1
|
Ives Tallman C, Zhang Y, Black N, Lynch K, Fayed M, Armenian P. Refractory vasodilatory shock secondary to metformin overdose supported with VA ECMO. Toxicol Rep 2022; 9:64-67. [PMID: 35004183 PMCID: PMC8718576 DOI: 10.1016/j.toxrep.2021.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 12/14/2021] [Accepted: 12/18/2021] [Indexed: 01/27/2023] Open
Abstract
Metformin overdose can lead to vasodilatory shock refractory to medical management. Extracorporeal circulatory support with venoarterial ECMO is an effective way to manage profound shock associated with metformin overdose. We report the highest recorded serum metformin level in the literature to date.
Metformin overdose may result in vasodilatory shock, lactic acidosis and death. Hemodialysis is an effective means of extracorporeal elimination, but may be insufficient in the shock setting. We present a case of a 39 yo male who presented with hypotension, coma, hypoglycemia, and lactate of 6.5 mmol/L after ingesting an unknown medication. Metformin overdose was suspected, and he was started on hemodialysis. He developed profound vasoplegia refractory to high doses of norepinephrine, vasopressin, epinephrine and phenylephrine. Venoarterial extracorporeal membrane oxygenation (VA ECMO) was initiated and he had full recovery. Serum analysis with high resolution liquid chromatography mass spectrometry revealed a metformin level of 678 μg/mL and trazodone level of 2.1 μg/mL. This case is one of only a handful of reported cases of metformin overdose requiring ECMO support, and we report the highest serum metformin levels in the literature to date. We recommend early aggressive hemodialysis and vasopressor support in all suspected cases of metformin toxicity as well as VA ECMO if refractory to these therapies. Objective We present a case of vasodilatory shock secondary to metformin overdose requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) support. This case is one of only a handful of reported cases of metformin overdose requiring ECMO support, and we report the highest serum metformin levels in the literature to date. Data sources University of San Francisco, Fresno. Study design Case report. Data extraction Clinical records and high resolution liquid chromatography mass spectroscopy analysis. Data synthesis None. Conclusions Venoarterial ECMO provided an effective means of hemodynamic support for a patient with severe metformin toxicity.
Collapse
Affiliation(s)
- Crystal Ives Tallman
- UCSF Fresno Department of Emergency Medicine, United States.,UCSF Fresno Department of Medicine, Pulmonary Critical Care Division, United States
| | - Yu Zhang
- UCSF Department of Laboratory Medicine, Division of Clinical Chemistry, San Francisco, CA, United States
| | - Nicholas Black
- UCSF Fresno Department of Emergency Medicine, United States
| | - Kara Lynch
- UCSF Department of Laboratory Medicine, Division of Clinical Chemistry, San Francisco, CA, United States
| | - Mohamed Fayed
- UCSF Fresno Department of Medicine, Pulmonary Critical Care Division, United States
| | - Patil Armenian
- UCSF Fresno Department of Emergency Medicine, United States
| |
Collapse
|
2
|
Armenian P, Rodda LN. Two Decades of Ecstasy: Shifting Demographic Trends in Decedents using MDMA. J Anal Toxicol 2020; 46:bkaa193. [PMID: 33305792 DOI: 10.1093/jat/bkaa193] [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: 11/02/2020] [Revised: 12/02/2020] [Accepted: 12/11/2020] [Indexed: 11/12/2022] Open
Abstract
Deaths with a toxicology finding of the party drug, 3,4-Methylenedioxymethamphetamine (MDMA), over the 20-year period from 2000-2019 in San Francisco are presented to identify shifting demographic trends. Of the 148 cases, 129 (87.2%) were male with mean and median ages of 30 and 28, respectively. The most common manner of death (MOD) in males was homicide (65 of 129) and accident (49 of 129). The most common MOD in females was accident (15 of 19). Regarding racial demographics, Black homicide deaths accounted for 59 of 67 (88.1%) of total homicides. The most prevalent cause of death for homicides was gunshot wounds (63 of 67, 94.0%). Homicide prevalence was high in the first decade of the study (53 of 88, 60.2%), sharply dropping off after 2011. White accidental deaths made up most of the accidental deaths (45 of 64, 70.3%). Since 2015, accidental deaths with MDMA began to rise (40 of 60, 66.7%), most with other coingestants. MDMA concentrations (median, mean ± SD) between homicide (290, 450 ± 490 ng/mL) and accidental (250, 680 ± 1120 ng/mL) deaths were similar. MDMA concentrations were elevated in central blood compared to peripheral blood from unmatched cases. MDMA was detected in a variety of decedents during the two decades, with primarily young Black male gunshot wound homicide victims in the first decade and primarily young White male accidental polydrug victims in the second decade. This study demonstrates that MDMA is no longer confined to a party setting, but can also be found in different socio-economic strata, including its association with violent homicidal deaths.
