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Maciulewicz TS, Kazzi Z, Navis IL, Nelsen GJ, Cieslak TJ, Newton C, Lin A, West DJ, Walter FG. Pediatric Medical Countermeasures: Antidotes and Cytokines for Radiological and Nuclear Incidents and Terrorism. Disaster Med Public Health Prep 2024; 18:e76. [PMID: 38651400 PMCID: PMC11047053 DOI: 10.1017/dmp.2024.35] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
The war in Ukraine raises concerns for potential hazards of radiological and nuclear incidents. Children are particularly vulnerable in these incidents and may need pharmaceutical countermeasures, including antidotes and cytokines. Searches found no published study comparing pediatric indications and dosing among standard references detailing pediatric medications for these incidents. This study addresses this gap by collecting, tabulating, and disseminating this information to healthcare professionals caring for children. Expert consensus chose the following references to compare their pediatric indications and dosing of medical countermeasures for radiation exposure and internal contamination with radioactive materials: Advanced Hazmat Life Support (AHLS) for Radiological Incidents and Terrorism, DailyMed, Internal Contamination Clinical Reference, Medical Aspects of Radiation Incidents, and Medical Management of Radiological Casualties, as well as Micromedex, POISINDEX, and Radiation Emergency Medical Management (REMM). This is the first study comparing pediatric indications and dosing for medical countermeasures among commonly used references for radiological and nuclear incidents.
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Affiliation(s)
- Thom S. Maciulewicz
- Arizona Poison and Drug Information Center, College of Pharmacy, University of Arizona, Tucson, Arizona, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona, USA
- Chemical, Biological, Radiological, & Nuclear (CBRN) Focus Group, Pediatric Countermeasures Sub-Group, Western Regional Alliance for Pediatric Emergency Management (WRAP-EM), Oakland, California, USA
| | - Ziad Kazzi
- Chemical, Biological, Radiological, & Nuclear (CBRN) Focus Group, Pediatric Countermeasures Sub-Group, Western Regional Alliance for Pediatric Emergency Management (WRAP-EM), Oakland, California, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Southern Regional Disaster Response System, Atlanta, Georgia, USA
| | - Irene L. Navis
- Chemical, Biological, Radiological, & Nuclear (CBRN) Focus Group, Pediatric Countermeasures Sub-Group, Western Regional Alliance for Pediatric Emergency Management (WRAP-EM), Oakland, California, USA
| | - Gregory J. Nelsen
- Chemical, Biological, Radiological, & Nuclear (CBRN) Focus Group, Pediatric Countermeasures Sub-Group, Western Regional Alliance for Pediatric Emergency Management (WRAP-EM), Oakland, California, USA
- Primary Children’s Hospital, Intermountain Health, Salt Lake City, Utah, USA
| | - Theodore J. Cieslak
- Chemical, Biological, Radiological, & Nuclear (CBRN) Focus Group, Pediatric Countermeasures Sub-Group, Western Regional Alliance for Pediatric Emergency Management (WRAP-EM), Oakland, California, USA
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Christopher Newton
- Chemical, Biological, Radiological, & Nuclear (CBRN) Focus Group, Pediatric Countermeasures Sub-Group, Western Regional Alliance for Pediatric Emergency Management (WRAP-EM), Oakland, California, USA
- University of California San Francisco (UCSF) – Benioff Children’s Hospital, Oakland, California, USA
| | - Anna Lin
- Chemical, Biological, Radiological, & Nuclear (CBRN) Focus Group, Pediatric Countermeasures Sub-Group, Western Regional Alliance for Pediatric Emergency Management (WRAP-EM), Oakland, California, USA
- Division of Pediatric Hospital Medicine, Stanford University, Stanford, California, USA
| | - Doneen J. West
- Chemical, Biological, Radiological, & Nuclear (CBRN) Focus Group, Pediatric Countermeasures Sub-Group, Western Regional Alliance for Pediatric Emergency Management (WRAP-EM), Oakland, California, USA
| | - Frank G. Walter
- Arizona Poison and Drug Information Center, College of Pharmacy, University of Arizona, Tucson, Arizona, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona, USA
- Chemical, Biological, Radiological, & Nuclear (CBRN) Focus Group, Pediatric Countermeasures Sub-Group, Western Regional Alliance for Pediatric Emergency Management (WRAP-EM), Oakland, California, USA
- Department of Emergency Medicine, College of Medicine, University of Arizona, Tucson, Arizona, USA
- Arizona Department of Health Services (ADHS), Phoenix, Arizona, USA
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Al-Sulaimani SK, Al-Balushi H, Al-Balushi A, Panchatcharam SM, Al-Shamsi M, Kazzi Z, Alhatali B. Knowledge, Attitude and Awareness of Oman Emergency Physicians and Residents Regarding Radiation Emergencies - CORRIGENDUM. Disaster Med Public Health Prep 2024; 18:e14. [PMID: 38291956 DOI: 10.1017/dmp.2024.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
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Al-Sulaimani SK, Al-Balushi H, Al-Balushi A, Panchatcharam SM, Al-Shamsi M, Kazzi Z, Al-Hatali B. Knowledge, Attitude and Awareness of Oman Emergency Physicians and Residents Regarding Radiation Emergencies. Disaster Med Public Health Prep 2024; 18:e7. [PMID: 38239015 DOI: 10.1017/dmp.2023.191] [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] [Indexed: 01/23/2024]
Abstract
OBJECTIVE Radiological emergency preparedness and response are increasingly acknowledged as vital components of both emergency readiness and public health. Previous studies have shown that medical providers feel unprepared to respond to radiation incidents. The existing level of knowledge, attitudes, and awareness held by emergency medicine residents and physicians in Oman, remain unexplored. This study aims to evaluate the knowledge, attitude, and awareness level of emergency residents and physicians in Oman regarding the management of radiation emergencies. METHODS An electronic survey was distributed to 44 emergency residents and 57 emergency physicians. RESULTS The response rate was 62.7% (N = 69/110). Notably, 62% reported no prior engagement in radiation emergency training. The majority of participants had neither employed nor received training in operating radiation detection devices. A significant gap in knowledge emerged, with the median self-reported knowledge score of 50/100. The majority of participants (59%) expressed a need for educational programs and materials. CONCLUSION Our findings underscore the imperative for enhanced training in radiological incident preparedness for emergency medicine residents and physicians in Oman. The study reveals a clear necessity to bridge the existing gaps in knowledge and attitudes to bolster the readiness of health-care professionals to respond effectively to radiation emergencies.
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Affiliation(s)
- Suad K Al-Sulaimani
- Emory University, School of Medicine, Department of Emergency Medicine, Division of Medical Toxicology, Atlanta, GA, United States
- Georgia Poison Center, Atlanta, GA, United States
- Armed forces hospital, Department of Emergency Medicine, Oman
| | - Hassan Al-Balushi
- Emory University, School of Medicine, Department of Emergency Medicine, Division of Medical Toxicology, Atlanta, GA, United States
- Georgia Poison Center, Atlanta, GA, United States
- Sohar Hospital, Sohar, Oman
| | | | | | - Mohamed Al-Shamsi
- Armed forces hospital, Department of Emergency Medicine, Oman
- Oman Medical Specialty Board, Muscat, Oman
| | - Ziad Kazzi
- Emory University, School of Medicine, Department of Emergency Medicine, Division of Medical Toxicology, Atlanta, GA, United States
- Georgia Poison Center, Atlanta, GA, United States
| | - Badria Al-Hatali
- Sohar Hospital, Sohar, Oman
- Oman Poison Control Center, MOH, Oman
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Al Sukaiti WS, Al Shuhoumi MA, Al Balushi HI, Al Faifi M, Kazzi Z. Lead Exposure Survey Tool (LEST): A methodological approach to highlight the invisible lead poisoning. MethodsX 2023; 11:102432. [PMID: 38023299 PMCID: PMC10643231 DOI: 10.1016/j.mex.2023.102432] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Lead is the most common heavy metal found in the Earth's crust. Lead has been widely dispersed and incorporated in the natural world since prehistoric times. In the majority of wealthy countries, the amount of lead entering the atmosphere has been significantly reduced. Acute lead exposure becomes relatively low, but chronic lead exposure remains a substantial public health hazard. Disadvantaged people, are developing and industrializing countries in the Middle East and North Africa (MENA). Between 1981 and 2018, a comprehensive literature search was undertaken in the PubMed and Scopus databases. All studies were evaluated equally based on predetermined inclusion and exclusion criteria. The Delphi method was used to identify numerous resources of lead pollutants. The Mixed Method Appraisal Tool (MMAT) was used to evaluate the quality of identified papers for inclusion in the systematic review synthesis. The studies and sources of lead toxicology were further evaluated using a scale of evidence to establish the degree of evidence based on SIGN & GRADE standards. There were 14 genres and 82 subgenres identified. Through a comprehensive analysis, our cohort developed an exposure survey tool that takes into account the local sociocultural aspects of MENA countries, which will serve as a resource forresearchers, medical toxicologists, and public health professionals in the MENA region to enhance early detection of potential subjects, conduct further studies and implement exposure prevention strategies.•There is no single tool available to detect the invisible lead poison. Lead poisoning is a serious public health problem that can have devastating consequences.•The tool, called the Lead Exposure Survey Tool (LEST), uses a combination of but not limited to data sources, including blood lead levels, environmental lead levels, and demographic information, to identify subjects who are at risk of lead poisoning. LEST is a powerful tool that can help to improve early detection and prevention of lead poisoning.•The development of LEST is a major breakthrough in the fight against lead poisoning. This tool has the potential to save lives and improve the health of high risk subjects around the world.
