First use of the Molecular Adsorbent Recirculating System technique on patients with hypoxic liver failure after cardiogenic shock.

The Molecular Adsorbent Recirculating System (MARS) has been proven to prolong survival in patients with hepatorenal syndrome. MARS is a modified dialysis that uses an albumin containing dialysate, which is recirculated and perfused online through charcoal and anion exchanger columns. It allows the selective removal of albumin bound substances. Despite advances in medical therapy and technology, the prognosis of patients with cardiogenic shock remains poor. Mortality rates are as high as 80%, often because of persistent multiple organ failure. To determine whether patients with hypoxic liver failure after cardiogenic shock after cardiac surgery might benefit from MARS, we performed a prospective, randomized, controlled, single center study. The primary objective was to prove that MARS improves survival. This article is a report on the interim analysis of the first 27 patients included between August 2000 and December 2001; 14 patients were in the MARS group, and 13 patients were in the non-MARS group. All had bilirubin levels greater than 8 mg/ml. Both groups had a similar risk profile. The MARS group received MARS for 3 consecutive days-if bilirubin was still greater than 6 mg/dl afterward, MARS was continued. The non-MARS group received conventional therapy. We had seven survivors in the MARS group (50%) compared with four (32%; p = ns) in the non-MARS group. We conclude that despite the limited number of patients included in this analysis, MARS can be recommended for patients with acute, hypoxic liver failure because it might prolong survival. Further studies in similar patient cohorts are needed to verify our results.

Should home ipecac-induced emesis be routinely recommended in the management of toxic berry ingestions?

Poison center (PC) management of toxic berry ingestions may include recommendations to administer syrup of ipecac (SI) regardless of the number of berries ingested. We investigated whether the routine use of SI in the home management of asymptomatic single or few (< 6) berry ingestions may be unnecessary. A prospective, randomized clinical trial compared SI + home observation (HO) to HO alone for management of pediatric toxic berry ingestions. Subjects were children 9 mo to 5 y who ingested a small number (< 6) of Taxus sp (yew), Solanum americanus (nightshade), Ilex sp (holly) or unknown potentially toxic berries. Exclusions were symptomatic subjects, ingestion of more than 1 type of berry or other plant part, or contraindication to SI. Outcome variables consisting of symptom assessment and disposition were assessed 24 h following the ingestion. Over a 27-mo period 103 subjects were entered into the study; 45 received SI/HO and 51 received only HO. While 100% of the SI/HO group experienced vomiting, none of the HO group vomited. Diarrhea and sedation were more common in the SI/HO group. Use of SI in the home management of young children who ingest fewer than 6 toxic berries (yew, nightshade, holly or unknown) and who are asymptomatic when the PC is contacted may be responsible for the majority of symptoms. Ingestion of small amounts of berries may require no intervention beyond observation. Methodological limitations of this study included the lack of confirmed identification of the berries and the inability to confirm ingestion and absorption.

A comparison of the bioavailabilities of oral and intravenous ethanol in healthy male volunteers.

OBJECTIVES: Ethanol (EtOH), the antidote for methanol and ethylene glycol, is administered by the oral (PO) and intravenous (IV) routes. Serum concentrations (SCs) of 100 mg/dL or more are targeted for clinical effect. This study was completed to validate the assumption that there are minimal differences in SC achieved between these two routes. METHODS: Twenty healthy male volunteers were randomized to receive either PO or IV EtOH. Subjects abstained from EtOH for 48 hours before each phase. After a seven-day washout period, the subjects crossed over to the other group. Inclusion criteria were no history of medical problems, age between 21 and 40 years, and actual body weight within 10% of ideal weight. Baseline EtOH SCs were obtained before participation in each phase. Two hours after a standard breakfast, the subjects received 700 mg/kg of PO or IV EtOH. PO EtOH was administered as a 20% solution in juice over 10 minutes. IV EtOH, controlled by an infusion pump, was administered as a 10% solution over 30 minutes. Blood was drawn for EtOH SCs at 45, 75, 105, 135, 165, 225, 285, and 345 minutes after start of the dose. RESULTS: All initial EtOH SCs were 0. EtOH SCs were higher after IV administration. Mean peak SC was 103.6 mg/dL after IV administration and 71.3 mg/dL after PO administration (p<0.0001). Mean time to peak was 46.5 minutes after IV administration and 103.5 minutes after PO administration (p<0.0001). Total area under the curve was 17,440 min-mg/dL after IV administration and 13,875 min-mg/dL after PO administration (p<0.003). The order of treatments did not affect results (p>0.1). CONCLUSION: Significant differences exist between the SCs of EtOH as well as the times to peak SC after PO and IV administrations.