Collapse
Affiliation(s)
- Patil Armenian
- Emergency Medicine and Medical Toxicology, Department of Emergency Medicine, University of California, San Francisco - Fresno, 155 N Fresno St, Fresno, California, United States
| | - Luke N Rodda
- Forensic Laboratory Division, Office of Chief Medical Examiner, 1 Newhall Street, San Francisco, California, United States
- Department of Laboratory Medicine, University of California, San Francisco 185 Berry Street, San Francisco, California, United States
| |
Collapse
|
3
|
Darracq MA, Lee J, Wilson T, Lasoff D, Armenian P. Pharmacist dispensed naloxone: Knowledge, availability, participation and cost in selected California counties. International Journal of Drug Policy 2019; 71:113-117. [PMID: 31301549 DOI: 10.1016/j.drugpo.2019.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 03/21/2019] [Accepted: 06/05/2019] [Indexed: 11/24/2022]
|
4
|
Thornton SL, Darracq MA, Gugelmann HM, Armenian P. Surface internet marketplace presence and availability of NPS sold as research chemicals: a snapshot study. Toxicology Communications 2019. [DOI: 10.1080/24734306.2019.1648067] [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: 10/26/2022] Open
Affiliation(s)
- Stephen L. Thornton
- Department of Emergency Medicine, Kansas Poison Control System, University of Kansas Medical Center, Kansas City, KS, USA
| | - Michael A. Darracq
- Department of Emergency Medicine, University of California San Francisco-Fresno, Fresno, CA, USA
| | - Hallam M. Gugelmann
- Department of Emergency Medicine, California Pacific Medical Center St. Luke’s Campus, and California Poison Control System, San Francisco Division, San Francisco, CA, USA
| | - Patil Armenian
- Department of Emergency Medicine, University of California San Francisco-Fresno, Fresno, CA, USA
| |
Collapse
|
5
|
Armenian P, Whitman JD, Badea A, Johnson W, Drake C, Dhillon SS, Rivera M, Brandehoff N, Lynch KL. Notes from the Field: Unintentional Fentanyl Overdoses Among Persons Who Thought They Were Snorting Cocaine - Fresno, California, January 7, 2019. MMWR Morb Mortal Wkly Rep 2019; 68:687-688. [PMID: 31393864 PMCID: PMC6687194 DOI: 10.15585/mmwr.mm6831a2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
6
|
|
7
|
Affiliation(s)
- Michael A Darracq
- Department of Emergency Medicine, Division of Medical Toxicology, University of California, San Francisco (UCSF) Fresno Medical Education Program, United States.