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Affiliation(s)
- Waleed S. Al Sukaiti
- Department of Emergency Medicine, Ibri Regional Hospital, MOH, Oman
- Oman Poison Control Center, MOH, Muscat, Oman
- Emory University School of Medicine, Atlanta, GA, USA
| | - Mohammed Abdullah Al Shuhoumi
- Medical Laboratory Scientist and Research Focal Point, Laboratory Department, Ibri Hospital, Oman
- Academic Lecturer, Oman College of Health Sciences, Oman
- Reviewer and Member at Centre of Studies and Research, Oman
| | - Hassan I. Al Balushi
- Oman Poison Control Center, MOH, Muscat, Oman
- Emory University School of Medicine, Atlanta, GA, USA
- Department of Emergency Medicine, Sohar Hospital, MOH, Oman
- Georgia Poison Control Center, Atlanta, GA, USA
| | - Musa Al Faifi
- Emory University School of Medicine, Atlanta, GA, USA
- Aseer Central Hospital KSA, Saudi Arabia
| | - Ziad Kazzi
- Emory University School of Medicine, Atlanta, GA, USA
- Georgia Poison Control Center, Atlanta, GA, USA
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Feldman RJ, Kazzi Z, Walter FG. Radiation Injuries: Acute Radiation Syndrome in Children. Pediatr Ann 2023; 52:e231-e237. [PMID: 37280005 DOI: 10.3928/19382359-20230411-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The conflict in Ukraine has raised the specter of radiological and nuclear incidents, including fighting at the Zaporizhzhia nuclear plant, the largest nuclear powerplant in Europe; concerns that a radiological dispersion device ("dirty bomb") may be used; and threats to deploy tactical nuclear weapons. Children are more susceptible than adults to immediate and delayed radiation health effects. This article reviews the diagnosis and treatment of acute radiation syndrome. Although definitive treatment of radiation injuries should involve consultation with specialists, nonspecialists should learn to recognize the distinctive signs of radiation injury and make an initial assessment of severity of exposure. [Pediatr Ann. 2023;52(6):e231-e237.].
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El Zahran T, Al Hassan S, Khalifeh M, Aboukhater D, Hammoud L, Al Hariri M, Kazzi Z. Melitracen and flupentixol (deanxit) use disorder in Lebanon. Heliyon 2023; 9:e15847. [PMID: 37215807 PMCID: PMC10195893 DOI: 10.1016/j.heliyon.2023.e15847] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/27/2023] [Accepted: 04/24/2023] [Indexed: 05/24/2023] Open
Abstract
Introduction Deanxit is a combination of melitracen and flupentixol, not approved as an antidepressant for sale and use in several countries but still widely available and commonly used among the Lebanese population. The study aimed to assess Deanxit use disorder, assess the source of the medication, and the consumers' awareness of the therapeutic and side effects of Deanxit, among the Lebanese population. Methods This is a cross-sectional study that included all patients taking Deanxit and visited the Emergency Department between October 2019 and October 2020. All patients who agreed to participate in the research through written consent forms were contacted by telephone and a questionnaire was filled out. Results A total of 125 patients taking Deanxit were included in the study. According to the DSM-V criteria, 36% (n = 45) had a Deanxit use disorder. Most of the participants were females (n = 99, 79.2%), married (n = 90, 72%), and between the ages of 40-65 years (n = 71, 56.8%). Most patients (n = 41, 91%) had Deanxit prescribed by a physician for anxiety (n = 28, 62%), and obtained it using a prescription (n = 41, 91%). Almost half of all patients (n = 60, 48%) did not have sufficient knowledge of the reason it was prescribed, 54.4% (n = 68) were not sure they are taking the medication appropriately, and 19.2% (n = 23) were satisfied by the overall explanation of the physicians concerning Deanxit use. Conclusion Deanxit use disorder is underrecognized among Lebanese patients. Most of our patients were prescribed Deanxit by their physicians but reported inadequate knowledge of its side effects and risk of abuse.
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Affiliation(s)
- Tharwat El Zahran
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Sally Al Hassan
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Malak Khalifeh
- Stony Brook Cancer Center, Stony Brook University, NY, USA
| | - Diana Aboukhater
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Lina Hammoud
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Moustafa Al Hariri
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ziad Kazzi
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA
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Özer V, Küçük AO, Eroğlu A, Güven KY, Ketenci HÇ, Şahin A, Kazzi Z. Successful Management of Severe Verapamil Overdose with VAECMO. Eurasian J Emerg Med 2022. [DOI: 10.4274/eajem.galenos.2021.05900] [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: 12/14/2022] Open
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Isakadze N, Kazzi Z, Bantsadze T, Gotsadze G, Butkhikridze N, El Chami M, Papiashvili G. UPDATED ATRIAL FIBRILLATION MANAGEMENT RECOMMENDATIONS FOR GEORGIAN HOSPITALS BASED ON THE 2020 EUROPEAN SOCIETY OF CARDIOLOGY ATRIAL FIBRILLATION GUIDELINES. Georgian Med News 2022:13-16. [PMID: 36780615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and a major public health problem. Recently substantial new evidence has accumulated regarding AF care. Furthermore, advances in technology for AF diagnosis and management have been made. 2020 European Society of Cardiology AF guideline document reflects recent evidence and contains several major updates in various aspects of AF management including rhythm control, anticoagulation, and risk factor modification. The objective of this report is to provide a summary of the 2020 European Society of Cardiology AF guideline recommendations for the management of AF for Georgian clinicians and to help promote AF management in an evidence-based manner.
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Affiliation(s)
- N Isakadze
- 1Johns Hopkins University, Department of Medicine, Division of Cardiology, Baltimore, Maryland, USA; 2Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Baltimore, Maryland, USA; 3Johns Hopkins Center for Mobile Technologies to Achieve Equity in Cardiovascular Health, Baltimore, Maryland, USA
| | - Z Kazzi
- 4Emory University, Department of Emergency Medicine, Atlanta, Georgia, USA
| | | | | | | | - M El Chami
- 7Emory University, Department of Medicine, Division of Cardiology, Atlanta, Georgia, USA
| | - G Papiashvili
- 8David Tvildiani Medical University, Tbilisi, Georgia; 9The Jo Ann Medical Center, Tbilisi, Georgia; 10Helsicore - Israeli-Georgian Medical Research Clinic, Tbilisi, Georgia
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Al-Sulaimani S, Titelbaum NV, Ward RE, Zahran TE, Chalhoub S, Kazzi Z. Case Report of Tetrodotoxin Poisoning from Lagocephalus sceleratus in Lebanon. Int J Environ Res Public Health 2022; 19:14648. [PMID: 36429360 PMCID: PMC9690907 DOI: 10.3390/ijerph192214648] [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] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/28/2022] [Accepted: 11/03/2022] [Indexed: 06/16/2023]
Abstract
The Indo-Pacific pufferfish Lagocephalus sceleratus is a tetrodotoxin-containing species believed to have entered the Mediterranean Sea through the Suez Canal. Tetrodotoxin (TTX) is primarily found in the liver, intestine, and ovaries of L. sceleratus. We report a case of a patient with TTX poisoning from L. sceleratus consumption in Lebanon. History of ingestion, clinical presentation, and exam findings were obtained during phone-based consultation with the patient and intensive care physician. A 46-year-old male presented to a hospital in Lebanon with perioral and extremity numbness as well as dizziness 1 h after ingestion of an L. sceleratus fish. He had caught and prepared the fish himself and had eaten a skinless piece of flesh. Over the following 6 h he also developed ataxia and generalized body numbness. His treatment included systemic hydrocortisone, antihistamine, activated charcoal, and fluids. He was admitted to the intensive care unit, where he developed self-limited, stable sinus bradycardia. He was discharged home on hospital day 5 with residual lightheadedness that improved over several days. This is one of the first reported cases of tetrodotoxin poisoning due to L. sceleratus in Lebanon. Public awareness regarding the toxicity of this species after any ingestion is essential to prevent toxicity and death.
