Tetrodotoxin poisoning outbreak from imported dried puffer fish--Minneapolis, Minnesota, 2014

On June 13, 2014, two patients went to the Hennepin County Medical Center Emergency Department in Minneapolis, Minnesota, with symptoms suggestive of tetrodotoxin poisoning (i.e., oral paresthesias, weakness, and dyspnea) after consuming dried puffer fish (also known as globefish) purchased during a recent visit to New York City. The patients said two friends who consumed the same fish had similar, although less pronounced, symptoms and had not sought care. The Minnesota Department of Health conducted an investigation to determine the source of the product and samples were sent to the Food and Drug Administration (FDA) Center for Food Safety and Applied Nutrition for chemical and genetic analysis. Genetic analysis identified the product as puffer fish (Lagocephalus lunaris) and chemical analysis determined it was contaminated with high levels of tetrodotoxin. A traceback investigation was unable to determine the original source of the product. Tetrodotoxin is a deadly, potent poison; the minimum lethal dose in an adult human is estimated to be 2-3 mg. Tetrodotoxin is a heat-stable and acid-stable, nonprotein, alkaloid toxin found in many species of the fish family Tetraodontidae (puffer fish) as well as in certain gobies, amphibians, invertebrates, and the blue-ringed octopus. Tetrodotoxin exerts its effects by blocking voltage-activated sodium channels, terminating nerve conduction and muscle action potentials, leading to progressive paralysis and, in extreme cases, to death from respiratory failure. Because these fish were reportedly purchased in the United States, they pose a substantial U.S. public health hazard given the potency of the toxin and the high levels of toxin found in the fish.

Feasibility of bedside thoracic ultrasound in the helicopter emergency medical services setting

INTRODUCTION

Bedside thoracic ultrasound has been shown to be a valuable diagnostic tool in the emergency department. The purpose of this study was to evaluate the feasibility of bedside thoracic ultrasound in the prehospital HEMS setting.

SETTING

Air ambulance helicopters during patient transportation.

METHODS

This was a prospective pilot study. 71 consecutive, nonpregnant patients over 18 years old were enrolled. While in flight, providers completed limited bedside thoracic ultrasounds with the patient supine and recorded their interpretation of the presence or absence of the ultrasonographic sliding lung sign on a closed data-set instrument.

RESULTS

41 (58%) of the eligible patients had a recorded thoracic ultrasound acquired in flight. The level of agreement in image interpretation between the flight crew and expert reviewer was substantial (Kappa 0.67, CI 0.44-0.90). The reviewer rated 54% of all images as "good" in quality. The most common reason cited for not completing the ultrasound was lack of enough provider time or space limitations within the aircraft cabin.

CONCLUSION

The results of this study suggest that, with limited training, bedside thoracic ultrasound image acquisition and interpretation for the sliding lung sign in the HEMS setting is feasible.

Unexpected arrest-related deaths in america: 12 months of open source surveillance

INTRODUCTION

Sudden, unexpected arrest-related death (ARD) has been associated with drug abuse, extreme delirium or certain police practices. There is insufficient surveillance and causation data available. We report 12 months of surveillance data using a novel data collection methodology.

METHODS

We used an open-source, prospective method to collect 12 consecutive months of data, including demographics, behavior, illicit substance use, control methods used, and time of collapse after law enforcement contact. Descriptive analysis and chi-square testing were applied.

RESULTS

There were 162 ARD events reported that met inclusion criteria. The majority were male with mean age 36 years, and involved bizarre, agitated behavior and reports of drug abuse just prior to death. Law enforcement control techniques included none (14%); empty-hand techniques (69%); intermediate weapons such as TASER((R)) device, impact weapon or chemical irritant spray (52%); and deadly force (12%). Time from contact to subject collapse included instantaneous (13%), within the first hour (53%) and 1-48 hours (35%). Significant collapse time associations occurred with the use of certain intermediate weapons.

