Cottonmouth snake bites reported to the ToxIC North American snakebite registry 2013-2017.

Introduction: The majority of venomous snake exposures in the United States are due to snakes from the subfamily Crotalinae (pit vipers). There are three types of US pit vipers: rattlesnakes (Crotalus and Sisturus spp.) copperheads (Agkistrodon contortrix), and cottonmouths (Agkistrodon piscivorus) also known as water moccasins. Cottonmouth bites are reported less frequently than other pit viper envenomations, and data on cottonmouth envenomation are limited. Our objective was to describe the epidemiology, clinical manifestations, and management of cottonmouth envenomations using prospective data reported to the Toxicology Investigators Consortium's (ToxIC) North American Snakebite Registry (NASBR)Methods: Cottonmouth envenomation cases reported to NASBR for the period from January 1, 2013, through December 31, 2017 were reviewed. Variables collected included patient demographics, bite location, clinical manifestations, and management.Results: Thirty-one cottonmouth envenomations were reported. Most bites occurred in children aged 7-12 (39%). Most bites involved the lower extremity (72%). Intentional interaction with the snake occurred in three cases (10%). Swelling was the most reported clinical effect and occurred in all patients. Gastrointestinal symptoms were reported in 19% of patients, and 19% developed coagulopathy. Antivenom treatment was used in 84% of patients. Nineteen patients (61%) required hospital stays of >24 hours.Discussion: Our study represents the first systematic prospective data collection on cottonmouth bites. Our data demonstrate that cottonmouth envenomations cause primarily local effects and, occasionally, systemic toxicity. Our study also demonstrates that antivenom is often indicated for these envenomations per published guidelines and recommendations.Conclusions: Cottonmouth envenomations are relatively infrequent. However, they can cause significant local and systemic toxicity. Most cottonmouth envenomations in this series were treated with antivenom and were hospitalized beyond 24 hours.

Assessing the toxicity and associated costs among pediatric patients admitted with unintentional poisonings of attention-deficit/hyperactivity disorder drugs in the United States.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is widespread, with a national (United States) prevalence of nearly 10%. The 2011 changes in the diagnostic criteria will likely further increase the prevalence of this disorder. Little is known about the incidence of toxicity from unintentional poisonings of ADHD medications. This study attempted to determine the incidence of these ingestions and the corresponding financial impact in the United States. METHODS: Four geographically different centers were chosen. Subjects with unintentional poisonings due to ADHD medications were included if the admission dates were between 2000 and 2002 (cohort A) or between 2009 and 2010 (cohort B). Using data from the participating hospitals and the number of monitored beds in each corresponding county, data were extrapolated on a national (United States) level. RESULTS: Sixty-three subjects were admitted at four hospitals (18, cohort A and 45, cohort B). The crude incidence rate ratio increased in the later time frame as compared to that in the earlier time frame (incidence rate ratio, 3.13; 95% CI, 1.80-5.68; p < 0.0001). The median (IQR) charges per patient, adjusted for inflation, were $4780 ($3,895-$8,287) and $5912 ($3,432-$9,433) for cohorts A and B, respectively (p = 0.57). If the subjects in the participating counties were only admitted to the participating hospitals, the annual charges, extrapolated throughout the United States for the two periods, would be $2,419,016 and $8,129,538, respectively. If the subjects were evenly distributed across all pediatric monitored beds in a given county, the annual charges extrapolated throughout the United States for the two periods would be $5,694,232 and $24,126,640, respectively. CONCLUSION: The incidence of unintentional poisonings from ADHD drugs is increasing and is associated with a significant cost.

Rattlesnake envenomations: unusual case presentations.

Rattlesnake envenomations are common in some areas of the United States. Although fatal rattlesnake envenomations are rare and usually preventable, morbidity may be significant. Patients may present with localized edema, hypotension, coagulopathy, or thrombocytopenia. Patients with progressive swelling or severe coagulopathy are typically treated with Crotalidae polyvalent antivenin. We present a series of 4 patients with unusual complications of rattlesnake envenomation to illustrate the wide spectrum of disease that may be encountered. These case presentations include anaphylaxis to rattlesnake venom, an acute airway emergency, progressive and marked edema with a large pleural fluid collection, and death.

Epidemiology and hospital course of rattlesnake envenomations cared for at a tertiary referral center in Central Arizona.

