Bupropion associated seizures following acute overdose: who develops late seizures.

Objectives: Bupropion is an antidepressant that is commonly known to cause seizures in overdose. Because of concern for delayed onset of seizures, patients are frequently observed for prolonged periods after overdose. The primary objective is to evaluate the incidence and clinical parameters associated with late seizures following bupropion overdose.Methods: This retrospective study of acute bupropion overdose who presented to 26 different hospitals in California and Arizona during an 8 year time period.Results: 437 patients were identified. Tachycardia and altered mental status were common. A total of 122 (27.9%) patients had seizures following their overdose. Only eight patients (1.8%) had a seizure more than 8 h after hospital arrival. None of these patients were asymptomatic on arrival. Among patients with tachycardia on arrival, the odds of having a seizure was 6.7 (95% CI 3.7-10.9); the odds of a seizure more than 8 h after arrival was 5.24 (95% CI 1.2-23.5). Similarly, altered mental status on arrival was significantly associated with the risk of a seizure; OR 3.93 (95% CI 2.21-7.0).Conclusion: Seizures are relatively common, and are associated with antecedent tachycardia or altered mental status.

Pediatric Bupropion Ingestions in Adolescents vs. Younger Children-a Tale of Two Populations.

BACKGROUND: Bupropion is a unique class of antidepressant. In overdose, it is associated with tachycardia, altered mental status, and a dose-dependent risk of seizures, which can be delayed. Despite being a common medication, there is a paucity of data comparing toxicity in younger versus older children with bupropion exposures. The primary purpose of this study is to examine bupropion toxicity in pediatric patients and assess for toxicity differences between younger and older (teenaged) groups. METHODS: This single-center, observational cohort study reviewed pediatric patients presenting to a toxicology service between 2011 and 2018. The primary outcome measures evaluated were the presence of any seizure, delayed seizure (defined as occurring at least 6 hours after hospital arrival), and a composite endpoint of seizure, hypotension, or need for endotracheal intubation. Patients were subdivided into two groups-those 12 years and under, compared with those 13-17 years. RESULTS: A total of 80 unique pediatric cases were identified. Overall, the median (IQR) age was 14 (2.4-16) years. Patients under 13 years accounted for 31 (39%) of cases, whereas the remaining 49 cases were adolescents. Compared with the adolescents, the younger patients were less likely to be female (41.9% vs. 71.4%; p = 0.009) and more likely to have an unintentional ingestion (100% vs. 10.2%; p < 0.001). The younger group was more likely to present to health care earlier after the ingestion (median 61 (IQR 39-103) min vs. 139 (67-399) min; p = 0.002). The older group was more likely to be tachycardic (73.5% vs. 19.4%; p < 0.001), have sustained tachycardia (71.4% vs. 29% p < 0.001), and more likely to have altered mental status on arrival (38.8% vs. 6.5%; p < 0.001). Seizures were also much more likely in the older group (40.8% vs. 3.2%; p < 0.001). Adolescents were much more likely than younger children to reach the pre-defined composite endpoint (42.9% vs. 6.5%; p < 0.001), but this was largely driven by the seizures. CONCLUSION: Bupropion ingestions are relatively common among pediatric patients. However, adolescents are much more likely to present with more severe toxicity. Seizures are uncommon among younger children with exploratory ingestions.

Implementation of a Clinical Decision Support System for Children With Minor Blunt Head Trauma Who Are at Nonnegligible Risk for Traumatic Brain Injuries.

STUDY OBJECTIVE: To determine the effect of providing risk estimates of clinically important traumatic brain injuries and management recommendations on emergency department (ED) outcomes for children with isolated intermediate Pediatric Emergency Care Applied Research Network clinically important traumatic brain injury risk factors. METHODS: This was a secondary analysis of a nonrandomized clinical trial with concurrent controls, conducted at 5 pediatric and 8 general EDs between November 2011 and June 2014, enrolling patients younger than 18 years who had minor blunt head trauma. After a baseline period, intervention sites received electronic clinical decision support providing patient-level clinically important traumatic brain injury risk estimates and management recommendations. The following primary outcomes in patients with one intermediate Pediatric Emergency Care Applied Research Network risk factor were compared before and after clinical decision support: proportion of ED computed tomography (CT) scans, adjusted for age, time trend, and site; and prevalence of clinically important traumatic brain injuries. RESULTS: The risk of clinically important traumatic brain injuries was known for 3,859 children with isolated findings (1,711 at intervention sites before clinical decision support, 1,702 at intervention sites after clinical decision support, and 446 at control sites). In this group, pooled CT proportion decreased from 24.2% to 21.6% after clinical decision support (odds ratio 0.86; 95% confidence interval 0.73 to 1.01). Decreases in CT use were noted across intervention EDs, but not in controls. The pooled adjusted odds ratio for CT use after clinical decision support was 0.73 (95% confidence interval 0.60 to 0.88). Among the entire cohort, clinically important traumatic brain injury was diagnosed at the index ED visit for 37 of 37 (100%) patients before clinical decision support and 32 of 33 patients (97.0%) after clinical decision support. CONCLUSION: Providing specific risks of clinically important traumatic brain injury through electronic clinical decision support was associated with a modest and safe decrease in ED CT use for children at nonnegligible risk of clinically important traumatic brain injuries.