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Affiliation(s)
- Suad Al-Sulaimani
- Division of Medical Toxicology, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA 30307, USA
- Georgia Poison Center, Atlanta, GA 30303, USA
| | - Nicholas Vincent Titelbaum
- Division of Medical Toxicology, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA 30307, USA
- Georgia Poison Center, Atlanta, GA 30303, USA
| | - Ricardo El Ward
- Department of Internal Medicine, Faculty of Medical Sciences, Rafic Hariri University Campus, Lebanese University, Hadath 6573, Lebanon
| | - Tharwat El Zahran
- Division of Medical Toxicology, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA 30307, USA
- Department of Emergency Medicine, Faculty of Medicine, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
| | - Sana Chalhoub
- Department of Emergency Medicine, Faculty of Medicine, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
| | - Ziad Kazzi
- Division of Medical Toxicology, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA 30307, USA
- Georgia Poison Center, Atlanta, GA 30303, USA
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Meisel EM, Morgan B, Schwartz M, Kazzi Z, Cetin H, Sahin A. Two Cases of Severe Amanita Muscaria Poisoning Including a Fatality. Wilderness Environ Med 2022; 33:412-416. [DOI: 10.1016/j.wem.2022.06.002] [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: 03/18/2022] [Revised: 06/02/2022] [Accepted: 06/19/2022] [Indexed: 11/21/2022]
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El Zahran T, Kanaan E, Kobeissi L, Bouassi J, Sarieddine A, Carpenter J, Kazzi Z, Hitti E. Benzodiazepine use disorder: A cross-sectional study at a tertiary care center in Lebanon. Medicine (Baltimore) 2022; 101:e30762. [PMID: 36197240 PMCID: PMC9509078 DOI: 10.1097/md.0000000000030762] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Benzodiazepines are medications used for the treatment of multiple conditions including anxiety disorders, insomnia, agitation, and seizures. They are the most prescribed psychiatric medications and the third most misused drugs among adults and adolescents in the US. This study aims to assess the patient utilization patterns and benzodiazepine use disorder among Lebanese patients. A cross-sectional study was performed on Lebanese patients presenting to the Emergency Department of the American University of Beirut Medical Center (AUBMC), between November 11th, 2019, and May 30th, 2020. Institutional review board approved the study, and an informed consent was obtained from patients. A total of 244 patients were included in the final analysis. A total of 154 (63.1%) patients were found to have benzodiazepine use disorder as per the DSM-V criteria with the majority (64%) being females and young adults aged 18 to 40 years. The most common medication was alprazolam, and anxiety was the most common reason for benzodiazepine use. The majority (88%) of patients obtained their medications using a physician's prescription. More than half of users were not satisfied with the physician's instructions and lacked knowledge about side effects and abuse potential. The high rate of benzodiazepine misuse among our young adults highlights an important public health concern that requires interventions and policy implementation.
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Affiliation(s)
- Tharwat El Zahran
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- *Correspondence: Tharwat El Zahran, Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, 1107 2020, Lebanon (e-mail: )
| | - Elie Kanaan
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Lynn Kobeissi
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Joseph Bouassi
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Aseel Sarieddine
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Joseph Carpenter
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA
| | - Ziad Kazzi
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA
| | - Eveline Hitti
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Tabbara F, Abdul Nabi SS, Sadek R, Kazzi Z, El Zahran T. A Case Report of a Lebanon Viper (Montivipera bornmuelleri) Envenomation in a Child. Clin Pract Cases Emerg Med 2022; 6:318-322. [PMID: 36427039 PMCID: PMC9697889 DOI: 10.5811/cpcem.2022.2.56176] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/12/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Snake envenomation is a serious public health concern. In the Middle East little is known about snakebite envenomation, which raises several challenges for emergency physicians caring for these patients. CASE REPORT We report the case of a five-year-old boy bitten by a rare snake, Montivipera bornmuelleri, who presented to an emergency department in Lebanon. We also discuss the proper management of snake envenomation. CONCLUSION This case is unique as snakebites in Lebanon are poorly studied, and little is known about the epidemiology and clinical manifestations of local snakebites.
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Affiliation(s)
- Faysal Tabbara
- American University of Beirut, Department of Emergency Medicine, Beirut, Lebanon
| | - Sarah S Abdul Nabi
- American University of Beirut, Department of Emergency Medicine, Beirut, Lebanon
| | - Riad Sadek
- American University of Beirut, Department of Biology, Beirut, Lebanon
| | - Ziad Kazzi
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - Tharwat El Zahran
- American University of Beirut, Department of Emergency Medicine, Beirut, Lebanon
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Farah R, Kazzi Z, Brent J, Burkhart K, Wax P, Aldy K. Ivermectin associated adverse events in the treatment and prevention of COVID-19 reported to the FACT pharmacovigilance project. Clin Toxicol (Phila) 2022; 60:942-946. [PMID: 35535587 DOI: 10.1080/15563650.2022.2070187] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND In August 2021, the Centers for Disease Control and Prevention (CDC) released a health alert following the rapid increase in ivermectin prescriptions and reports of severe illness associated with use of products containing ivermectin for the prevention or treatment of COVID-19 infections. The United States Food and Drug Administration (FDA) and the CDC have explicitly discouraged the use of ivermectin in the prevention or treatment of COVID-19 outside of clinical trials. The study aims to describe the adverse events (AEs) related to ivermectin use for the prevention or treatment of COVID-19. METHODS This is a prospective case series of adverse events related to therapeutics used in the prevention or treatment of COVID-19 submitted to the FDA ACMT COVID-19 ToxIC (FACT) Pharmacovigilance Project sub-registry between October 2020 and December 2021. This is an ongoing toxico-surveillance system at 15 major academic medical centers in 12 states. Data collected included sociodemographics, exposure related information including dose, frequency, route, duration, and reason for taking ivermectin as well as a clinical description of the adverse event and the outcome. RESULTS A total of 40 patients who developed AEs following ivermectin use were reported to FACT over 15 months. Self-medication with veterinary formulations were reported in 18/40 patients Thirty-three patients presented to emergency departments and nineteen patients were admitted to the hospital. Patients reported using ivermectin for prevention (24/40), treatment of symptoms (19/40), and for treatment of documented COVID-19 (8/40). Neurological toxicity was the most frequent finding. Fifteen patients had minor symptoms while 25 developed severe toxicity. CONCLUSIONS Ivermectin use for the attempted treatment of COVID-19 has potential adverse health effects primarily related to neurological function. This is especially true when patients are self-treating with this medication and when they are using formulations intended for non-human use.
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Affiliation(s)
- Rita Farah
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.,Georgia Poison Center, Atlanta, GA, USA
| | - Ziad Kazzi
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.,Georgia Poison Center, Atlanta, GA, USA
| | - Jeffrey Brent
- School of Medicine, University of Colorado, Aurora, CO, USA
| | - Keith Burkhart
- United States Food and Drug Administration, Rockville, MD, USA
| | - Paul Wax
- American College of Medical Toxicology, Phoenix, AZ, USA.,University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kim Aldy
- American College of Medical Toxicology, Phoenix, AZ, USA.,University of Texas Southwestern Medical Center, Dallas, TX, USA
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- American College of Medical Toxicology, Phoenix, AZ, USA
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Cohen N, Mathew M, Davis A, Brent J, Wax P, Schuh S, Freedman SB, Froberg B, Schwarz E, Canning J, Tortora L, Hoyte C, Koons AL, Burns MM, McFalls J, Wiegand TJ, Hendrickson RG, Judge B, Quang LS, Hodgman M, Chenoweth JA, Algren DA, Carey J, Caravati EM, Akpunonu P, Geib AJ, Seifert SA, Kazzi Z, Othong R, Greene SC, Holstege C, Tweet MS, Vearrier D, Pizon AF, Campleman SL, Li S, Aldy K, Finkelstein Y. Predictors of severe outcome following opioid intoxication in children. Clin Toxicol (Phila) 2022; 60:702-707. [PMID: 35333145 DOI: 10.1080/15563650.2022.2038188] [Citation(s) in RCA: 2] [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: 01/26/2023]
Abstract
INTRODUCTION While the opioid crisis has claimed the lives of nearly 500,000 in the U.S. over the past two decades, and pediatric cases of opioid intoxications are increasing, only sparse data exist regarding risk factors for severe outcome in children following an opioid intoxication. We explore predictors of severe outcome (i.e., intensive care unit [ICU] admission or in-hospital death) in children who presented to the Emergency Department with an opioid intoxication. METHODS In this prospective cohort study we collected data on all children (0-18 years) who presented with an opioid intoxication to the 50 medical centers in the US and two international centers affiliated with the Toxicology Investigators Consortium (ToxIC) of the American College of Medical Toxicology, from August 2017 through June 2020, and who received a bedside consultation by a medical toxicologist. We collected relevant demographic, clinical, management, disposition, and outcome data, and we conducted a multivariable logistic regression analysis to explore predictors of severe outcome. The primary outcome was a composite severe outcome endpoint, defined as ICU admission or in-hospital death. Covariates included sociodemographic, exposure and clinical characteristics. RESULTS Of the 165 (87 females, 52.7%) children with an opioid intoxication, 89 (53.9%) were admitted to ICU or died during hospitalization, and 76 did not meet these criteria. Seventy-four (44.8%) children were exposed to opioids prescribed to family members. Fentanyl exposure (adjusted OR [aOR] = 3.6, 95% CI: 1.0-11.6; p = 0.03) and age ≥10 years (aOR = 2.5, 95% CI: 1.2-4.8; p = 0.01) were independent predictors of severe outcome. CONCLUSIONS Children with an opioid toxicity that have been exposed to fentanyl and those aged ≥10 years had 3.6 and 2.5 higher odds of ICU admission or death, respectively, than those without these characteristics. Prevention efforts should target these risk factors to mitigate poor outcomes in children with an opioid intoxication.
