Mad Honey Ingestion Leading to Grayanotoxin Poisoning During the Burning Man Music Festival: A Case Series.

This is a case series of three patients who presented to the medical facilities at Burning Man, an annual week-long gathering in the Black Rock Desert of Nevada, for recreational grayanotoxin ingestion. Grayanotoxin, also known as "mad honey," caused the patients to present with varying degrees of dizziness, nausea, vomiting, and diarrhea based on the quantity ingested. Vital signs showed significant bradycardia and hypotension and were successfully treated with atropine and intravenous fluids. Patients were later discharged after a period of observation and resolution of symptoms.

Ramen noodle neuropathy: an atypical case of partial paralysis from malnutrition.

INTRODUCTION: Due to a COVID-related job loss resulting in financial and food insecurity, a 28-year-old woman initiated a diet consisting solely of one cup of ramen noodles daily for twenty-two months, leading to 27 kg of weight loss. Ramen noodles are low in calories and lack key nutrients, including potassium, chloride, and vitamin B12. CASE DESCRIPTION: The patient presented to the emergency department with acute, worsening weakness and paresthesias in her left wrist and hand. Exam revealed no other abnormalities aside from a cachectic appearance. Labs revealed marked hypokalemia, hypochloremia, lactic acidosis, a mixed metabolic alkalosis with respiratory acidosis, and low levels of zinc and copper. An EKG revealed a prolonged QT interval. After a neurology and psychiatry consult, the patient was admitted for failure to thrive with malnutrition, peripheral neuropathy, hypokalemia, and an acid-base disorder. An MRI of the brain was unremarkable. Studies of other nutritional deficiencies, autoimmune conditions, and sexually transmitted infections were unremarkable. The patient received food and vitamin supplementation, was monitored for re-feeding syndrome, and had a significant recovery. DISCUSSION: After stroke, spinal injury, multiple sclerosis, and the most common focal mononeuropathies were ruled out, the clinical focus turned to nutritional deficiencies, the most significant of which was hypokalemia. Prior research has shown that severe hypokalemia can lead to weakness. It has also shown that chronically insufficient dietary intake is a common cause of hypokalemia. This case, with its partial paralysis of a unilateral upper extremity, may add to the known clinical manifestations of hypokalemia. We review the role of hypokalemia and hypochloremia in acid-base dynamics. Etiologies and clinical manifestations of cobalamin, thiamine, pyridoxine, and copper deficiencies, along with lead toxicity, are also discussed. Diagnostic clarity of mononeuropathies in the context of malnutrition and hypokalemia can be aided by urine potassium levels prior to repletion, neuroimaging that includes the cervical spine, and follow-up electromyography.

Massive Apixaban Overdose Confirmed with Blood Concentrations and Managed Without Bleeding: A Single Case Report.

BACKGROUND: Acute overdoses of apixaban, and other direct oral anticoagulants are relatively uncommon. The number of direct oral anticoagulants prescriptions in the United States is increasing, however reports on patient outcomes after documented overdose are sparse. CASE REPORT: A 76-year-old man with a past medical history of atrial fibrillation and taking apixaban 5 mg twice daily presented to the emergency department 10 hours after reportedly ingesting 60-70 of his pills. He was alert and had a normal physical examination. Blood tests demonstrated an INR of 12, platelets of 161 000 cells/mm3, hemoglobin 9.7 g/dL, and creatinine 1.81 mg/dL. He received 60 g of activated charcoal and 4 units of fresh frozen plasma prophylactically. Initial blood apixaban concentration was 4 000 ng/mL. Repeat blood apixaban concentrations were 3 000 ng/mL and 2 200 ng/mL at 7 and 14 hours, respectively (thrapeutic range 91-321 ng/mL for a 5 mg twice daily dose). The hybrid anti-factor Xa activity did not correlate with blood apixaban concentrations. Apixaban elimination followed first-order kinetics with an apparent elimination half-life of 14 hours in the presence of impaired renal function. He did not have any minor or major bleeding events.

