14 months of data collection, 5,412 patients were entered. The experience thus far demonstrates that the creation of this registry is feasible and constitutes a potentially powerful toxicosurveillance and robust research tool.

State of the art review: Intravenous fat emulsions: Current applications, safety profile, and clinical implications

OBJECTIVE

To review the current state of the science regarding intravenous fat emulsions (IVFEs), with an emphasis on their safety profile.

DATA SOURCES

Articles were identified via a search of the MEDLINE database, including publications from 1979 to December 2009, using a search string that included the terms parenteral nutrition, lipid emulsion, fat emulsion, IVFE, safety, adverse effect, neonate intralipid, and terms describing a range of specific adverse events (AEs) such as pancreatitis.

STUDY SELECTION AND DATA EXTRACTION

We selected articles that allowed us to compare the results of clinical trials involving delivery of medications via IVFEs with the historical use and effects of IVFEs in parenteral nutrition, with an emphasis on AEs. We focused on 2 drugs in current use that are administered intravenously in lipid emulsions: propofol and clevidipine.

DATA SYNTHESIS

Clearance of the fat particles in IVFEs is mediated by the enzyme lipoprotein lipase. AEs are more likely if the rate or duration of IVFE administration exceeds the enzyme's clearance capacity. AEs are also more likely after administration of a 10% IVFE formulation than a 20% formulation, because the higher concentration of free phospholipid in the 10% formulation interferes with lipoprotein lipase activity. AEs can be reduced by administering IVFEs at a dosage < or = 2.5 g/kg/day and at a rate < or = 0.11 g/kg/h. The anesthetic agent propofol, which is formulated in a 10% IVFE, has been used clinically for 25 years. Typical AEs associated with propofol use include infection, high plasma triglyceride concentrations, and pancreatitis. Recent clinical trials involving clevidipine, which is formulated in a 20% IVFE, have demonstrated a low rate of lipid-related AEs.

CONCLUSIONS

The results of this review demonstrate that IVFEs are well tolerated when administered in accordance with guideline recommendations.

Late-onset seizures associated with quetiapine poisoning

INTRODUCTION

Quetiapine, a second-generation antipsychotic, acts at multiple brain neurotransmitter receptors and has the potential for serious complications. Although seizures have been described in the literature, delayed seizure onset has not been reported. We report the first case of delayed seizures after a significant quetiapine overdose.

CASE REPORT

A 27-year-old female presented to the emergency department following an overdose of approximately 30 g of quetiapine. Twenty-four hours after arrival, the patient had 2 seizures. The patient was then intubated and remained in the ICU for four days. EEG was negative for epileptiform activity. The serum quetiapine levels (MedTox, St. Paul, MN) were 8.67 mg/L on hospital day one and 3.28 mg/L on hospital day three.

DISCUSSION

Quetiapine poisoning, with serum levels, associated with seizures has been reported in one prior case. Our case report represents late-onset seizures with serum levels above therapeutic range (>1 mg/L). The serum concentrations of quetiapine in this case were consistent with those in postmortem case reports.

Intravenous fat emulsion therapy for intentional sustained-release verapamil overdose

We report the first case of sustained-release verapamil toxicity treated with Intralipid fat emulsion (IFE). Toxicity was confirmed by elevated serial serum verapamil and metabolite, norverapamil, levels. Most previously reported cases of IFE therapy involve local anaesthetic toxicity and cardiac arrest. Our patient was in shock despite standard therapy. No adverse events were noted and the patient fully recovered.

Delayed Salicylate Toxicity at 35 Hours Without Early Manifestations Following a Single Salicylate Ingestion

OBJECTIVE:

To report a case of delayed toxicity following a single ingestion of aspirin, where the initial concentrations were nearly undetectable and the patient was completely asymptomatic for the first 35 hours.

CASE SUMMARY:

A 14-year-old white female was evaluated after a single ingestion of 120 tablets of aspirin 81 mg/tablet hours before arrival to the emergency department. She denied nausea, abdominal pain, tinnitus, or shortness of breath. She received one dose of activated charcoal. The first salicylate concentration (4 h after ingestion) was 1 mg/dL. At 35 hours, the patient became symptomatic (dizziness, tinnitus, epigastric discomfort). Her salicylate concentration at that time was 46 mg/dL. A second dose of activated charcoal was administered, and intravenous bicarbonate with potassium was started as a continuous infusion for 30 hours.

DISCUSSION:

While delayed salicylate toxicity is well reported in the literature, no report was found regarding concentrations increasing to toxicity 35 hours after ingestion. The delayed aspirin absorption may be due to salicylate-induced pylorospasm or the formation of pharmacobezoars.

CONCLUSIONS:

In cases with known salicylate ingestion, it is important to follow salicylate concentrations every 4 hours until they are steadily decreasing according to a 4-hour half-life and the patient shows no symptoms of salicylate intoxication.

Elder abuse: a review

Elder abuse exists in many forms: physical, emotional, financial, and sexual; neglect; and self-neglect. As many as 2.5 million older people are abused each year, and the number of cases will likely increase as this population grows. Elder abuse receives less attention than other forms of domestic violence, and fewer than 10% of cases are reported. Although all states have legislation addressing elder abuse, financial support for evaluation and protective services is lacking. Most states have mandatory reporting; however, it may infringe on the autonomy of competent geriatric individuals. Physicians infrequently report elder abuse because they are not familiar with reporting laws, fear offending patients, are concerned with time limitations, and believe they do not have appropriate evaluation skills. Victims often have low self-esteem, blame themselves for the abuse, and do not want to admit their vulnerabilities or betray their families. The "caregiver stress hypothesis," which suggests abuse stems from caregiver stress and resentment resulting from chronic care of dependent geriatric patients, is a misconception. Abuse is actually better correlated with the emotional and financial dependence of the caregivers on the geriatric victims. Older patients are most commonly abused by the people with whom they live. Older men and women have similar per capita abuse rates. Assessment and management should be supportive without assigning blame and should focus on both the patient and the caregiver. Patients in immediate danger should be hospitalized or placed in emergency shelters. Suspected abuse should be reported directly to the appropriate state agency, which can provide a thorough long-term assessment.