Home observation for asymptomatic coin ingestion: acceptance and outcomes. The New York State Poison Control Center Coin Ingestion Study Group.

OBJECTIVES: To obtain preliminary estimates of the acceptance rate and the frequency of adverse outcomes, and to identify issues related to acceptance, associated with management of asymptomatic pediatric coin ingestion by home observation, in preparation for a large-scale prospective study. METHODS: Scripted telephone follow-up of callers who had reported asymptomatic pediatric coin ingestions to one of five poison control centers six to 36 months previously, which had been managed by home observation. RESULTS: Of the 67 callers enrolled, 41 (67%) reported contacting a physician regarding the coin ingestion, despite home observation instruction by poison control center personnel. Those who did not recall being instructed in home observation were more likely to have contacted a physician than those who did. Nearly all, however, were satisfied with the advice they had been given. One child developed subsequent symptoms; as per the instructions that had been given by poison control center personnel, his parent sought physician evaluation, revealing an esophageal coin, which was removed uneventfully. No other child developed complications. CONCLUSIONS: Although all of the 67 children managed by home observation did well, most of their caretakers had not accepted this management strategy. Acceptance, while unrelated to satisfaction, may be related to comprehension of the instructions caregivers are given. A prospective study of home observation for asymptomatic pediatric coin ingestion would be safe and would allow further examination of factors affecting acceptance.

Toxicology training of paramedic students in the United States.

A 16-item survey was mailed to the directors of 618 paramedic training programs in the United States to determine (1) the number of lecture hours devoted to toxicology topics and (2) how often paramedic training includes a rotation in a poison control center. The response rate was 82%. Toxicology accounts for approximately 2% of paramedic students' total training. Cardiovascular drug toxicity and hazardous materials are discussed for over 60 minutes by more than 50% of paramedic training programs. Four paramedic programs have no lecture time on cyclic antidepressant overdoses and one program has no lecture time on carbon monoxide poisoning. Eighty-one percent (377 of 467) have access to a regional poison control center; 11% (42 of 377) use the poison control center as a paramedic training site. Some US paramedic training programs spend insufficient time covering topics that have significant out-of-hospital morbidity. Although poison control centers are often available, they are underutilized for paramedic training.

Experimental tricyclic antidepressant toxicity: a randomized, controlled comparison of hypertonic saline solution, sodium bicarbonate, and hyperventilation.

STUDY OBJECTIVE: We sought to compare the effects of hypertonic sodium chloride solution (HTS), sodium bicarbonate solution, and hyperventilation (HV) on severe tricyclic antidepressant (TCA) toxicity in a swine model. METHODS: Twenty-four mixed-breed, domestic swine of either sex were given an intravenous infusion of nortriptyline (NT) until development of both a QRS duration longer than 120 ms and a systolic blood pressure (SBP) less than or equal to 50 mm Hg. Animals were randomly assigned to 1 of 4 groups. On reaching toxicity, the control group received 10 mL/kg of 5% dextrose in water (D5W); the HTS group received 10 mL/kg of 7.5% NaCl solution (15 mEq Na+/kg); the NaHCO3 group received 3 mEq/kg of 8.4% sodium bicarbonate solution followed by enough D5W solution to equal 10 mL/kg of total volume; and the HV group was mechanically hyperventilated to maintain arterial pH between 7.50 and 7.60 and given 10 mL/kg of D5W. RESULTS: The mean SBP 10 minutes after treatment was 54+/-18 mm Hg in the control group, 134+/-21 mm Hg in the HTS group, 85+/-19 mm Hg in the NaHCO3 group, and 60+/-12 mm Hg in the HV group (P<.05). Mean QRS duration 10 minutes after treatment was 144+/-38 ms in the control group, 80+/-14 ms in the HTS group, 105+/-38 ms in the NaHCO3 group, and 125+/-46 ms in the HV group (P<.05). CONCLUSION: In this model of TCA, toxicity HTS was more effective than sodium bicarbonate. Hyperventilation had little effect. Sodium loading may be the most important factor in reversing TCA toxicity.

Gatekeepers: a missed opportunity for safe transport.