Two Cases of Acute Direct Oral Anticoagulant Overdose Without Adverse Effect.

We report 2 pediatric patients who had acute overdoses of the direct oral anticoagulants medications. Both patients were managed conservatively; neither required reversal agents or blood products nor had any major or minor bleeding events. With therapeutic usage of direct oral anticoagulants, routine coagulation studies typically are considered insufficient measures of anticoagulation and the preferred chromogenic anti-Factor Xa assay is recommended but not widely available. Using a routine hybrid heparin anti-Factor Xa assay, 1 patient demonstrated a strong linear correlation up to a serum rivaroxaban concentration of 940 ng/mL.

Tenosynovial fluid as an indication of early posterior tibial tendon dysfunction in patients with normal tendon appearance.

OBJECTIVE: Our primary aim was to quantify the posterior tibial tendon (PTT) sheath fluid volume in individuals with the clinical diagnosis of stage 1 posterior tibial tendon dysfunction (PTTD) and no MRI-detectable intra-substance tendon pathology and compare them with patients with other causes of medial ankle pain, also without MRI-detectable intra-substance PTT pathology and with normal controls. We also wanted to determine if there is a fluid measurement that correlates with the clinical diagnosis of PTTD. MATERIALS AND METHODS: A total of 326 individuals with medial ankle pain and no intra-substance PTT pathology were studied. Group 1 included 48 patients with a clinical diagnosis of stage 1 PTT dysfunction, group 2 comprised 278 patients with other causes of medial ankle pain, and a third control group consisted of 56 patients without any medial ankle pain. MRI-based geometric measurements included PTT fluid volume, maximum cross-sectional fluid area, and fluid width. Fluid measurements were compared between groups and measurement reliability was tested. RESULTS: Group 1 showed greater PTT fluid volume, area, and width compared with groups 2 (other causes of medial ankle pain) and 3 (asymptomatic controls) (all p values < 0.001). A 9-mm threshold maximum fluid width was associated with PTTD (sensitivity 84%, specificity 85%). Measurements were reliable (all p values < 0.03) among three observers blinded to the gold standard. CONCLUSION: Patients with stage 1 PTT dysfunction displayed greater volumes of tendon-sheath fluid than those with other causes of medial ankle pain and compared with asymptomatic controls. A threshold maximum fluid width greater than or equal to 9 mm distinguishes those with PTTD. An association between tendon sheath fluid distension and the clinical diagnosis of stage 1 posterior tibial tendon disease in the setting of no MRI-detectable intra-substance tendon pathology may allow for differentiation of medial ankle pain from other sources and may allow for early intervention aimed at preventing progressive PTTD. The level of evidence was prognostic (level III).

Changing Trends in Eye-Related Complaints Presenting to the Emergency Department in Beirut, Lebanon, over 15 Years.

OBJECTIVE: To report the 15-year trend in ophthalmic presentations to the emergency department (ED) at the only medical center in Lebanon that provides 24-hour ophthalmologic care. METHODS: Retrospective review of 1967 patients presenting to the ED with eye-related complaints between September 1997 and August 1998 and between September 2012 and August 2013. Diagnoses were classified into 4 categories according to the International Society of Ocular Trauma and include penetrating eye injuries, nonpenetrating eye trauma, nontraumatic ophthalmic emergencies, and nontraumatic, nonurgent ophthalmic conditions. RESULTS: One thousand sixty eye-related presentations out of 39,158 total ED visits (2.71%) presented in 1997 compared to 907 out of 46,363 in 2012 (1.96%). Penetrating and nonpenetrating eye emergencies decreased between 1997 and 2012 (7.17% to 4.19%, p = 0.003 and 52.64% to 29.00%, p < 0.001, resp.) while nonurgent cases increased from 30.19% to 53.47% (p < 0.001). 57% of patients were covered by third-party guarantors in 1997 versus 73% in 2012. CONCLUSION: Our results demonstrate a significant increase in nonurgent cases in parallel with the proportion of third-party payers, an issue to be addressed by public health policies and proper resource allocation. A detailed nationwide review is needed to make solid recommendations for the management of ophthalmologic presentations in the ED.