| | - Patil Armenian
- Department of Emergency Medicine, Division of Medical Toxicology, University of California, San Francisco (UCSF) Fresno Medical Education Program, United States
| | - James Comes
- Department of Emergency Medicine, University of California, San Francisco (UCSF) Fresno Medical Education Program, United States
| | - Stephen Thornton
- Department of Emergency Medicine, University of Kansas Medical Center, Kansas Poison Control System, United States
| |
Collapse
|
8
|
Sheehy M, Armenian P, Mason J, Grock A. Beware the Danger Lurking Under the Shroud of Alcohol. Ann Emerg Med 2018; 71:289-291. [DOI: 10.1016/j.annemergmed.2018.01.032] [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] [Indexed: 10/18/2022]
|
9
|
Armenian P, Vo KT, Barr-Walker J, Lynch KL. Fentanyl, fentanyl analogs and novel synthetic opioids: A comprehensive review. Neuropharmacology 2017; 134:121-132. [PMID: 29042317 DOI: 10.1016/j.neuropharm.2017.10.016] [Citation(s) in RCA: 334] [Impact Index Per Article: 47.7] [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: 06/12/2017] [Revised: 09/30/2017] [Accepted: 10/12/2017] [Indexed: 12/14/2022]
Abstract
Deaths from opioid use are increasing in the US, with a growing proportion due to synthetic opioids. Until 2013, sporadic outbreaks of fentanyl and fentanyl analogs contaminating the heroin supply caused some deaths in heroin users. Since then, fentanyl has caused deaths in every state and fentanyl and its analogs have completely infiltrated the North American heroin supply. In 2014, the first illicit pills containing fentanyl, fentanyl analogs, and other novel synthetic opioids such as U-47700 were detected. These pills, which look like known opioids or benzodiazepines, have introduced synthetic opioids to more unsuspecting customers. As soon as these drugs are regulated by various countries, new compounds quickly appear on the market, making detection difficult and the number of cases likely underreported. Standard targeted analytical techniques such as GC-MS (gas chromatography mass spectrometry) and LC-MS/MS (liquid chromatography tandem mass spectrometry) can detect these drugs, but novel compound identification is aided by nontargeted testing with LC-HRMS (liquid chromatography high resolution mass spectrometry). Fentanyl, fentanyl analogs and other novel synthetic opioids are all full agonists of varying potencies at the μ-opioid receptor, leading to typical clinical effects of miosis and respiratory and central nervous system depression. Due to their high affinity for μ-opioid receptors, larger doses of naloxone are required to reverse the effects than are commonly used. Synthetic opioids are an increasingly major public health threat requiring vigilance from multiple fields including law enforcement, government agencies, clinical chemists, pharmacists, and physicians, to name a few, in order to stem its tide. This article is part of the Special Issue entitled 'Designer Drugs and Legal Highs.'
Collapse
Affiliation(s)
- Patil Armenian
- Department of Emergency Medicine, University of California, San Francisco-Fresno, 155 N Fresno St., Fresno, CA 93701, USA.
| | - Kathy T Vo
- Department of Emergency Medicine, University of California, San Francisco, California Poison Control System, San Francisco Division, UCSF Box 1369, San Francisco, CA 94143-1369, USA.
| | - Jill Barr-Walker
- University of California, San Francisco, 1001 Potrero Avenue, Library, San Francisco, CA 94110, USA.
| | - Kara L Lynch
- Department of Laboratory Medicine, University of California, San Francisco, 1001 Potrero Avenue, Clinical Chemistry, San Francisco, CA 94110, USA.
| |
Collapse
|
10
|
Armenian P, Darracq M, Gevorkyan J, Clark S, Kaye B, Brandehoff NP. Intoxication from the novel synthetic cannabinoids AB-PINACA and ADB-PINACA: A case series and review of the literature. Neuropharmacology 2017; 134:82-91. [PMID: 29037744 DOI: 10.1016/j.neuropharm.2017.10.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [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: 06/23/2017] [Revised: 09/22/2017] [Accepted: 10/12/2017] [Indexed: 12/21/2022]
Abstract
Synthetic cannabinoids (SC), are a novel class of designer drugs which emerged as a drug of abuse in the late 2000's. We report a case series of 6 patients who may have smoked a synthetic cannabinoid product in a remote wilderness setting. They presented with varying degrees of altered mental status, agitation, and seizures. Two were confirmed to have AB-PINACA, ADB-PINACA and their respective pentanoic acid metabolites in biological specimens via liquid chromatography time-of-flight mass spectrometry (LC-TOF/MS). Both compounds had DEA Schedule I classification at the time of case presentation, and 22 SCs are currently temporary or permanent DEA Schedule I. More than 150 SCs are known to date, and new compounds are appearing at a rapid rate on darknet and surface web e-commerce websites, marketed as "research chemicals" or "legal highs." The scale and rapidity of SC evolution make legal control and analytical detection difficult. Nontargeted testing with liquid chromatography high resolution mass spectrometry (LC-HRMS), examining both parent compounds and metabolites, is the ideal method for novel SC identification and confirmation. Due to full agonism at the cannabinoid receptors CB1 and CB2, clinical effects are more severe than marijuana, which is a partial cannabinoid receptor agonist. They include agitated delirium, lethargy and coma, seizures, tachycardia, hypertension, and hallucinations, among other findings. Treatment is primarily symptomatic and aimed at airway protection and control of agitation and seizures. SCs do not appear to be abating anytime soon and require the cooperation of law enforcement, analytical scientists, and clinicians to adequately control. This article is part of the Special Issue entitled 'Designer Drugs and Legal Highs.'