Assessing the Effect of a Medical Toxicologist in the Care of Rattlesnake-envenomated Patients.

BACKGROUND: Rattlesnake envenomation is an important problem in the United States, and the management of these envenomations can be complex. Despite these complexities, however, the majority of such cases are managed without the involvement of a medical toxicologist. The primary objective of this study was to evaluate the impact of a medical toxicology service (MTS) on the length of stay (LOS) of such patients. METHODS: The authors conducted a retrospective study at six centers in California. Patients were included if they were admitted in the 2 years before the establishment of a MTS (pre-MTS) or in the 2 years after the creation of a MTS (post-MTS). RESULTS: A total of 300 subjects were included (169 pre-MTS, 131 post MTS). Baseline characteristics between the pre-MTS and post-MTS groups were very similar. The creation of a MTS was associated with a significant reduction in the mean (95% confidence interval) LOS (69.5 [59.1-79.9] hours vs. 48.1 [41.4-54.8] hours). This reduced LOS was not associated with any statistically significant change in readmission rates. CONCLUSION: Rattlesnake bite patients treated by a medical toxicologist have a significantly reduced LOS compared to those without direct involvement of a medical toxicologist.

Use of Traumatic Brain Injury Prediction Rules With Clinical Decision Support.

OBJECTIVES: We determined whether implementing the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) prediction rules and providing risks of clinically important TBIs (ciTBIs) with computerized clinical decision support (CDS) reduces computed tomography (CT) use for children with minor head trauma. METHODS: Nonrandomized trial with concurrent controls at 5 pediatric emergency departments (PEDs) and 8 general EDs (GEDs) between November 2011 and June 2014. Patients were <18 years old with minor blunt head trauma. Intervention sites received CDS with CT recommendations and risks of ciTBI, both for patients at very low risk of ciTBI (no Pediatric Emergency Care Applied Research Network rule factors) and those not at very low risk. The primary outcome was the rate of CT, analyzed by site, controlling for time trend. RESULTS: We analyzed 16 635 intervention and 2394 control patients. Adjusted for time trends, CT rates decreased significantly (P < .05) but modestly (2.3%-3.7%) at 2 of 4 intervention PEDs for children at very low risk. The other 2 PEDs had small (0.8%-1.5%) nonsignificant decreases. CT rates did not decrease consistently at the intervention GEDs, with low baseline CT rates (2.1%-4.0%) in those at very low risk. The control PED had little change in CT use in similar children (from 1.6% to 2.9%); the control GED showed a decrease in the CT rate (from 7.1% to 2.6%). For all children with minor head trauma, intervention sites had small decreases in CT rates (1.7%-6.2%). CONCLUSIONS: The implementation of TBI prediction rules and provision of risks of ciTBIs by using CDS was associated with modest, safe, but variable decreases in CT use. However, some secular trends were also noted.

Vasopressin treatment of verapamil toxicity in the porcine model.

INTRODUCTION: Vasopressin is a novel vasopressor agent used for intractable hypotension. There is little published data available on its use in the poisoned patient. We performed a randomized, controlled, blinded trial in a porcine model to study the effects of vasopressin infusion on mean arterial pressure after verapamil poisoning. METHODS: Eighteen anesthetized monitored swine received a verapamil infusion of 1 mg/kg/hr until the mean arterial pressure (MAP) had decreased to 70% of baseline. At this time, a continuous infusion of either vasopressin (0.01 U/kg/min) or an equal volume of normal saline was initiated. The swine were monitored for 60 minutes after initiation of the study infusion. The primary outcome was MAP. RESULTS: There was no statistically significant difference between the two groups in MAP, cardiac output or systemic vascular resistance. One half (four of eight) of the animals in the vasopressin group died, compared with 20% (two of ten) of those in the saline group. CONCLUSIONS: Vasopressin infusion decreased the survival of verapamil-poisoned swine when compared to those treated with saline alone in this experimental model.