Early Echocardiography Has a Low Yield in Patients with Transient Ischemic Attack.

STUDY OBJECTIVE: Current guidelines recommend patients presenting with transient ischemic attack (TIA) undergo echocardiography to evaluate for a cardiac source. However, echocardiography is not available daily at many centers. We assessed the yield from early transthoracic echocardiography (TTE) in consecutive patients with TIA evaluated in an emergency department observation unit (EDOU) protocol. METHODS: This observational cohort study took place in an academic medical center from January 1, 2011 to July 31, 2013. Patients seen in the emergency department, assigned to the EDOU for a TIA accelerated diagnostic protocol and discharged with a diagnosis of TIA were included. We retrospectively collected baseline patient characteristics, ABCD2 score, neuroimaging, telemetry, TTE, and 3-month clinical outcomes. RESULTS: Of 236 subjects (mean age 62 ± 15 years, 68% female, 57% African American, 17% with history of stroke, 27% with history of cardiac disease, mean ABCD2 score 3.8 ± 1.5, mean EDOU length of stay 18.6 ± 6.2 hours), abnormal bedside cardiac examination was identified in 19 (8%) patients, abnormal electrocardiogram (ECG)/telemetry in 41 (17%), and abnormal TTE in 64 (27%), 41 of which suggested a patent foramen ovale. Among 136 (58%) patients with no previous cardiac disease or stroke, a normal bedside cardiac examination, and normal ECG/telemetry, TTE identified no high-risk cardiac causes. CONCLUSION: In patients with TIA presenting to an EDOU with no previous cardiac disease or stroke, normal cardiac examination, and normal ECG/telemetry, early TTE had a low yield for identifying high-risk cardiac causes. In EDOUs where TTE is not available daily, outpatient TTE for this patient subgroup may be considered to limit prolonged lengths of stay.

USMLE Scores Predict Success in ABEM Initial Certification: A Multicenter Study.

INTRODUCTION: There are no existing data on whether performance on the United States Medical Licensing Examination (USMLE) predicts success in American Board of Emergency Medicine (ABEM) certification. The aim of this study was to determine the presence of any association between USMLE scores and first-time success on the ABEM qualifying and oral certification examinations. METHODS: We retrospectively collected USMLE Step 1, Step 2 Clinical Knowledge (CK) scores and pass/fail results from the first attempt at ABEM qualifying and oral examinations from residents graduating between 2009 and 2011 from nine EM programs. A composite score was defined as the sum of USMLE Step 1 and Step 2 CK scores. RESULTS: Sample was composed of 197 residents. Median Step 1, Step 2 CK and composite scores were 218 ([IQR] 207-232), 228 (IQR 217-239) and 444 (IQR 427-468). First-time pass rates were 95% for the qualifying examination and 93% for both parts of the examination. Step 2 CK and composite scores were better predictors of achieving ABEM initial certification compared to Step 1 score (area under the curve 0.800, 0.759 and 0.656). Step 1 score of 227, Step 2 CK score of 225 and composite score of 444 predicted a 95% chance of passing both boards. CONCLUSION: Higher USMLE Step 1, Step 2 CK and composite scores are associated with better performance on ABEM examinations, with Step 2 CK being the strongest predictor. Cutoff scores for USMLE Step 1, Step 2 CK and composite score were established to predict first-time success on ABEM initial certification.

Diagnostic value of end tidal capnography in patients with hyperglycemia in the emergency department.

