Use of QT-prolonging medications in US emergency departments, 1995-2009.

PURPOSE: Emergency department (ED) patients receive medications that place them at risk for adverse events, including drug-induced prolongation of the QT interval, which can lead to Torsade de Pointes and sudden cardiac death. We report the frequency of prescription and co-prescription of QT-prolonging medications in US EDs and factors associated with high-risk prescribing practices. METHODS: We analyzed the ED component of the National Hospital Ambulatory Medical Care Survey for 1995 through 2009. Yearly rates of visits involving the prescription of QT-prolonging medications were determined. Multivariate regression analyses identified factors associated with the prescription of two or more QT-prolonging medications. RESULTS: Approximately 16.5 million visits annually (15.0%) involved prescription of a QT-prolonging drug, with 1.7 million (1.6%) involving multiple prescriptions. Visits associated with QT-prolonging drugs more than doubled over the study period (10.4% to 22.2%). Diphenhydramine, azithromycin, and ondansetron were most frequently implicated (46.1% of cases). The most commonly prescribed combination was diphenhydramine and famotidine, both QT-prolonging medications available over-the-counter. Female gender and older age were associated with co-prescription of QT-prolonging medications. The rate of EKG screening among visits associated with QT-prolonging drug combinations was low (20.9%), but more common than among visits without a QT-prolonging drug (OR 1.3; 95% CI 1.2-1.5). CONCLUSION: Use of QT-prolonging medications is increasing in EDs nationally. A small number of agents account for a large proportion of these visits and may represent an area for targeted screening or monitoring interventions in the ED.

Adult prescription drug use and pediatric medication exposures and poisonings.

BACKGROUND AND OBJECTIVES: Nontherapeutic medication ingestions continue to be a major pediatric health problem, with recent increases in ingestions despite a number of public health interventions. It is unknown how changes in adult prescription drug use relate to pediatric medication poisonings. The objective of the study was to measure the association between changing adult prescription drug patterns and pediatric medication exposures and poisonings and identify high-risk classes of medications and pediatric age groups. METHODS: We measured monthly pediatric exposures and poisonings using the National Poison Data System and prescriptions written for adults using the National Ambulatory Medical Care Surveys for 2000 through 2009. Associations between adult prescriptions for oral hypoglycemics, antihyperlipidemics, ß-blockers, and opioids and exposures and poisonings among children 0 to 5, 6 to 12, and 13 to 19 years were analyzed by using multiple time-series analysis. Emergency department visits, serious injuries, and hospitalizations stemming from these associations were described. RESULTS: Adult medication prescriptions were statistically significantly associated with exposures and poisonings in children of all ages, with the strongest association observed for opioids. Across medications, the greatest risk was among children 0 to 5 years old, followed by 13- to 19-year-olds. Rates of emergency department visits were highest for events related to hypoglycemics (60.1%) and ß-blockers (59.7%), whereas serious injuries and hospitalizations occurred most frequently with opioids (26.8% and 35.2%, respectively) and hypoglycemics (19.5% and 49.4%, respectively). CONCLUSIONS: Increasing adult drug prescriptions are strongly associated with rising pediatric exposures and poisonings, particularly for opioids and among children 0 to 5 years old. These associations have sizable impacts, including high rates of serious injury and health care use.

Pediatric scorpion envenomation in the United States: morbidity, mortality, and therapeutic innovations.

In the Southwestern United States, the venom of the scorpion Centruroides sculpturatus (common name bark scorpion) can cause serious and potentially fatal neurotoxicity, with young children most vulnerable to its effects. Historically, advances in the quality of supportive care have made significant improvements in morbidity and mortality. In recent years, the development of effective antivenom therapies has changed the landscape of caring for these patients. This article reviews the background, pathophysiology, diagnosis, and treatment options for C. sculpturatus envenomation. Recent advances in immunotherapy and subsequent implications for pediatric emergency care providers are discussed.

Methadone toxicity and possible induction and enhanced elimination in a premature neonate.

INTRODUCTION: Reports describing methadone overdose in adult and pediatric patient populations are not uncommon. Reports in the preterm neonate patient population, however, are infrequent even though the utilization of methadone in that population continues to increase. Significant age-related pharmacokinetic differences complicate the management of methadone overdose in neonates, and literature involving methadone toxicokinetics and toxicodynamics in pediatric and neonate populations is largely limited. CASE REPORT: The clinical course and pharmacologic data of a massive methadone overdose in a 20-day-old male neonate is described, and a contemporary review of developmental pharmacology is presented. DISCUSSION: As clinicians continue to use methadone in neonates, they should be aware of the many significant peculiarities regarding its toxicology and pharmacology in that patient population.

Toxicity of weight loss agents.

INTRODUCTION: With the rise of the obesity epidemic in the United States over the last several decades and the medical complications seen with it, weight loss and dieting have become a national public health concern. DISCUSSION: Because of their increased use and availability through internet sales, several different dieting agents were reviewed for potential toxicity. These included: syrup of ipecac, cathartics, human chorionic gonadotropin hormone, 2,4 Dinitrophenol, guar gum, phenylpropanolamine, ma huang/ ephedra, caffeine, clenbuterol, fenfluramine, sibutramine, thyroid hormone, orlistat and cannabinoid antagonists. CONCLUSIONS: With the internet making even banned products readily accessible, healthcare providers need to be aware of the potential toxicities of a wide range of weight loss agents. Our review covered topics we thought to be most historically significant as well as pertinent to the practice of medical toxicology today.