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Affiliation(s)
- Neta Cohen
- Division of Paediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Mathew Mathew
- Division of Paediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Adrienne Davis
- Division of Paediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Jeffrey Brent
- Department of Internal Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Paul Wax
- Southwestern School of Medicine, University of Texas, Dallas, TX, USA
| | - Suzanne Schuh
- Division of Paediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Stephen B Freedman
- Department of Paediatrics and Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Blake Froberg
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | - Laura Tortora
- Banner - University Medical Centre, Phoenix, AZ, USA
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO, USA
| | - Andrew L Koons
- Lehigh Valley Health Network, USF Morsani College of Medicine, Allentown, PA, USA
| | | | - Joshua McFalls
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Bryan Judge
- Spectrum Health - Michigan State University, Grand Rapids, MI, USA
| | - Lawrence S Quang
- Arkansas Children's Hospital/University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Douglas A Algren
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Jennifer Carey
- University of Massachusetts Medical School, Worcester, MA, USA
| | | | | | | | | | - Ziad Kazzi
- Emory University School of Medicine, Atlanta, GA, USA
| | - Rittirak Othong
- Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | | | | | | | - David Vearrier
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Anthony F Pizon
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Shao Li
- American College of Medical Toxicology, Phoenix, AZ, USA
| | - Kim Aldy
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yaron Finkelstein
- Division of Paediatric Emergency Medicine, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,University of Toronto, Toronto, Canada.,Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
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15
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El Zahran T, Mostafa H, Hamade H, Al Hariri M, Saab A, Tamim H, Tohme R, Al Hamod DA, Sinno D, Sawaya RD, Kazzi Z. Lead screening in children presenting to three hospitals in Lebanon. Arch Dis Child 2022; 107:251-256. [PMID: 34429329 DOI: 10.1136/archdischild-2021-322012] [Citation(s) in RCA: 1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 08/10/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Lead damages most body organs and its effects are most profound in children. In a study in Beirut in 2003, before banning the leaded gasoline, 79% of the participants showed blood lead levels (BLLs) higher than 5 µg/dL. The prevalence of lead exposure in Lebanon after the ban on leaded gasoline has not been studied. This study assessed the BLL in Lebanese children aged 1-6 years. METHODS This cross-sectional study was conducted in three hospitals in Beirut. The children's BLLs were tested, and their caregiver completed a questionnaire to identify subgroups at risk of exposure. Participants were provided with a WHO brochure highlighting the risks of lead. RESULTS Ninety children with a mean age of 3.5±1.5 years were enrolled in the study and had a mean BLL of 1.1±0.7 µg/dL, with all values being below 5.0 µg/dL, showing a marked decrease in BLL compared with the mean BLL before the ban on leaded gasoline in 2002. Having a father or a mother with a college degree (p=0.01 and p=0.035, respectively) and having a monthly household income greater than $1000 (p=0.021) were associated with significantly lower BLL. Having more rooms at home and residing close to construction sites were associated with a significantly lower BLL (p=0.001 and p=0.026, respectively). Residing in a house aged >40 years and receiving traditional remedies were associated with a significantly higher BLL (p=0.009 and p<0.0001, respectively). CONCLUSION BLLs have declined among Lebanese children and this could be attributed to multiple factors including the ban of leaded gasoline. It would be beneficial to conduct a larger study with a nationally representative sample to better characterise the BLL.
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Affiliation(s)
- Tharwat El Zahran
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hala Mostafa
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Hamade
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Moustafa Al Hariri
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Aed Saab
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Tamim
- Biostatistics Unit, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rasha Tohme
- Department of Pediatrics, Saint George Hospital University Medical Center, Beirut, Lebanon
| | - Dany A Al Hamod
- Department of Pediatrics, Saint George Hospital University Medical Center, Beirut, Lebanon
| | - Durriyah Sinno
- Department of Pediatrics, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rasha Dorothy Sawaya
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ziad Kazzi
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon.,Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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16
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Goldfine C, Lung D, Beauchamp G, O'Connor A, Stolbach A, Kao L, Judge B, Wax P, Patwari R, Kazzi Z. Consensus Development of a Core Content for a Standardized Medical Toxicology Curriculum for Medical Students. J Med Toxicol 2022; 18:139-144. [PMID: 35089533 PMCID: PMC8796743 DOI: 10.1007/s13181-021-00874-z] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 11/16/2022] Open
Abstract
Background Currently, no standardized core content in medical toxicology exists for medical students. The goals of this study were to (1) assess the current state and needs of medical toxicology clerkships and (2) develop a consensus-derived list of core topics that should be covered during a medical toxicology clerkship. Methods We assembled a task force established by the American College of Medical Toxicology (ACMT) of nine experts in medical toxicology or emergency medicine. We developed a needs assessment survey that was sent to all medical student clerkship directors in medical toxicology. Based on their responses, we used a modified Delphi process to develop a consensus of core topics that should be covered during a medical student clerkship. Results Nineteen out of 42 (45%) clerkship directors completed the survey; 18 met inclusion criteria. The majority of clerkships were 4 weeks in duration with an average of 15 students/year. The three most common teaching methods used were bedside teaching (n = 17/18), classroom teaching (n = 17/18), and journal club (n = 14/18). All the clerkship directors (n = 18/18) reported they would use a standardized curriculum as well as educational content developed by ACMT. There was overwhelming consensus on the core topics which included, but were not limited to, pharmacology/toxicology; drugs; drugs of abuse; natural products; pharmacological basis of antidote use; toxicologic syndromes; vital sign abnormalities; initial management; supportive and other care; withdrawal syndrome management; industrial, household, and environmental toxins; differential diagnosis by clinical findings; and ABCs-resuscitation. Conclusion The ACMT task force developed a medical toxicology clerkship core content. The task force also identified a need for shared resources among clerkships.
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Affiliation(s)
- Charlotte Goldfine
- Division of Medical Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Derrick Lung
- Division of Clinical Pharmacology and Medical Toxicology, Department of Emergency Medicine, San Mateo Medical Center, San Mateo, CA, USA
| | - Gillian Beauchamp
- Department of Emergency and Hospital Medicine, Division of Medical Toxicology, Lehigh Valley Health Network, University of South Florida Morsani College of Medicine, Allentown, PA, USA
| | - Ayrn O'Connor
- Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Andrew Stolbach
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Louise Kao
- Department of Emergency Medicine, Division of Medical Toxicology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bryan Judge
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Paul Wax
- Southwestern School of Medicine, University of Texas, Dallas, TX, USA
| | | | - Ziad Kazzi
- Georgia Poison Center, Emory University, Atlanta, GA, USA
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17
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Calello DP, Kazzi Z, Stolbach A. American College of Medical Toxicology (ACMT) Cautions Against Off-Label Prescribing of Ivermectin for the Prevention or Treatment of COVID-19. J Med Toxicol 2022; 18:69-70. [PMID: 35006547 PMCID: PMC8744041 DOI: 10.1007/s13181-021-00866-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 10/27/2021] [Accepted: 11/02/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
| | | | - Andrew Stolbach
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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18
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Alhatali B, Al Lawatia S, Khamis F, Kantur S, Al-Abri S, Kapil V, Thomas J, Johnson R, Hamelin EI, Coleman RM, Kazzi Z. A cluster of tetrodotoxin poisoning in Oman. Clin Toxicol (Phila) 2021; 60:262-266. [PMID: 33913398 DOI: 10.1080/15563650.2021.1917595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Tetrodotoxin (TTX) is a potent sodium channel blocker, with significant neurotoxicity, found in marine animals like pufferfish and blue-ringed octopus. The severity of toxicity depends on the amount of toxin ingested and the outcome depends on the time-lapse to appropriate medical care. CASES REPORT We report five patients who presented with tetrodotoxin poisoning after consuming fried internal organs of local pufferfish from the coast of Oman. The patients' clinical manifestations were consistent with the expected TTX toxidrome of perioral and generalized paresthesia, weakness of upper and lower extremities, gastrointestinal manifestations, dyspnea, dysarthria, ascending paralysis, hypotension, bradycardia and coma. The severity varied among the patients who recovered completely except one patient who developed a subarachnoid hemorrhage without underlying aneurysms on computed tomography-angiogram. This complication was potentially related to TTX poisoning and has not been previously reported. In addition to standard supportive management, patients with severe illness should potentially receive the intravenous acetylcholinesterase inhibitor neostigmine, and intermittent dialysis. Urine specimens were sent to CDC in Atlanta, where they were analyzed using online solid phase extraction (SPE) with LC-MS/MS and confirmed the diagnosis in all five cases. DISCUSSION In general, the patients' clinical manifestations were consistent with the expected TTX toxidrome except patient 3 who developed a subarachnoid hemorrhage early during his clinical course. Two patients received neostigmine and underwent dialysis with complete recovery.
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Affiliation(s)
- Badria Alhatali
- Department of Environmental and Occupational Health, Directorate General for Disease Surveillance and Control, Ministry of Health, Muscat, Oman
| | | | - Faryal Khamis
- Infectious Diseases Unit, Department of Internal Medicine, Royal Hospital, Muscat, Oman
| | | | - Seif Al-Abri
- Directorate General for Disease Surveillance and Control, Ministry of Health, Muscat, Oman
| | - Vikas Kapil
- Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Jerry Thomas
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rudolph Johnson
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Elizabeth I Hamelin
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rebecca M Coleman
- National Biodefense Analysis and Countermeasures Center, Ft. Detrick, Frederick, MD, USA
| | - Ziad Kazzi
- Emory University School of Medicine, Atlanta, GA, USA
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19
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Hitti E, El Zahran T, Hamade H, Morgan BW, Kazzi Z. Telephonic Medical Toxicology Service in a Low-Resource Setting: Setup, Challenges, and Opportunities. West J Emerg Med 2021; 22:450-453. [PMID: 33856338 PMCID: PMC7972382 DOI: 10.5811/westjem.2020.10.48534] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/16/2020] [Indexed: 11/24/2022] Open
Abstract
Poisoning and envenomation are a global health problem for which the mortality burden is shouldered heavily by middle- and low-income countries that often lack poison prevention programs and medical toxicology expertise. Although telehealth or teleconsult services have been used to bridge the expertise gap between countries for multiple specialties, the use of medical toxicology teleconsult services across borders has been limited. We aim to describe the use of a United States-based medical toxicology teleconsult service to support patient care at a hospital in a middle-income country that lacks this expertise. This report outlines the logistics involved in setting up such a service, including the challenges and opportunities that emerged from establishing medical toxicology teleconsult service in a low-resource setting.