Collapse
Affiliation(s)
- Patil Armenian
- Department of Emergency Medicine, University of California, San Francisco-Fresno. 155 N Fresno St., Fresno, CA 93701, USA.
| | - Michael Darracq
- Department of Emergency Medicine, University of California, San Francisco-Fresno. 155 N Fresno St., Fresno, CA 93701, USA.
| | - Jirair Gevorkyan
- Central Valley Toxicology, 1580 Tollhouse Rd, Clovis, CA 93611, USA.
| | - Shane Clark
- SkyLife Air Ambulance, 5526 E Aircorp Way, Fresno, CA 93727, USA.
| | - Bryan Kaye
- Department of Emergency Medicine, University of California, San Francisco-Fresno. 155 N Fresno St., Fresno, CA 93701, USA.
| | - Nicklaus P Brandehoff
- Department of Emergency Medicine, University of California, San Francisco-Fresno. 155 N Fresno St., Fresno, CA 93701, USA.
| |
Collapse
|
11
|
Fockele C, Armenian P. A cross-sectional emergency department survey of novel psychoactive substance prevalence. Am J Emerg Med 2017; 35:1580. [DOI: 10.1016/j.ajem.2017.04.057] [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: 03/10/2017] [Revised: 04/22/2017] [Accepted: 04/26/2017] [Indexed: 10/19/2022] Open
|
12
|
Armenian P, Fleurat M, Mittendorf G, Olson KR. Unintentional Pediatric Cocaine Exposures Result in Worse Outcomes than Other Unintentional Pediatric Poisonings. J Emerg Med 2017; 52:825-832. [DOI: 10.1016/j.jemermed.2017.03.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 02/20/2017] [Accepted: 03/08/2017] [Indexed: 01/21/2023]
|
13
|
Armenian P, Campagne D, Stroh G, Ives Tallman C, Zeng WZD, Lin T, Gerona RR. Hot and Cold Drugs: National Park Service Medication Stability at the Extremes of Temperature. PREHOSP EMERG CARE 2017; 21:378-385. [PMID: 28059581 DOI: 10.1080/10903127.2016.1258098] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE National Park Service (NPS) Parkmedics provide medical care in austere environments. The objective of this study was to evaluate the stability of specific medications used by Parkmedics at extremes of temperatures likely to be faced in the field. METHODS This is a bench research study conducted in the laboratory setting over a 4-week period. Parenteral medications were separated into 4 temperature exposure groups: A) 45°C (hot); B) -20°C (cold); C) hot then cold temperatures alternating weekly; and D) cold then hot temperatures alternating weekly. At study start and the end of each week, three aliquots from each group were sampled to determine the remaining drug concentration through liquid chromatography-quadrupole time-of-flight mass spectrometry (Agilent LC 1260- QTOF/MS 6550). Quantitative analysis was done using Agilent MassHunter Quantitative Analysis software. The mean drug concentration from triplicate aliquots was expressed as percentage of its baseline concentration to monitor the drug's stability during storage. RESULTS Eight medications were analyzed (atropine, diphenhydramine, fentanyl, hydromorphone, midazolam, morphine, naloxone, ondansetron). Hydromorphone, morphine, and ondansetron showed the greatest stability, at above 90% of original concentration in all study arms. Diphenhydramine, fentanyl and midazolam showed heat independent degradation, degrading the same way regardless of heat exposure. By the end of the study period, 51-56% midazolam remained in all groups. Atropine and naloxone showed heat dependent degradation, degrading more when exposed to heat. Atropine had the most degradation, being undetectable after 4 weeks of heat exposure. CONCLUSIONS We recommend that EMS providers replace atropine, naloxone, diphenhydramine, fentanyl, and midazolam frequently if they are practicing in low call volume or high-temperature environments. Further studies will be needed to determine if re-dosing midazolam, naloxone, and atropine is the appropriate clinical strategy in this setting if adequate clinical effect is not reached with a single dose.