Interference by carbamazepine and oxcarbazepine with serum- and urine-screening assays for tricyclic antidepressants.

OBJECTIVE: The purpose of this work was to evaluate the potential cross-reactivity of 2 antiepileptic medications containing 3-ringed structures, namely, carbamazepine and oxcarbazepine, with screening assays for tricyclic antidepressants. METHODS: A cross-sectional study of 52 patients between 3 and 19 years of age who had been prescribed either carbamazepine or oxcarbazepine was conducted. A serum fluorescence-polarized immunoassay and a urine enzyme-linked immunoassay were used. The serum carbamazepine or oxcarbazepine level was measured. Gas chromatography/mass spectrometry, a confirmatory test for tricyclic antidepressant detection, was subsequently performed on the serum specimen. RESULTS: A linear dependency on medication level was observed with the serum fluorescence-polarized immunoassay assay. This relationship was stronger for carbamazepine (4.2 microg/L tricyclic antidepressant detected per microgram/liter of carbamazepine) than for oxcarbazepine (0.7 microg/L tricyclic antidepressant detected per milligram/liter). At higher carbamazepine levels (8.0-11.6 mg/L), 12 of 13 patients had a positive serum fluorescence-polarized immunoassay result; at lower levels (0.1-7.9 mg/L), only 1 of 20 had a positive result. None of the patients who were receiving oxcarbazepine showed significant tricyclic antidepressant activity on either assay. CONCLUSIONS: Carbamazepine interferes at a statistically significant level with serum fluorescence-polarized immunoassay assay and in a dose-dependent fashion. Neither carbamazepine nor oxcarbazepine exhibit significant tricyclic antidepressant activity on urine enzyme-linked immunoassay assay.

Adverse effects in children after unintentional buprenorphine exposure.

Buprenorphine in sublingual formulation was recently introduced to the American market for treatment of opioid dependence. We report a series of 5 toddlers with respiratory and mental-status depression after unintentional buprenorphine exposure. Despite buprenorphine's partial agonist activity and ceiling effect on respiratory depression, all children required hospital admission and either opioid-antagonist therapy or mechanical ventilation. Results of routine urine toxicology screening for opioids were negative in all cases. Confirmatory testing was sent for 1 child and returned with a positive result. The increasing use of buprenorphine as a home-based therapy for opioid addiction in the United States raises public health concerns for the pediatric population.

Nutritional rickets: beyond the chief complaint.

In the emergency department, opportunities exist for the emergency physician to make a diagnosis beyond the chief complaint. For example, an astute reader of pediatric radiographs may detect signs of rickets on plain films that are obtained for other reasons. Risk factors that should suggest nutritional rickets in an infant include a history of exclusive breast-feeding, time of presentation in late winter or early spring, and a physical examination that reveals pigmented skin.

Acute arsenic poisoning in two siblings.

We report a case series of acute arsenic poisoning of 2 siblings, a 4-month-old male infant and his 2-year-old sister. Each child ingested solubilized inorganic arsenic from an outdated pesticide that was misidentified as spring water. The 4-month-old child ingested a dose of arsenic that was lethal despite extraordinary attempts at arsenic removal, including chelation therapy, extracorporeal membrane oxygenation, exchange transfusion, and hemodialysis. The 2-year-old fared well with conventional therapy.

Pyomyositis: a fatal case in a healthy teenager.

Pyomyositis is a common disease in the tropics that is reported with increasing frequency in the United States. We describe an unusually fulminant, fatal case in a previously healthy adolescent male. This case illustrates the clinical progression of pyomyositis from localized muscle infection to disseminated disease, and highlights the importance of considering this rare diagnosis in any stage of occult sepsis.

Transient psychosis in an immune-competent patient after oral trimethoprim-sulfamethoxazole administration.

We describe a rare adverse reaction to trimethoprim-sulfamethoxazole (TMP-SMX; Septra, Bactrim) in an immune-competent female adolescent. She was prescribed TMP-SMX for a urinary tract infection, which she had developed while being treated in the hospital for an extensive leg cellulitis. Shortly after receiving her third dose of TMP-SMX, she developed an acute altered mental status with agitation as well as vivid visual and auditory hallucinations. After prompt discontinuation of TMP-SMX, the patient slowly began to improve and was able to return to her baseline mental status within 10 days. No residual mental status changes were present. Despite the recent emergence of multidrug-resistant bacterial pathogens, TMP-SMX, one of the first-generation broad-spectrum antibiotics, continues to be widely prescribed, in part because of its low cost and its easy availability. It is generally well tolerated and is associated with relatively few adverse effects. More common toxicities associated with TMP-SMX include hypersensitivity reactions, bone marrow suppression, and gastrointestinal side effects. Central nervous system toxicity is very rare; when reported, it has been in an immune-compromised or an elderly patient.