CONCLUSION

This surveillance report can be a foundation for discussing ARD. These data support the premise that ARDs primarily occur in persons with a certain demographic and behavior profile that includes middle-aged males exhibiting agitated, bizarre behavior generally following illicit drug abuse. Collapse time associations were demonstrated with the use of TASER devices and impact weapons. We recommend further study in this area to validate our data collection method and findings.

Human research review of the TASER electronic control device

TASER Electronic Control Devices have become mainstream methods of applying electricity to control unruly suspects. There has been speculation that they may be associated with worsening human physiology or death. The lay impressions that these devices are unsafe are not founded on known human research findings. This presentation briefly reviews the most pertinent human research on this subject.

Successful Transcutaneous Pacing in 2 Severely Hypothermic Patients

The clinical condition of profound hypothermia is well described in the medical literature. There have been many case reports and studies describing successful aspects of caring for this problem. Significant bradycardia is a known pathophysiologic consequence of profound hypothermia. Transcutaneous pacing for this condition is not a routine or recommended practice in the literature. This case report details 2 patients with profound hypothermia and resultant bradycardia with hypotension. In both cases, transcutaneous pacing was successfully applied and used as part of the resuscitation. In both cases, transcutaneous pacing was required to maintain an adequate blood pressure so that continuous arteriovenous rewarming could be used during the resuscitation. Both cases had successful outcomes, and the rewarming process was greatly assisted by the pacing procedure.

Cardiovascular and physiologic effects of conducted electrical weapon discharge in resting adults

OBJECTIVES

The TASER is a conducted electrical weapon (CEW) that has been used on people in custody. Individuals occasionally die unexpectedly while in custody, proximal to the application of a CEW. In this study, the authors sought to examine the effects of CEW application in resting adult volunteers to determine if there was evidence of induced electrical dysrhythmia or direct cellular damage that would indicate a causal relationship between application of the device and in-custody death.

METHODS

Human subjects (N = 66) underwent 24-hour monitoring after a standard CEW application. Blood samples were collected before and after exposure and again at 16 and 24 hours after exposure. A subpopulation (n = 32) had 12-lead electrocardiography performed at similar time intervals. Blood samples were analyzed for markers of skeletal and cardiac muscle injury and renal impairment. The electrocardiograms were read by a cardiologist blinded to the study. Data were analyzed using descriptive statistics.

RESULTS

There was no significant change from baseline at any of the four time points for serum electrolyte levels and the blood urea nitrogen/creatinine ratio. An increase in serum bicarbonate and creatine kinase levels was noted at 16 and 24 hours. An increase in serum lactate level was noted immediately after exposure that decreased at 16 and 24 hours. Serum myoglobin level was increased from baseline at all three time points. All troponin levels measured were < 0.3 ng/mL, except for a single value of 0.6 ng/mL in a single subject. This subject was evaluated, and no evidence of acute myocardial infarction or disability was identified. At baseline, 30 of 32 electrocardiograms were interpreted as normal. The two abnormal electrocardiograms were abnormal at baseline and remained the same at all four time points.

CONCLUSIONS

In this resting adult population, the TASER X26 CEW did not affect the recordable cardiac electrical activity within a 24-hour period following a standard five-second application. The authors were unable to detect any induced electrical dysrhythmias or significant direct cardiac cellular damage that may be related to sudden and unexpected death proximal to CEW exposure. Additionally, no evidence of dangerous hyperkalemia or induced acidosis was found. Further study in the area of the in-custody death phenomenon to better understand its causes is recommended.

Use of the endotracheal tube introducer as an adjunct for oral tracheal intubation in the prehospital setting

OBJECTIVE

To prospectively evaluate the effectiveness of the endotracheal tube introducer (ETTI) versus standard orotracheal intubation (SOTI) in the prehospital air medical setting.