Collapse
|
14
|
Armenian P, Olson A, Anaya A, Kurtz A, Ruegner R, Gerona RR. Fentanyl and a Novel Synthetic Opioid U-47700 Masquerading as Street “Norco” in Central California: A Case Report. Ann Emerg Med 2017; 69:87-90. [DOI: 10.1016/j.annemergmed.2016.06.014] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Indexed: 01/16/2023]
|
15
|
Doddamreddy P, Tulyagankhodjaev J, Ives C, Armenian P, Vohra R, Balasubramanian V. Critical Illness Associated With Methamphetamine Exposure in the Central Valley of California (CRIME). Chest 2016. [DOI: 10.1016/j.chest.2016.08.346] [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] [Indexed: 10/20/2022] Open
|
16
|
Donkor J, Armenian P, Hartman IN, Vohra R. Analysis of Gastric Lavage Reported to a Statewide Poison Control System. J Emerg Med 2016; 51:394-400. [PMID: 27595368 DOI: 10.1016/j.jemermed.2016.05.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 09/22/2015] [Revised: 04/23/2016] [Accepted: 05/26/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND As decontamination trends have evolved, gastric lavage (GL) has become a rare procedure. The current information regarding use, outcomes, and complications of GL could help refine indications for this invasive procedure. OBJECTIVES We sought to determine case type, location, and complications of GL cases reported to a statewide poison control system. METHODS This is a retrospective review of the California Poison Control System (CPCS) records from 2009 to 2012. Specific substances ingested, results and complications of GL, referring hospital ZIP codes, and outcomes were examined. RESULTS Nine hundred twenty-three patients who underwent GL were included in the final analysis, ranging in age from 9 months to 88 years. There were 381 single and 540 multiple substance ingestions, with pill fragment return in 27%. Five hundred thirty-six GLs were performed with CPCS recommendation, while 387 were performed without. Complications were reported for 20 cases. There were 5 deaths, all after multiple ingestions. Among survivors, 37% were released from the emergency department, 13% were admitted to hospital wards, and 48% were admitted to intensive care units. The most commonly ingested substances were nontricyclic antidepressant psychotropics (n = 313), benzodiazepines (n = 233), acetaminophen (n = 191), nonsteroidal anti-inflammatory drugs (n = 107), diphenhydramine (n = 70), tricyclic antidepressants (n = 45), aspirin (n = 45), lithium (n = 36), and antifreeze (n = 10). The geographic distribution was clustered near regions of high population density, with a few exceptions. CONCLUSIONS Toxic agents for which GL was performed reflected a broad spectrum of potential hazards, some of which are not life-threatening or have effective treatments. Continuing emergency physician and poison center staff education is required to assist in patient selection.
Collapse
Affiliation(s)
- Jimmy Donkor
- Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, California
| | - Patil Armenian
- Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, California
| | - Isaac N Hartman
- Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, California
| | - Rais Vohra
- Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, California; California Poison Control System, Fresno-Madera Division, Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, Madera, California
| |
Collapse
|
17
|
Armenian P, Gerona RR. The electric Kool-Aid NBOMe test: LC-TOF/MS confirmed 2C-C-NBOMe (25C) intoxication at Burning Man. Am J Emerg Med 2014; 32:1444.e3-5. [DOI: 10.1016/j.ajem.2014.04.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 04/18/2014] [Indexed: 10/25/2022] Open
|
18
|
Abstract
Objective: To report a case of life-threatening cinchonism from illicit purchase of chloroquine and survey local ethnic markets to determine what medications are sold without a prescription. Case Report: A 44-year-old Hmong woman presented with abdominal pain and vomiting 30 minutes after ingesting 20 presumed acetaminophen pills in a self-harm gesture. Initial vital signs were normal, and an electrocardiogram (ECG) showed normal sinus rhythm, QRS = 130 ms, and QTc = 455 ms. Her systolic blood pressure dropped to 84 mm Hg, which was unchanged after 3 L normal saline, but improved after 150 mEq NaHCO3. A repeat ECG showed QRS = 114 ms and QTc = 588 ms. Serum labs were significant for K 2.8 mmol/L and Mg 1.8 mg/dL; 2.5 hours later, the family brought in the medication, which was 250 mg tablets of chloroquine phosphate. K and Mg were repleted, and she was admitted to the intensive care unit with complete recovery. Serum chloroquine level 9 hours after ingestion was 530 ng/mL (therapeutic = 20-400 ng/mL). Methods: We identified local ethnic markets through patient and hospital employee referrals and Internet searches. Results: In our survey, 3 of 4 ethnic markets sold prescription medications: 35 were identified, of which 5 are discontinued by the FDA (diphenidol, phenacetin, metamizole, phenylbutazone, and sibutramine). Conclusions: A variety of prescription medications, including 5 discontinued by the FDA, were available in markets serving our community’s ethnic minorities. Health care workers should be aware of this public health risk, which can result in serious toxicity, as described in this case of chloroquine overdose.