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Affiliation(s)
- Eveline Hitti
- American University of Beirut, Department of Emergency Medicine, Beirut, Lebanon
| | - Tharwat El Zahran
- American University of Beirut, Department of Emergency Medicine, Beirut, Lebanon
| | - Hani Hamade
- American University of Beirut, Department of Emergency Medicine, Beirut, Lebanon
| | - Brent W Morgan
- Emory University, Department of Emergency Medicine, Atlanta, Georgia
| | - Ziad Kazzi
- American University of Beirut, Department of Emergency Medicine, Beirut, Lebanon.,Emory University, Department of Emergency Medicine, Atlanta, Georgia
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20
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El Zahran T, Mostafa H, Hamade H, Hitti E, Morgan BW, Kazzi Z. Toxicological exposures among the pediatric patients at a tertiary care center in Lebanon: the case for establishing a national poison center. Clin Toxicol (Phila) 2021; 59:780-785. [PMID: 33555968 DOI: 10.1080/15563650.2021.1874404] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Despite its preventable nature, poisoning remains one of the leading causes of morbidity and mortality in the pediatric population. In Lebanon, this population is poorly studied and there is no poison center to which healthcare providers and the public can refer in case of toxicological exposure, leading to unnecessary Emergency Department (ED) visits. This study describes the pediatric toxicological exposures seen at the largest tertiary care center in Lebanon. It also evaluates the appropriateness of ED visits among confirmed or suspected toxicological exposures in children, in order to assess the role of a national poison center in reducing unnecessary ED visits. METHODS This is a secondary analysis of a database for a telephonic medical toxicology service at the American University of Beirut Medical Center, the largest tertiary care center in Lebanon. Data relating to all pediatric patients aged 0-19 years of age were entered into the database by the medical toxicology team. The cases were independently reviewed by 2 medical toxicologists for the adequacy of referral to the ED and performance of invasive procedures. RESULTS Two hundred and nine exposures were recorded between 15 April 2015 and 31 December 2019, of which 53.1% were females. Children aged less than 5 years were involved in 67.0% of cases while adolescents aged 13-19 years were involved in 21.1%. The most commonly involved substances were analgesics (14.8%) and cardiovascular drugs (10.0%). The majority had no (59.3%) or minor (26.3%) effects and were treated and discharged home (67.5%). More than a third of ED visits were deemed unnecessary by the toxicologists (Kappa = 0.705), and when including only unintentional cases, around 45% of the ED visits were deemed unnecessary (Kappa = 0.677). CONCLUSION Our data show that 37% of all pediatric poisoning ED visits and 45% of ED visits due to unintentional pediatric poisonings were unnecessary. Additionally, more often than not lavage suctions were done unnecessarily. Future research investigating the possibility of preventing unnecessary visits by establishing a national poison center is needed.
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Affiliation(s)
- Tharwat El Zahran
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hala Mostafa
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Hamade
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Eveline Hitti
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Brent W Morgan
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA
| | - Ziad Kazzi
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon.,Department of Emergency Medicine, Emory University, Atlanta, GA, USA
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21
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Hamade H, Sahin A, Sukhn C, El Tawil C, Rizk J, Kazzi Z, El Zahran T. Human Zinc Phosphide Exposure in Lebanon: A Case Report and Review of the Literature. Clin Pract Cases Emerg Med 2021; 5:50-57. [PMID: 33560952 PMCID: PMC7872605 DOI: 10.5811/cpcem.2020.10.47397] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 10/05/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction Toxicity from rodenticides such as metal phosphides is common worldwide, particularly in developing countries where consumers have access to unlabeled and uncontrolled insecticides and pesticides. Case Report We present the first documentation of a metal phosphide exposure in Lebanon. A middle-aged woman presented to the emergency department following the ingestion of an unknown rodenticide. Spectroscopy analysis of the sample brought by the patient was used and helped identify zinc phosphide. The patient developed mild gastrointestinal symptoms and was admitted to the intensive care unit for observation without further complications. Review We subsequently conducted a literature review to understand the diagnosis, pathophysiology, clinical presentation, and management of metal phosphide toxicity. Multiple searches were conducted on MEDLINE and PubMed, and articles related to the topics under discussion were included in the review. Metal phosphide is associated with significant morbidity and mortality involving all body systems. Patients presenting with metal phosphide intoxication need extensive workup including blood testing, electrocardiogram, and chest radiography. To date there is no antidote for metal phosphide toxicity, and management is mostly supportive. Many treatment modalities have been investigated to improve outcomes in patients presenting with metal phosphide toxicities. Conclusion Emergency physicians and toxicologists in developing countries need to consider zinc and aluminum phosphides on their differential when dealing with unlabeled rodenticide ingestion. Treatment is mostly supportive with close monitoring for sick patients. Further research is needed to better understand metal phosphide toxicity and to develop better treatment options.
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Affiliation(s)
- Hani Hamade
- American University of Beirut, Department of Emergency Medicine, Beirut, Lebanon
| | - Aynur Sahin
- Karadeniz Technical University, Trabzon, Turkey
| | - Carol Sukhn
- American University of Beirut, Department of Pathology and Laboratory Medicine, Beirut, Lebanon
| | - Chady El Tawil
- American University of Beirut, Department of Emergency Medicine, Beirut, Lebanon
| | - Jennifer Rizk
- American University of Beirut, Department of Emergency Medicine, Beirut, Lebanon
| | - Ziad Kazzi
- American University of Beirut, Department of Emergency Medicine, Beirut, Lebanon.,Emory University, Department of Emergency Medicine, Atlanta, Georgia, USA
| | - Tharwat El Zahran
- American University of Beirut, Department of Emergency Medicine, Beirut, Lebanon
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22
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El Zahran T, Mostafa H, Hamade H, Mneimneh Z, Kazzi Z, El Sayed MJ. Riot-related injuries managed at a hospital in Beirut, Lebanon. Am J Emerg Med 2021; 42:55-59. [PMID: 33453616 DOI: 10.1016/j.ajem.2020.12.084] [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] [Received: 09/29/2020] [Revised: 12/05/2020] [Accepted: 12/30/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Between October 2019 and February 2020, massive crowds protested in Lebanon against economic collapse. Various less than lethal weapons including riot control agents and rubber bullets were used by law enforcement, which led to several traumatic and chemical injuries among victims. This study describes the clinical presentation, management, outcome, and healthcare costs of injuries. METHODS A retrospective review of the hospital records of all the casualties presenting to the Emergency Department of the American University of Beirut Medical Center between October 17th, 2019, and February 29th, 2020, was conducted. RESULTS A total of 313 casualties were evaluated in the ED, with a mean age of 30.2 +/- 9.6 years and a predominance of males (91.1%). Most were protestors (71.9%) and arrived through EMS (43.5%) at an influx rate of one patient presenting every 2.7-8 min. Most patients (91.1%) presented with an Emergency Severity Index of 3. Most patients (77.6%) required imaging with 10% having major findings including fractures and hemorrhages. Stones, rocks, and tear gas canisters (30.7%) were the most common mechanism of injury. Musculoskeletal injuries were most common (62.6%), followed by lacerations (44.7%). The majority (93.3%) were treated and discharged home and 3.2% required hospital admission, with 2.6% requiring surgery. CONCLUSION Less-than-lethal weapons can cause severe injuries and permanent morbidity. The use of riot control agents needs to be better controlled, and users need to be well trained in order to avoid misuse and to lessen the morbidity, mortality, and financial burden.
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Affiliation(s)
- Tharwat El Zahran
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Hala Mostafa
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hani Hamade
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Zeina Mneimneh
- Quality Accreditation and Risk Management Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ziad Kazzi
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon; Department of Emergency Medicine, Emory University, Atlanta, GA, USA
| | - Mazen J El Sayed
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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23
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Murray BP, Carpenter JE, Sayers J, Yeh M, Beau J, Kiernan EA, Wolf MJ, Bolton TA, Kazzi Z. Two Cases of Serotonin Syndrome After Bupropion Overdose Treated With Cyproheptadine. J Emerg Med 2020; 60:e67-e71. [PMID: 33308914 DOI: 10.1016/j.jemermed.2020.10.039] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/21/2020] [Accepted: 10/19/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Bupropion is not known to have direct serotonin agonism or inhibit serotonin reuptake. In spite of this, it has been implicated as a causative agent of serotonin syndrome. We highlight two cases of single-agent bupropion overdose that subsequently met the diagnosis of serotonin syndrome by the Hunter criteria, despite the absence of direct serotonergic agents. CASE 1: A 14-year-old boy intentionally ingested an estimated 30 bupropion 75-mg immediate-release tablets. He presented in status epilepticus, was intubated, and was placed on midazolam and fentanyl infusions. He developed tremor, ankle clonus, and agitation. He was administered cyproheptadine for presumed serotonin syndrome with temporal improvement in his symptoms. CASE 2: A 19-year-old woman intentionally ingested an estimated 53 bupropion 150-mg extended-release tablets. She had a seizure and required sedation and intubation. During her course, she developed hyperthermia, inducible clonus, and hyperreflexia. She was treated with cyproheptadine without temporal improvement of symptoms but improved the following day. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although bupropion is not known to be directly serotonergic, it has been implicated as the single causative agent after overdose. This may be due to an indirect increase in activity of serotonergic cells. In these cases, bupropion overdose resulted in a clinical presentation consistent with serotonin syndrome, with the first having a temporal improvement after treatment with cyproheptadine. Physicians need to be aware of the potential serotonergic activity of bupropion for accurate assessment and treatment of this dangerous condition.