METHODS

Critically ill patients were randomized to ETTI versus SOTI based on an odd/even day regimen. Data were collected on initial intubation attempt used, success using initial approach, number of intubation attempts until success, and laryngeal view encountered. The 2 approaches then were compared and statistically analyzed.

RESULTS

Fifty-one patients were entered into the 10-month study; 20 patients were randomized to the ETTI group and 31 to SOTI. Overall success rate for first intubation attempt was 70% for the ETTI and 65% SOTI (P =.67). Total intubation time was 62 seconds (95% CI = 16-108) for the ETTI versus 62 seconds (95% CI = 38-86) for SOTI (P =.4). The ETTI group had a higher percentage of intubating difficult laryngeal views (grade 3 and 4) on first attempts than SOTI.

CONCLUSION

In this study, the authors found the ETTI to be a safe airway adjunct with results equal to SOTI. The ETTI may have a useful role in prehospital airway management.

Vital signs fail to correlate with hemoperitoneum from ruptured ectopic pregnancy

The objective was to determine correlation between vital signs and hemoperitoneum in ruptured ectopic pregnancy. A retrospective chart review of ectopic pregnancies at our urban county hospital between 1990 and 1998 was conducted. Fifty-one cases met inclusion criteria. Mean minimum systolic blood pressure (SBP) 89mmHg (range 40-118), mean maximum heart rate (HR) 101 beats/min (range 62-156). Mean volume of hemoperitoneum 1,050 mL (range 400-2,000 mL). Correlation between vital signs and volume of hemoperitoneum was poor (R(2) = 0.04 for HR, R(2) = 0.1 for SBP). Association of tachycardia with hypotension was also poor (R(2) = 0.1). Extreme individual variations were observed. If surgical decisions were made on the basis of hypotension, 38% of patients could have received either inappropriate additional studies or surgical approach. Patients with normal vital signs had a 20% chance of having class IV blood loss at surgery. HR and blood pressure do not correlate well with volumes of hemoperitoneum from ruptured ectopic pregnancy.

Emergency department right upper quadrant ultrasound is associated with a reduced time to diagnosis and treatment of ruptured ectopic pregnancies

OBJECTIVE

To determine whether the time to diagnosis and treatment of patients with ruptured ectopic pregnancy is significantly less for patients who had emergency department (ED) right upper quadrant (RUQ) ultrasound (US) compared with those who had US in the radiology department.

METHODS

The authors conducted a retrospective review of eligible patients presenting to an urban ED between January 1990 and December 1998. Patients were included in the study if they were seen in the ED, had a discharge diagnosis of ruptured ectopic pregnancy, were brought immediately to the operating room after a definitive diagnosis of ectopic pregnancy rupture was made, and had more than 400 mL of intraperitoneal blood found at the time of surgery. The ED, hospital, radiology, and operative records were reviewed to determine presenting vital signs, intraperitoneal blood loss, time to diagnosis, time to treatment, and type of US performed.

RESULTS

There were 37 patients enrolled; 16 received ED RUQ US (group I) and 21 had a formal US in radiology (group II). The ages, pulses, systolic blood pressures, and volumes of hemoperitoneum were similar between the two groups. The average time to diagnosis from ED arrival was 58 minutes for group I (SD = 57; 95% CI = 28 to 87) and 197 minutes for group II (SD = 82; 95% CI = 162 to 232) (p < or = 0.0001). The average time to operative treatment was 111 minutes (group I) (SD = 86; 95% CI = 69 to 153) and 322 minutes (group II) (SD = 107; 95% CI = 270 to 364) (p < or = 0.0001), respectively.

CONCLUSIONS

Patients with ruptured ectopic pregnancy, who were selected to have RUQ US performed in the ED by emergency physicians, had an average decrease in time to diagnosis of two and a quarter hours, and an average decrease in time to treatment of three and a half hours, compared with those having a formal pelvic US in the radiology department. Further prospective investigation is needed to determine whether ED RUQ US can safely expedite care of patients with suspected ectopic pregnancy.