Collapse
Affiliation(s)
| | | | - Rais Vohra
- California Poison Control System–Fresno/Madera Division, Madera, CA, USA
| |
Collapse
|
19
|
Manternach S, Armenian P. Finger injury. Arch Emerg Med 2014; 31:352. [DOI: 10.1136/emermed-2013-203085] [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] [Indexed: 11/03/2022]
|
20
|
Abstract
CONTEXT The risk of toxicity from exposure to ergot alkaloid-containing medications in children is uncertain. Due to the alarming historical experience with severe toxicity and the syndrome of ergotism from natural and synthetic ergot alkaloids, triage recommendations for pediatric exposures to medicinal agents containing ergot alkaloids may be inappropriate and inconsistent. OBJECTIVES The goal of this study was to describe the clinical effects of unintentional ergot alkaloid exposures in children and to identify the need for hospitalization in these cases. METHODS This was a retrospective cohort study of all pediatric (< 7 years old) ergot alkaloid exposures reported to the California Poison Control System (CPCS) from 1997 to 2008. Case narratives were reviewed and assessed for patient demographics, ergot alkaloid agent and dose, route of and reason for exposure, symptoms, therapy, hospitalization period, and final outcome. RESULTS Of the 374 cases, 353 met the inclusion criteria. The median age was 24 months (Range: 7-72 months) with more than 99% oral route of exposure. The most frequent clinical effect was gastrointestinal distress (16%), followed by lethargy (5%). Two cases with significant vascular and CNS symptoms were identified, both with complete recovery. For symptomatic patients, all symptoms were there at time of initial presentation. The majority, 62%, of all patients were treated in the hospital setting. The median length of hospital stay was 4 h (Range: 1-36 h). Ergot exposures had a similar number of serious outcomes (moderate or worse effects) compared to all other pediatric poisonings reported to the CPCS during the study period (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.25-3.95), but were associated with a disproportionately higher number of hospitalizations (OR, 13.8; 95% CI, 11.1-17.1). CONCLUSIONS Pediatric ergot exposures were associated with few transient adverse effects but multiple hospitalizations. Rare cases of significant toxicity associated with methylergonovine exposures were found. Current poison control send-in protocols and emergency department (ED) guidelines should consider home management and short ED stays as opposed to lengthy critical care bed admissions.
Collapse
Affiliation(s)
- P Armenian
- Department of Emergency Medicine, University of California , San Francisco-Fresno, Fresno, CA , USA
| | | |
Collapse
|
21
|
Armenian P. The Spotlight That Saw Everything. Acad Emerg Med 2013. [DOI: 10.1111/acem.12238] [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]
Affiliation(s)
- Patil Armenian
- Department of Emergency Medicine; University of California; San Francisco-Fresno; Fresno CA
| |
Collapse
|
22
|
Wu AH, Gerona R, Armenian P, French D, Petrie M, Lynch KL. Role of liquid chromatography–high-resolution mass spectrometry (LC-HR/MS) in clinical toxicology. Clin Toxicol (Phila) 2012; 50:733-42. [DOI: 10.3109/15563650.2012.713108] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
23
|
Armenian P, Mamantov TM, Tsutaoka BT, Gerona RRL, Silman EF, Wu AHB, Olson KR. Multiple MDMA (Ecstasy) overdoses at a rave event: a case series. J Intensive Care Med 2012; 28:252-8. [PMID: 22640978 DOI: 10.1177/0885066612445982] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [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: 11/15/2022]
Abstract
Twelve patients with 3,4-methylenedioxymethamphetamine (MDMA) toxicity from a single rave event presented to multiple San Francisco Bay area hospitals with various life-threatening complications including seizures and hyperthermia. Eight required emergent endotracheal intubation and six had hypotension. Hyperkalemia, acute kidney injury, and rhabdomyolysis were present in most of the patients. In all, 2 patients died, 4 survived with permanent neurologic, musculoskeletal, and/or renal sequelae, and 6 survived without any apparent lasting deficits. Hyperthermia was present in 10 patients and was severe (40.9-43° C) in 7. Using multiple cooling methods, the average time to achieve cooling was 2.7 hours. Serum drug analysis was performed on 3 patients, demonstrating toxic MDMA concentrations without the presence of other xenobiotics. Two capsules confiscated by police at the event contained 82% and 98% MDMA, respectively, without other pharmacologically active compounds. Capsule #2 contained 270 mg MDMA, which is more than twice the amount of MDMA usually contained in 1 dose. The MDMA-induced hyperthermia significantly contributed to the morbidity and mortality in this case series. Factors contributing to the severity of the hyperthermia include ingestion of large doses of MDMA, a warm ambient environment, and physical exertion.