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Affiliation(s)
- Brian P Murray
- Department of Emergency Medicine, Wright State Boonsoft School of Medicine, Dayton, Ohio
| | | | - Joshua Sayers
- Department of Emergency Medicine, Wright State Boonsoft School of Medicine, Dayton, Ohio
| | - Michael Yeh
- Emory University School of Medicine, Atlanta, Georgia
| | - Jordan Beau
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Matthew J Wolf
- Department of Emergency Medicine, Wright State Boonsoft School of Medicine, Dayton, Ohio
| | | | - Ziad Kazzi
- Emory University School of Medicine, Atlanta, Georgia
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Murray BP, Carpenter J, Moran TP, Calello DP, Kazzi Z. In Response to Borgsteede et al. About Bupropion and Serotonin Toxicity. J Med Toxicol 2020; 16:335-336. [DOI: 10.1007/s13181-020-00764-w] [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: 02/14/2020] [Revised: 02/15/2020] [Accepted: 02/15/2020] [Indexed: 11/28/2022] Open
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25
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Dagher GA, Lewandowski C, Ali SS, Barsky C, Kazzi B, Cheaito MA, Lotfipour S, Kazzi A, Kazzi Z. The International Medical Graduate and Emergency Medicine. J Emerg Med 2020; 58:e99-e104. [PMID: 31812453 DOI: 10.1016/j.jemermed.2019.10.023] [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: 09/12/2019] [Accepted: 10/15/2019] [Indexed: 06/10/2023]
Abstract
International medical graduates (IMGs) are medical graduates who have received their degree from international medical schools. IMGs must undertake a 3-step process to apply to the National Residency Matching Program match. First, they must obtain a valid standard certificate from the Educational Commission for Foreign Medical Graduates. Following certification, they must apply for and secure a position in a residency training program. Third, they must obtain a visa that would enable them to commence their training. In this article, we delve thoroughly into these stepladders to provide IMGs with a clear roadmap of the process as well as contacts to key agencies that may provide more comprehensive assistance.
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Affiliation(s)
| | - Christopher Lewandowski
- Department of Emergency Medicine, Henry Ford Hospital and Wayne State University, Detroit, Michigan
| | - Syed S Ali
- Memorial Hermann Memorial City Hospital, Houston, Texas
| | - Carol Barsky
- Department of Emergency Medicine, Yale School of Medicine, Yale-New Haven Hospital, New Haven, Connecticut
| | - Brigitte Kazzi
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | | | | | - Amin Kazzi
- American University of Beirut, Beirut, Lebanon; University of California, Irvine, Rivine, California
| | - Ziad Kazzi
- American University of Beirut, Beirut, Lebanon; Department of Emergency Medicine, Emory University, Atlanta, Georgia
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26
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Atti SK, Silver EM, Chokshi Y, Casteel S, Kiernan E, Dela Cruz R, Kazzi Z, Geller RJ. All that glitters is not gold: Mercury poisoning in a family mimicking an infectious illness. Curr Probl Pediatr Adolesc Health Care 2020; 50:100758. [PMID: 32151591 DOI: 10.1016/j.cppeds.2020.100758] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Three siblings with inhalational elemental mercury toxicity presented with fever, rash, and upper respiratory tract symptoms. The patients were heavily exposed to elemental mercury that was spilled in their home and then vacuumed. Initial whole blood mercury levels were elevated at >200 µg/L, 153 µg/L and 130 µg/L (Mayo Clinic Laboratories lab reference range <9 µg/L) for Cases 1, 2, and 3, respectively. All three required chelation with succimer. Clinically significant elemental mercury toxicity can resemble an infectious illness. Severe morbidity and mortality can be prevented if heavy metal poisoning is considered early, through a detailed history including an environmental exposure history. For elemental mercury spills in the home, safe and effective clean-up steps are needed. Improved public health education is needed to prevent similar household exposures.
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Affiliation(s)
- Sukhshant K Atti
- Departments of Emergency Medicine and Pediatrics, Emory University, 80 Jesse Hill Jr Drive SE, Atlanta, GA 30303, United States.
| | | | - Yera Chokshi
- Department of Pediatrics, Navicent Medical Center, Macon, GA, United States
| | - Sue Casteel
- Agency for Toxicological Substances and Disease Registry, Centers for Disease Control, Atlanta, GA, United States
| | - Emily Kiernan
- Departments of Emergency Medicine and Pediatrics, Emory University, 80 Jesse Hill Jr Drive SE, Atlanta, GA 30303, United States
| | - Rogelio Dela Cruz
- Department of Pediatrics, Navicent Medical Center, Macon, GA, United States
| | - Ziad Kazzi
- Departments of Emergency Medicine and Pediatrics, Emory University, 80 Jesse Hill Jr Drive SE, Atlanta, GA 30303, United States; Georgia Poison Center, Atlanta, GA, United States
| | - Robert J Geller
- Departments of Emergency Medicine and Pediatrics, Emory University, 80 Jesse Hill Jr Drive SE, Atlanta, GA 30303, United States; Georgia Poison Center, Atlanta, GA, United States.
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27
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Hitti E, El Zahran T, Hamade H, Kaddoura R, Mneimneh Z, Morgan BW, Kazzi Z. Toxicological exposures reported to a telephonic consultation service at a tertiary care hospital in Lebanon. Clin Toxicol (Phila) 2020; 58:886-892. [PMID: 31933390 DOI: 10.1080/15563650.2019.1709643] [Citation(s) in RCA: 6] [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] [Indexed: 10/25/2022]
Abstract
Introduction: This study aims to describe the epidemiology of toxicological exposures reported to a telephonic medical toxicology service at a tertiary care center in Lebanon during a 46-months period.Methods: This study is a secondary analysis of a database for a telephonic medical toxicology service at a tertiary care center in Lebanon. Clinical information from all pediatric and adult patients, presenting with intentional or unintentional toxicological exposure, was entered into the database by the medical toxicology team.Results: Four hundred and seventy-seven exposures were recorded from 1 March 2015 to 31 December 2018. Female patients were involved in 60.2% of cases. Children less than 5 years old constituted 23.5% of cases and adults aged 20-49 constituted 48.6%. Up to 51.6% of cases were intentional, with 37.7% resulting from suicidal attempts. The majority of patients displayed no effects (33.1%) or minor effects (39.2%). Almost half of patients were treated and discharged from the Emergency Department (ED) without further hospitalization, and another 18.9% of patients left the ED against medical advice. The most common pharmaceutical agents involved were sedative/hypnotics/antipsychotics (14.7%), analgesics (12.6%) and antidepressants (11.3%). The most common non-pharmaceutical agents involved were household cleaning substances (8.0%), pesticides (5.2%) and bites and envenomations (3.8%).Conclusions: The results of this study suggest that sedative/hypnotics/antipsychotics, analgesics, antidepressants and household cleaning substances are the most common agents involved. Adult women and children ≤5 years old constitute a large portion of patients with toxicological exposures. Prevention strategies and policies should be implemented to mitigate these hazards.
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Affiliation(s)
- Eveline Hitti
- Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon
| | - Tharwat El Zahran
- Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon
| | - Hani Hamade
- Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon
| | - Rima Kaddoura
- Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon
| | - Zeina Mneimneh
- Quality Accreditation and Risk Management Program, American University of Beirut, Beirut, Lebanon
| | - Brent W Morgan
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA
| | - Ziad Kazzi
- Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon.,Department of Emergency Medicine, Emory University, Atlanta, GA, USA
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Kopec KT, Vohra R, Santos C, Kazzi Z, Wong A. The Global Educational Toxicology Toolkit (GETKIT): A 1-Day Course for Teaching Poisoning Essentials in Low- and Middle-Income Countries (LMIC): Course Development and Pilot Data Analysis. J Med Toxicol 2020; 16:255-261. [PMID: 31898153 DOI: 10.1007/s13181-019-00745-8] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/26/2019] [Accepted: 10/24/2019] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Worldwide an estimated one million deaths occur annually as a result of poisoning. Internationally there is a lack of toxicology training programs, especially in resource poor settings. We developed a one-day, interactive toxicology curriculum for healthcare practitioners in countries lacking clinical toxicology training and evaluated its feasibility and effectiveness for knowledge dissemination. METHODS GETKIT was developed with 3 sections: didactics, hands on toxicology case lab, and technology clinic. The investigators, who are medical toxicologists,created 23 didactic lectures and 42 workshop cases. All materials were peer reviewed by 5 senior medical toxicologists for content validity. Participants atpilot sites were given pre-course, post-course, and 3-month follow-up tests and surveys. RESULTS GETKIT was delivered internationally at 7 sites between November 2017 and April 2018. There were 186 total participants. One hundred and ten participants (59%) reported their hospital lacked a clinical toxicology service. The median post course score 12 (60%), IQR (6,14) was significantly higher compared to the pre-course score 9 (45%), IQR (6,11) (p < 0.0001). There was a significantly higher median 3-month post course score 13 (65%), IQR (8,14) vs. a median pre course score of 9 (45%), IQR (6,11) (p 0.0005). At 3-month follow up 86% of participants reported GETKIT had changed their clinical practice. CONCLUSIONS An improvement in and retention of medical toxicology knowledge was demonstrated with the GETKIT course. It also conferred improvement in selfreportedpoisoning management practices in participants from low resource settings.