OBJECTIVE: To assess whether contact with a health care provider or gatekeeper increases the use of an ambulance for patients with acute chest pain. METHODS: A convenience sample of adults > or =40 years of age presenting with a chief complaint of chest pain were interviewed by trained personnel regarding transport used to come to the ED. The study was performed at the ED of an urban university hospital. Patients with hemodynamic instability and those receiving thrombolytics or emergency angioplasty were excluded. Patients were asked about access to a primary health care provider and contact with a provider regarding this ED visit, including instructions given for transportation. RESULTS: Of the 450 interviewed patients, 42% arrived by ambulance. Those who had contact with a health care provider prior to the ED visit were less likely to come by ambulance than those without contact, 31% vs 51% (p < 0.001). Of the patients who had cardiac enzymes obtained to work up for their chest pain, 34% with health provider contact vs 57% without health provider contact arrived by ambulance (p < 0.001). Of those with acute myocardial infarction, 30% with health provider contact vs 66% without health provider contact came by ambulance (p < 0.03). Patients who recalled transport instructions from their providers tended to follow those instructions. The majority of patients who recalled no specific transport instructions arrived by personal automobile. CONCLUSION: Of patients presenting to an ED for evaluation of chest pain, those who made contact with a health care provider were less likely to arrive via ambulance.

Prehospital gastrointestinal decontamination of toxic ingestions: a missed opportunity.

The purpose of this study was to determine if emergency medical services (EMS) providers routinely initiate field gastrointestinal decontamination of adult drug overdose patients transported to the emergency department (ED). A retrospective prehospital chart review was performed on adult patients identified as drug overdose who were transported by EMS. ED charts on patients transported to a university hospital were reviewed for follow-up data. Prehospital care records showed that gastrointestinal decontamination was initiated in only 6 of 361 (2%) patients, all of whom received ipecac. No patient received activated charcoal. The median transport time was 25 minutes (range, 5 to 66 minutes). Follow-up data on patients transported to the university hospital revealed that 30 of 43 (70%) patients who might have been suitable candidates for prehospital activated charcoal actually received activated charcoal in the ED. Median time to activated charcoal in the ED was 82 minutes (range, 32 to 329 min). Use of activated charcoal in the field appears to be deferred despite its known loss of efficacy over time. The failure to start activated charcoal in the field contributes to the delay in initiating activated charcoal therapy.

Cocaine balloon aspiration: successful removal with bronchoscopy.

Ingestion of balloons containing illicit substances along with the potential toxic sequelae associated with these ingestions have been described in the literature. This report describes the successful bronchoscopic retrieval of a cocaine balloon after aspiration. A 39-year-old man was witnessed swallowing several balloons that were thought to contain heroin. Shortly after ingestion, the patient became unconscious and required nasotracheal intubation. Before intubation, several balloons were removed from the oropharynx. Naloxone 4 mg was administered en route to the emergency department (ED). Following naloxone, the patient awoke and became agitated and combative. On arrival in the ED, midazolam, succinylcholine, and vecuronium were required to manage his combativeness. Vital signs were: heart rate, 130 beats/min; blood pressure, 128/86 mm Hg; respirations, 12 breaths/min; temperature, 96.5 degrees F. A balloon and balloon tip were removed during lavage. Whole bowel irrigation with a polyethylene glycol electrolyte solution was initiated. A right upper lobe infiltrate was identified on chest X-ray and aspiration of a balloon was suspected. At bronchoscopy, a small yellow, intact balloon visualized in the basilar segment of the right lower lobe was removed. Toxicologic analysis of the balloon contents found cocaine. The rest of the patient's hospital course was unremarkable and he was discharged 5 days after admission. This case brings to light the potential concerns, such as respiratory compromise, associated with aspiration of small balloons in the body stuffer. Additionally, the potential for the development of toxicity if the balloon ruptures and toxin absorption occurs through through the lungs should be considered. Emergency physicians and toxicologists should be aware of this significant complication of packet ingestion in the body packer or stuffer and be prepared to intervene early during the course of the patient's treatment.

Frequent users of the emergency department: can we intervene?

OBJECTIVE: To determine whether the use of individualized patient care plans and multidisciplinary case management would decrease ED utilization by frequent ED users. METHODS: The authors performed a prospective, randomized clinical trial of the impact of a care plan on ED use by adults with frequent ED visits. Patients with > 10 ED visits to a university hospital in 1993 were identified. Patients were matched for age, sex, and number of visits and then randomized into 2 groups. The control group received standard emergency care. The treatment group was managed by a multidisciplinary team and treated in the ED according to individualized care plans. ED use was tracked at the university hospital and at the other 5 community hospitals in the city. RESULTS: Of the 70 enrolled patients, 25 of 37 control patients and 27 of 33 treatment patients made visits to the university hospital during the 1-year study period. Only those patients with follow-up visits were included in the data analysis. Patients remaining in the control group made 247 total visits (range 1-65) to the university hospital and 179 total visits (range 0-38) to the community hospitals during the study period. Patients in the treatment group made 320 total visits (range 1-72) to the university hospital and 254 total visits (range 0-135) to the community hospitals during the study period. There was no significant difference in the median number of visits made to either the university hospital or the community hospitals by the patients in the control group and those in the treatment group. CONCLUSIONS: The use of individualized care plans and case management did not significantly decrease ED utilization by frequent ED users. However, the impact of individualized care plans and case management on other quality-of-care measures (e.g., patient satisfaction, ED length of stay, hospitalizations, primary care visits, and health care costs) remains to be determined.