Collapse
Affiliation(s)
- Patil Armenian
- Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, CA 93701, USA.
| | | | | | | | | | | | | |
Collapse
|
24
|
Armenian P, Gerona RR, Blanc PD, Wu AHB, Mookherjee S. 5-oxoprolinemia causing elevated anion gap metabolic acidosis in the setting of acetaminophen use. J Emerg Med 2011; 43:54-7. [PMID: 21978879 DOI: 10.1016/j.jemermed.2011.06.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 02/23/2011] [Accepted: 06/02/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Anion gap metabolic acidosis is typically encountered in the emergency department (ED) setting as the result of shock, other endogenous metabolic derangements, or from exogenous toxicants. The differential diagnosis for toxicant-related acidosis (exemplified by common mnemonics) emphasizes acute overdose. CASE REPORT The case we present manifested an anion gap (AG) metabolic acidosis due to a chronic intoxication: acetaminophen (APAP) overuse over a period of weeks. Lactic acidemia did not account for the AG. In this case, chronic APAP overuse, combined with decreased caloric intake and weight loss, was associated with excess 5-oxoproline (pyroglutamic acid), an organic acid accounting for the AG metabolic acidosis. Overproduction of 5-oxoproline is attributed to depleted glutathione stores, leading to perturbation in the γ-glutamyl cycle. The patient was treated with supportive care and with N-acetylcysteine (NAC). By repleting glutathione, NAC may facilitate the resolution of excess 5-oxoproline. CONCLUSIONS The ED differential diagnosis of AG metabolic acidosis in chronic APAP overuse, especially with concomitant nutritional compromise, should include 5-oxoprolinemia.
Collapse
Affiliation(s)
- Patil Armenian
- Division of Clinical Pharmacology, California Poison Control System, San Francisco Division, San Francisco, California, USA
| | | | | | | | | |
Collapse
|
25
|
French D, Armenian P, Ruan W, Wong A, Drasner K, Olson KR, Wu AHB. Serum verapamil concentrations before and after Intralipid® therapy during treatment of an overdose. Clin Toxicol (Phila) 2011; 49:340-4. [PMID: 21563913 DOI: 10.3109/15563650.2011.572556] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT. Intralipid® infusion is useful in reversing cardiac and central nervous system toxicity of local anesthetic drugs, and recent reports suggest utility in other drug overdoses. CASE DETAILS. A 47-year-old man presented to the emergency department with hypotension and complete heart block 3 h after a sustained-release verapamil overdose. He was given supportive care including calcium and hyperinsulinemia/euglycemia therapy. Nineteen and 29 h post-ingestion, Intralipid® was administered as a bolus, followed by an infusion. OBJECTIVE. The objective of this study was to determine the serum verapamil concentrations before and after Intralipid® administration and to ascertain its clinical effects. DISCUSSION. It was found that administration of Intralipid® was followed by a decrease in verapamil concentration once the lipid had been removed from the sample, demonstrating that Intralipid® was effective in sequestering verapamil, effectively removing it from the serum, and supporting its use in the treatment of verapamil overdose. Intralipid® administration was associated with an increase in the patient's blood pressure, but because other vasoactive drugs were given at the same time, it was difficult to determine its relative contribution to clinical improvement.
Collapse
Affiliation(s)
- Deborah French
- Department of Laboratory Medicine, University of California San Francisco, USA.
| | | | | | | | | | | | | |
Collapse
|
26
|
Weichenthal L, Armenian P, Campgane D, Snowden B, Kallsen G. 48: The Impact of an Intake Model on Patient Care, Resident Education, and Staff Satisfaction at an Academic Emergency Department. Ann Emerg Med 2010. [DOI: 10.1016/j.annemergmed.2010.06.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|