OBJECTIVE: To describe the demographics and primary inpatient treatment of victims of rattle-snake bites (RSBs) referred to a teritiary referral poison treatment center in central Arizona, and to compare the frequency of local tissue complications and hematologic toxicity during hospitalization in children with those for adults. METHODS: This was a chart review of patients diagnosed as having RSB by a toxicology service between July 1994 and April 2000. Data collected included: age, sex, date, bite location, time to and length of hospitalization, time to and amount of antivenin, serial hematologic studies, and inpatient complications. RESULTS: Of 241 patients admitted, 236 charts met inclusion criteria. The majority of RSB victims were male (81%). Children (< or =13 years) represented 22%. Most RSBs (78%) occurred between April and September. Mean time (+/-SEM) to presentation was 1.7 +/- 0.2 hours. Antivenin was administered to 77% of patients, with an average (+/-SEM) of 28.5 +/- 0.9 vials administered. Hematologic abnormalities included: coagulopathy (60%), hypofibrinogenemia (49%), and thrombocytopenia (33%). No statistically significant difference in the above parameters was detected between upper- and lower-extremity envenomations, or between children and adults. Immediate antivenin reactions occurred in 36% of patients. Hemorrhagic bullae formation occurred in 22%, occurring most frequently in upper extremities. Operative procedures were required in 3.4% of patients. Hospitalization averaged 2.5 +/- 0.1 days. There was no fatality. CONCLUSIONS: In Arizona, RSB victims were typically adult males with upper-extremity bites. Hematologic abnormalities were common. Local tissue complications were more common with upper-extremity envenomations. No statistically significant difference was detected in frequency of hematologic disorders or local tissue complications when children were compared with adults.

Combined ingestion and subcutaneous injection of elemental mercury.

A 40-year-old man with a history of schizophrenia and inflammatory soft tissue lesions after self-injection of elemental mercury presented to the Emergency Department. Multiple skin abscesses associated with fever required operative debridement. An incidental finding of oral mercury ingestion was followed clinically and did not result in complications. Exposure to elemental mercury through injection or ingestion is an uncommon event, but one the Emergency Physician may encounter. Subcutaneous mercury injection should be managed with local wound debridement, whereas ingestions are rarely of clinical significance.

Hypertonic sodium bicarbonate is effective in the acute management of verapamil toxicity in a swine model.

STUDY OBJECTIVE: This study was conducted to determine whether hypertonic sodium bicarbonate would improve the hypotension associated with severe verapamil toxicity compared with volume expansion. METHODS: The study design used a nonblinded acute animal preparation. Twenty-four anesthetized and instrumented swine were poisoned with verapamil delivered at a rate of 1 mg/kg per hour for 10 minutes followed by incremental increases of 1 mg/kg per hour every 10 minutes until the endpoint of a mean arterial blood pressure of 45% of baseline was achieved. Animals alternately received either 4 mEq/kg of hypertonic sodium bicarbonate intravenously over 4 minutes or similar volumes of 0.6% sodium chloride in 10% mannitol (control). The main outcome parameter followed was mean arterial pressure. In addition, physiologic parameters including cardiac output, heart rate, pH, PCO (2), PO (2), plasma ionized calcium, sodium, and potassium were monitored. RESULTS: Verapamil toxicity, as defined by a mean arterial pressure of 45% of baseline, was produced in all animals following an average verapamil infusion dose of 0.6+/-0.12 mg/kg. This dose produced an average plasma verapamil concentration of 728.1+/-155.4 microgram/L, with no significant difference between groups. Swine treated with hypertonic sodium bicarbonate experienced a significant increase in mean arterial pressure (>50%) and cardiac output (>30%) over the first 20 minutes that slowly equilibrated with the control group over the remainder of the experiment. As expected, plasma sodium concentrations were elevated significantly in the sodium bicarbonate group while plasma potassium concentrations were decreased significantly. Finally, there was a significant decrease in plasma ionized calcium concentration in the sodium bicarbonate-treated group compared with controls. CONCLUSION: Hypertonic sodium bicarbonate reversed the hypotension and cardiac output depression of severe verapamil toxicity in a swine model.

A real-time microprocessor QRS detector system with a 1-ms timing accuracy for the measurement of ambulatory HRV.

The design, test methods and results of an ambulatory QRS detector are presented. The device is intended for the accurate measurement of heart rate variability (HRV) and reliable QRS detection in both ambulatory and clinical use. The aim of the design work was to achieve high QRS detection performance in terms of timing accuracy and reliability, without compromising the size and power consumption of the device. The complete monitor system consists of a host computer and the detector unit. The detector device is constructed of a commonly available digital signal processing (DSP) microprocessor and other components. The QRS detection algorithm uses optimized prefiltering in conjunction with a matched filter and dual edge threshold detection. The purpose of the prefiltering is to attenuate various noise components in order to achieve improved detection reliability. The matched filter further improves signal-to-noise ratio (SNR) and symmetries the QRS complex for the threshold detection, which is essential in order to achieve the desired performance. The decision for detection is made in real-time and no search-back method is employed. The host computer is used to configure the detector unit, which includes the setting of the matched filter impulse response, and in the retrieval and postprocessing of the measurement results. The QRS detection timing accuracy and detection reliability of the detector system was tested with an artificially generated electrocardiogram (ECG) signal corrupted with various noise types and a timing standard deviation of less than 1 ms was achieved with most noise types and levels similar to those encountered in real measurements. A QRS detection error rate (ER) of 0.1 and 2.2% was achieved with records 103 and 105 from the MIT-BIH Arrhythmia database, respectively.