BACKGROUND: Diabetic Ketoacidosis (DKA) is a potentially life-threatening emergency that requires prompt diagnosis and treatment. In paediatric populations an end tidal capnography value greater than 36 mmHg was found to be 100 % sensitive in ruling out DKA. METHODS: A cross sectional observational study of adults ≥ 17 years of age presenting to the emergency department between January 2014 and May 2014 with glucose > 550 mg/dL. In all patients, nasal capnography and venous blood gas analysis were performed prior to any insulin or intravenous fluid administration. The diagnosis of DKA was based on the presence of anion gap metabolic acidosis, hyperglycaemia and ketonemia. The overall diagnostic performance (area under the curve [AUC]), sensitivity, specificity and likelihood ratios at different end tidal CO2 (ETCO2) cut-offs were determined. RESULTS: 71 patients were enrolled in the study of which 21 (30 %) met the diagnosis of DKA. The area under the curve for ETCO2 was 0.95 with a 95 % CI of 0.91 to 0.99. Test sensitivity for DKA at ETCO2 level ≥35 mmHg was 100 % (95 % CI, 83.9-100). An ETCO2 level ≤ 21 mmHg was 100 % specific (95 % CI, 92.9-100.0) for DKA. CONCLUSION: Nasal capnography exhibits favourable diagnostic performance in detecting patients with or without DKA among those who present to the emergency department with a glucometer reading > 550 mg/dL.

Sepsis in hemodialysis patients.

BACKGROUND: Bacterial infections are very common in End Stage Renal Disease (ESRD) patients. The diagnosis of sepsis in such patients is often challenging and requires a high index of suspicion. The aim of this study is to report on a series of patient with ESRD on hemodialysis (HD) diagnosed with sepsis. METHODS: Single center retrospective study looking at ESRD on HD who presented to our tertiary hospital were retrieved. Inclusion criteria included a discharge diagnosis of sepsis, septic shock or bacteremia. RESULTS: Our sample was composed of 41 females and 49 males, with a mean age of 70 ± 15 years. Infections from the HD catheters followed by lower respiratory tract infections were the most common cause of bacteremia. IV fluid replacement for the first 6 and 24 h were 0.58 and 1.27 l respectively. Vasopressors were used in 30 patients with norepinephrine, dopamine and dobutamine used in 22, nine and one patients respectively. Out of 90 subjects, 24 (26.6 %) were dead within the same hospital visit. the 28 days out of hospital mortality was 25.6 %. There was no significant difference in mortality in patients who presented with less than two SIRS or two or more SIRS criteria. CONCLUSION: This is the first study looking at an in depth analysis of sepsis in the specific dialysis population and examining the influence of fluid resuscitation, role of SIRS criteria and vasopressor use on their mortality.

Specific Radiological Findings of Traumatic Gastrointestinal Tract Injuries in Patients With Blunt Chest and Abdominal Trauma.

Gastrointestinal hollow viscus injury after blunt chest and abdominal trauma is uncommon and complicates 0.6%-1.2% of all cases of trauma. Early recognition of such injuries significantly decreases morbidity and mortality. Since physical examination is not accurate in detecting such injuries, contrast-enhanced computed tomography has been the mainstay for diagnosis in many emergency departments. This pictorial essay aims to review the incidence, mechanisms, and signs of gastrointestinal hollow viscus injuries in the setting of blunt chest and abdominal trauma.

Association of lumbar fractures, abdominal aortic calcification, and osteopenia.

PURPOSE: The purpose was to assess if abdominal aortic calcification (AAC) and low bone mineral density (BMD) are associated with fractures on lumbar spine radiographs in trauma patients. METHODS: Retrospectively, 303 consecutive lumbar radiographs were independently reviewed by two radiologists for AAC, low BMD, and traumatic findings. RESULTS: Thirty-one percent of patients had low BMD, 34% had AAC, and 24% had both. Eleven percent of radiographs showed traumatic findings. Seventy-six percent of positive cases had low BMD (P<.001), and 64% had AAC (P<.001). CONCLUSION: A higher index of suspicion for fractures is warranted when AAC and low BMD are present.