Assessment of learning by emergency medicine residents and pharmacy students participating in a poison center clerkship.

An AAPCC-designated poison center developed and validated an objective testing instrument to evaluate learning during a poison center clinical rotation for 2nd-year emergency medicine residents and 5th-year pharmacy students. The examination contained multiple-choice, true-false, and fill-in questions pertaining to basic clinical toxicology. A pretest was administered prior to the rotation and a post-test was administered upon completion of the rotation. Overall pre-test mean was 56.2%; physician pre-test mean was 73.8%, and student pre-test mean was 43.9%. Overall post-test mean was 78.7%; physician post-test mean was 85.7%, and student post-test mean was 81%. Pre-test scores ranged from 21 to 86% for the group, and post-test scores ranged from 68 to 96%. The mean difference in pre-test to post-test score was 26.9%. These data suggest that a poison center rotation can result in significant increases in post-test scores in comparison to pre-test scores.

Research subject enroller program: a key to successful emergency medicine research.

OBJECTIVE: To describe the successful use and impact of individuals paid to enroll clinical research subjects in support of emergency medicine (EM) research. PROGRAM DESCRIPTION: Paramedics and college students were hired to identify/enroll subjects in EM research studies 14 hours/day, 7 days/week. Potential subjects were identified by monitoring emergency medical services radios, routine rounding in the ED, and communication with the ED attending and charge nurse. Enrollers were trained in phlebotomy, obtaining ECGs, obtaining consent in appropriate studies, and post-ED follow-up. They supported ED prospective studies and multicenter clinical trials, as well as departmental surveys and retrospective studies. Survey support included mailing list development, mailing completion, survey database design, and data entry. PROGRAM OUTCOMES: Over 18 months, 17 prospective studies and 8 surveys/retrospective studies were completed. 2,175 subjects were enrolled in prospective studies and 6,500 surveys/retrospective reviews were completed. In the year prior to enroller program initiation, < 100 subjects were enrolled in 3 departmental studies. CONCLUSION: Use of paid, clinical research subject enrollers supports successful recruitment of study subjects and the completion of EM research studies.

Valerian overdose: a case report.

We present the first reported case of valerian (Valeriana officianalis) overdose. This herb is popular as a sedative but little is known about its toxic effects. The patient presented with mild symptoms, all of which resolved within 24 h. Valerian overdose, at approximately 20 times the recommended therapeutic dose, appears to be benign.

Recovery from severe cyclic antidepressant overdose with hypertonic saline/dextran in a swine model.

OBJECTIVE: To determine the effect of a hypertonic saline and dextran (HSD) solution on blood pressure and QS duration during severe cyclic antidepressant (CA) toxicity in swine. METHODS: Ten domestic swine weighing 20-24 kg were anesthetized and placed on mechanical ventilation. Nortriptyline solution was infused intravenously to achieve hypotension (systolic blood pressure equal to 50% of baseline) and a QRS duration of 120 msec. After reaching toxicity, the animals received in a randomized fashion either 10 mL/kg of a 7.5% saline/6% dextran solution or an equal volume of 0.9% saline as a rapid intravenous bolus. The animals were observed for one hour or until they died. Blood pressure and ECG were recorded continuously. Arterial pH was maintained in the physiologic range by controlled ventilation. RESULTS: Mean systolic blood pressure 10 minutes after treatment was 45 +/- 8 torr in the normal- saline group compared with 115 +/- 12 torr in the HSD group (p < 0.05). Mean QRS duration 10 minutes after treatment was 180 +/- 8 msec in the normal-saline group; it was 88 +/- 13 msec in the HSD group (p < 0.05). All normal-saline--group animals died within 20 minutes, and four of the five animals in the HSD group survived to 60 minutes (p < 0.05). The mean peak sodium concentration was 157 mmol/dL (mEq/dL) in the HSD group, and this was transient. CONCLUSION: In this swine model of severe CA toxicity, a solution of 7.5% saline/6% dextran significantly reversed hypotension and QRS prolongation. HSD also improved survival to 60 minutes.