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Affiliation(s)
| | - Rais Vohra
- California Poison Control System and UCSF Fresno Medical Education Program, Fresno, CA, USA
| | | | | | - Anselm Wong
- Victorian Poisons Information Centre and Austin Toxicology Service, Austin Hospital, Heidelberg, Australia.,School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia.,Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
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29
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Murray B, Carpenter J, Dunkley C, Moran TP, Kiernan EA, Rianprakaisang T, Alsukaiti WS, Calello DP, Kazzi Z. Single-Agent Bupropion Exposures: Clinical Characteristics and an Atypical Cause of Serotonin Toxicity. J Med Toxicol 2019; 16:12-16. [PMID: 31823333 DOI: 10.1007/s13181-019-00749-4] [Citation(s) in RCA: 10] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 11/08/2019] [Accepted: 11/14/2019] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Bupropion is the only Food and Drug Administration-approved synthetic cathinone. It increases the release of norepinephrine in the locus coeruleus and dorsal raphe nucleus, causing an increase in the frequency of serotonergic neuron firing. The diagnosis of serotonin toxicity (ST) from bupropion poisoning is controversial due to the lack of direct serotonergic activity. Nonetheless, there is one documented report of ST after single-agent bupropion overdose and multiple reports describing polypharmacy overdoses where bupropion may have contributed to ST. METHODS This is a retrospective analysis of data collected by the Toxicology Investigators Consortium (ToxIC), a prospective multi-center toxico-surveillance and research network registry, from 2014 to 2017. Cases were identified if ST was a clinical effect and bupropion was the single agent listed. Data is presented descriptively. RESULTS Of the 266 recorded single bupropion overdoses, the most common symptoms were seizures (47.1%), tachycardia (greater than 140 bpm) (33.9%), agitation (31.7%), toxic psychosis (20.4%), and myoclonus/tremor/hyperreflexia (19%). Benzodiazepines were the most common therapy (69.2%). Thirteen patients (5.9%) were diagnosed with ST by a medical toxicologist. CONCLUSION Bupropion overdose is primarily associated with seizures, tachycardia, and agitation; bupropion may be an atypical cause of serotonin toxicity.
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Affiliation(s)
- Brian Murray
- Emory University School of Medicine, Atlanta, GA, USA. .,Georgia Poison Center, Atlanta, GA, USA.
| | - Joseph Carpenter
- Emory University School of Medicine, Atlanta, GA, USA.,Georgia Poison Center, Atlanta, GA, USA
| | - Camille Dunkley
- Emory University School of Medicine, Atlanta, GA, USA.,Georgia Poison Center, Atlanta, GA, USA
| | - Tim P Moran
- Emory University School of Medicine, Atlanta, GA, USA
| | - Emily A Kiernan
- Emory University School of Medicine, Atlanta, GA, USA.,Georgia Poison Center, Atlanta, GA, USA
| | | | | | | | - Ziad Kazzi
- Emory University School of Medicine, Atlanta, GA, USA.,Georgia Poison Center, Atlanta, GA, USA
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Mrad S, El Tawil C, Sukaiti WA, Bou Chebl R, Abou Dagher G, Kazzi Z. Cardiac Arrest Following Liposuction: A Case Report of Lidocaine Toxicity. Oman Med J 2019; 34:341-344. [PMID: 31360324 PMCID: PMC6642719 DOI: 10.5001/omj.2019.66] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a case of a patient presenting to the emergency department in cardiac arrest following a liposuction procedure, which was performed in a physician office using lidocaine anesthesia. During liposuction of the thighs, using the power-assisted technique, the patient was given a subcutaneous dose of lidocaine equal to 71 mg/kg without any noticeable intraoperative complication. Two hours later, the patient experienced dizziness, a rapid decline in mental status, tonic-clonic seizure, and cardiac arrest. The patient was successfully resuscitated in the emergency department with the return of spontaneous circulation after 22 minutes of continuous advanced cardiovascular life support resuscitation. The patient suffered from subsequent severe hypoxic-ischemic brain injury, and a complicated hospital stay, including brain edema, electrolytes disturbances, and nosocomial infections contributed to her death two months later due to septic shock.
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Affiliation(s)
- Sandra Mrad
- Emergency Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Chady El Tawil
- Emergency Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Waleed A Sukaiti
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ralph Bou Chebl
- Emergency Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Gilbert Abou Dagher
- Emergency Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ziad Kazzi
- Emergency Department, American University of Beirut Medical Center, Beirut, Lebanon.,Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Georgia Poison Center, Atlanta, Georgia, USA
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Affiliation(s)
- Brian Patrick Murray
- Georgia Poison Center, Grady Hospital, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Air Force Institute of Technology, US Air Force, Wright Patterson AFB, OH, USA
| | - Joseph E. Carpenter
- Georgia Poison Center, Grady Hospital, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Camille A. Dunkley
- Georgia Poison Center, Grady Hospital, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Tim P. Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Ziad Kazzi
- Georgia Poison Center, Grady Hospital, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Murray BP, Carpenter JE, Dunkley CA, Moran TP, Alfaifi M, Alsukaiti WS, Kazzi Z. Seizures in tramadol overdoses reported in the ToxIC registry: predisposing factors and the role of naloxone. Clin Toxicol (Phila) 2019; 57:692-696. [DOI: 10.1080/15563650.2018.1547826] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Brian Patrick Murray
- Georgia Poison Center, Grady Hospital, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
- US Air Force, Air Force Institute of Technology, Wright Patterson AFB, Dayton, OH, USA
| | - Joseph E. Carpenter
- Georgia Poison Center, Grady Hospital, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Camille A. Dunkley
- Georgia Poison Center, Grady Hospital, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Tim P. Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Musa Alfaifi
- Georgia Poison Center, Grady Hospital, Atlanta, GA, USA
| | | | - Ziad Kazzi
- Georgia Poison Center, Grady Hospital, Atlanta, GA, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Abstract
Infants, children, and adolescents can be exposed unexpectedly to ionizing radiation from nuclear power plant events, improvised nuclear or radiologic dispersal device explosions, or inappropriate disposal of radiotherapy equipment. Children are likely to experience higher external and internal radiation exposure levels than adults because of their smaller body and organ size and other physiologic characteristics as well as their tendency to pick up contaminated items and consume contaminated milk or foodstuffs. This technical report accompanies the revision of the 2003 American Academy of Pediatrics policy statement on pediatric radiation emergencies by summarizing newer scientific data from studies of the Chernobyl and the Fukushima Daiichi nuclear power plant events, use of improvised radiologic dispersal devices, exposures from inappropriate disposal of radiotherapy equipment, and potential health effects from residential proximity to nuclear plants. Also included are recommendations from epidemiological studies and biokinetic models to address mitigation efforts. The report includes major emphases on acute radiation syndrome, acute and long-term psychological effects, cancer risks, and other late tissue reactions after low-to-high levels of radiation exposure. Results, along with public health and clinical implications, are described from studies of the Japanese atomic bomb survivors, nuclear plant accidents (eg, Three Mile Island, Chernobyl, and Fukushima), improper disposal of radiotherapy equipment in Goiania, Brazil, and residence in proximity to nuclear plants. Measures to reduce radiation exposure in the immediate aftermath of a radiologic or nuclear disaster are described, including the diagnosis and management of external and internal contamination, use of potassium iodide, and actions in relation to breastfeeding.
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Carpenter J, Lumanauw D, Arndt J, Fleischman R, Kazzi Z, Tanen D. 385 Ethanol Metabolism in a Group of Experienced Users. Ann Emerg Med 2018. [DOI: 10.1016/j.annemergmed.2018.08.390] [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: 10/28/2022]
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Othong R, Wattanasansomboon S, Kruutsaha T, Chesson D, Arj-Ong Vallibhakara S, Kazzi Z. Utility of QT interval corrected by Rautaharju method to predict drug-induced torsade de pointes. Clin Toxicol (Phila) 2018; 57:234-239. [DOI: 10.1080/15563650.2018.1510501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Rittirak Othong
- Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Suttisak Wattanasansomboon
- Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Thanakorn Kruutsaha
- Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Douglas Chesson
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA
| | - Sakda Arj-Ong Vallibhakara
- Section for Clinical Epidemiology and Biostatistics, Ramathibodi Hospital, Faculty of Medicine, Mahidol University, Bangkok, Thailand
| | - Ziad Kazzi
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA
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Gittinger MH, Carpenter JE, Dunkley CA, Murray BP, Morgan B, Kazzi Z. Articles You Might Have Missed. J Med Toxicol 2018. [DOI: 10.1007/s13181-018-0666-4] [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: 11/30/2022] Open
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El Zahran T, Kazzi Z, Chehadeh AAH, Sadek R, El Sayed MJ. Snakebites in Lebanon: A Descriptive Study of Snakebite Victims Treated at a Tertiary Care Center in Beirut, Lebanon. J Emerg Trauma Shock 2018; 11:119-124. [PMID: 29937642 PMCID: PMC5994845 DOI: 10.4103/jets.jets_141_16] [Citation(s) in RCA: 9] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Snakebites lead to at least 421,000 envenomations and result in more than 20,000 deaths per year worldwide. Few reports exist in the Mediterranean region. This study describes demographic and clinical characteristics, treatment modalities, and outcomes of snakebites in Lebanon. Materials and Methods: This was a retrospective chart review of patients who presented with snakebite complaint to the emergency department between January 2000 and September 2014. Results: A total of 24 patients were included in this study. The mean age was 34.6 (±16.4) years and 58.3% were males. Local manifestations were documented in 15 (62.5%) patients, systemic effects in 10 (41.7%), hematologic abnormalities in 10 (41.7%), and neurologic effects in 4 (16.7%) patients. Nine patients (37.5%) received antivenom. The median amount of antivenom administered was 40 ml or 4 vials (range: 1–8 vials). About 50% of patients were admitted to the hospital with 75% to an Intensive Care Unit and 25% to a regular bed. All were discharged home with a median hospital length of stay of 4 (interquartile range 11) days. Among those admitted, seven patients (58.3%) had at least one documented complication (compartment syndrome, fasciotomy, intubation, deep vein thrombosis, coagulopathy, acute respiratory distress syndrome, sepsis, congestive heart failure, cellulitis, upper gastrointestinal bleeding, and vaginal bleeding). Conclusion: Victims of snakebites in Lebanon developed local, systemic, hematologic, or neurologic manifestations. Complications from snakebites were frequent despite antivenom administration. Larger studies are needed to assess the efficacy of available antivenom and to possibly create a local antivenom for the treatment of snakebites in Lebanon.
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Affiliation(s)
- Tharwat El Zahran
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ziad Kazzi
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon.,Department of Emergency Medicine, Emory University, Georgia Poison Center, Atlanta, Georgia
| | - Ahel Al-Hajj Chehadeh
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Riyad Sadek
- Department of Biology, Faculty of Arts and Sciences, American University of Beirut, Beirut, Lebanon
| | - Mazen J El Sayed
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Murray BP, Ralston SA, Dunkley CA, Carpenter JE, Geller RJ, Kazzi Z. Pneumonitis and Respiratory Failure Secondary to Civilian Exposure to a Smoke Bomb in a Partially Enclosed Space. J Spec Oper Med 2018; 18:24-26. [PMID: 30566719 DOI: 10.55460/ud9x-auxa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/01/2018] [Indexed: 06/09/2023]
Abstract
Smoke grenades are used during drills, police and military exercises, and crowd control. We report on a 25-year-old man who was exposed to a Superior 3C smoke bomb. He was initially stable but developed respiratory distress after 3 days and ultimately developed pulmonary fibrosis with marked loss in pulmonary function. The Superior 3C smoke bomb is similar in composition to the British Military's L83A1/2 and L132A1 and the US M18 smoke grenades, all commonly used as multipurpose smoke-producing devices for combat and training. They are primarily composed of zinc oxide and hexachlorethane, the combustion of which produces zinc chloride. These devices are safe when used properly in open air but can cause significant morbidity in an enclosed space. This case emphasizes the potential hazards of using smoke bombs even in semienclosed spaces and the potential delay in the development of significant pulmonary complications.
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Kairus R, Santos C, Kazzi Z, Bentley S, Olmedo R. Development of a medical Toxicology Curriculum in Spanish with content informed by a population survey for medical trainees in the Dominican Republic. Toxicol Lett 2016. [DOI: 10.1016/j.toxlet.2016.07.271] [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]
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40
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Davlantes E, Kazzi Z, Meer J. Elderly Man With Dyspnea. Ann Emerg Med 2016; 67:438-57. [DOI: 10.1016/j.annemergmed.2015.09.006] [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: 04/27/2015] [Indexed: 11/29/2022]
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Abstract
After a radiation emergency that involves the dispersal of radioactive material, patients can become externally and internally contaminated with 1 or more radionuclides. Internal contamination can lead to the delivery of harmful ionizing radiation doses to various organs and tissues or the whole body. The clinical consequences can range from acute radiation syndrome to the long-term development of cancer. Estimating the amount of radioactive material absorbed into the body can guide the management of patients. Treatment includes, in addition to supportive care and long term monitoring, certain medical countermeasures like Prussian blue, calcium diethylenetriamine pentaacetic acid (DTPA) and zinc DTPA.
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Affiliation(s)
- Ziad Kazzi
- National Center for Environmental Health, Centers for Disease Control and Prevention, 4770 Buford Highway, Northeast, MS-F59, Atlanta, GA 30341-3717, USA; Department of Emergency Medicine, Emory University, 531 Asbury Cir-Annex, Suite N-340, Atlanta, GA 30322, USA.
| | - Jennifer Buzzell
- National Center for Environmental Health, Centers for Disease Control and Prevention, 4770 Buford Highway, Northeast, MS-F59, Atlanta, GA 30341-3717, USA
| | - Luiz Bertelli
- Los Alamos National Laboratory, Mailstop G761, Los Alamos, NM 87545, USA
| | - Doran Christensen
- Radiation Emergency Assistance Center/Training Site, PO Box 117, Oak Ridge TN 37831, USA
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Devlin JJ, Punja M, Kazzi Z. Manual corrected QT and Tpeak-Tend calculations may assist emergency physicians risk stratify patients for arrhythmia. Am J Emerg Med 2013; 31:1411. [PMID: 23816192 DOI: 10.1016/j.ajem.2013.05.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 05/28/2013] [Indexed: 10/26/2022] Open
Affiliation(s)
- John J Devlin
- Georgia Poison Center, Atlanta, GA; Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA.
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43
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Abstract
INTRODUCTION Amantadine hydrochloride is an antiviral medication used as therapy for parkinsonism and as a cognitive enhancer. We report 2 cases of massive, acute ingestion of amantadine hydrochloride confirmed with serial serum levels. CASE REPORTS A 47-year-old woman presented to the emergency department (ED) 30 minutes after ingesting 10 g of amantadine (150 mg/kg) by her report. Initial ECG revealed a sinus rhythm with rate of 93 bpm, and a QRS of 84 msec. While in the ED, the patient sustained a pulseless cardiac arrest and the monitor revealed ventricular tachycardia. She was successfully defibrillated. Postdefibrillation ECG showed a sinus rhythm (rate = 82 bpm), QRS of 236 msec, and QTc of 567 msec. The serum potassium was 1.0 mEq/L (1.0 mmol/L). The patient was given 300 ml (300 cc) 3% sodium chloride IV over 10 minutes. Ten minutes after completion of the hypertonic saline infusion, the patient's ECG abnormalities resolved and the QRS was 88 msec. Her potassium was repleted over the next 11 hours postpresentation, and she also received an IV bolus of 4 g of magnesium sulfate immediately after the cardiac arrest. No further hypotension, dysrhythmia, conduction delay, or ectopy was noted during the patient's hospital stay. The second case involved a 33-year-old female patient who presented 1 hour after ingesting 100 tablets of amantadine hydrochloride (100 mg/tab). Initial ECG revealed sinus tachycardia with a QRS of 113 msec, an R wave in lead aVR of 4-5 mm and a QTc of 526 msec. Her serum potassium was 3.0 mEq/L (3.0 mmol/L), her serum calcium was 9.4 mg/dl (2.35 mmol/L), and serum magnesium was 2.1 mg/dl (0.86 mmol/L) on labs drawn at initial presentation. The patient was intubated for airway protection, and her potassium was repleted and corrected over the next 9 hours. Her ECG abnormalities improved 8 hours after initial presentation and normalized at approximately 14 hours postingestion. The patient was discharged home 11 days after her ingestion. CONCLUSION Acute amantadine toxicity manifests with life-threatening cardiotoxicity. Concurrent, often profound, hypokalemia may complicate the administration of sodium bicarbonate in the management of cardiac dysrhythmias.
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Affiliation(s)
- Michael Schwartz
- Georgia Poison Center, Emory University School of Medicine, Atlanta, GA 30333, USA.
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Gullett J, Kazzi Z. Book and media review. Ann Emerg Med 2007. [DOI: 10.1016/j.annemergmed.2007.01.031] [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: 10/23/2022]
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Mirza M, Saini D, Dickens MA, Kazzi Z, Orthner HF. A regional database of antidote availability. AMIA Annu Symp Proc 2006; 2006:1034. [PMID: 17238653 PMCID: PMC1839589] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Timely pre-hospital management of snake bite and poisoning cases is hindered by the lack of information about availability of antidotes in hospitals. We aim to build a regional antidote database by collecting real-time antidote stock information from hospital pharmacy inventory systems and make this information available to the emergency medical technicians (EMTs). This would save valuable time, leading to improved outcomes for the patients.
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Affiliation(s)
- Muzna Mirza
- Health Informatics Program, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
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