Accidental Ingestion of a Novel Psychoactive Substance: A Case Report.

Novel psychoactive substances (NPSs) are a new generation of designer drugs that are quickly replacing the traditionally abused street drugs. Since their development, the number of molecules in NPSs and their variants have expanded exponentially. Little is known locally about the toxic effects of the exposure of these NPSs. We report two cases of accidental ingestion of methyl (2S)-2-{[1-(5-fluoropentyl)-1H-indole-3-arbonyl]amino}-3,3-dimethylbutanoate (5-fluoro-MDMB-PICA), a recent NPS. They were drinking the liquid in a winter melon tea bottle, and one patient had a seizure episode directly after ingestion. Both patients were managed supportively and discharged after a brief hospitalization period. Presentation to the emergency departments (EDs) following exposure to NPSs may become more common. Knowledge about the impact of NPS exposure and their clinical effects is lacking amongst emergency physicians in Singapore, and this case report serves as a potential resource for physicians.

Cost Savings and Efficacy in Management of Paracetamol Poisoning in a 23-hours Emergency Department Observation Unit: A Comparison to Inpatient Care.

Introduction Emergency department observation units (EDOU) have been shown to be effective in decreasing hospitalization rates and length of stay (LOS) for various conditions. However, cost savings and efficacy in the management of poisoning in EDOU have not been widely studied. The objective of our study is to compare the costs and effectiveness of managing paracetamol poisoned patients in the EDOU with those treated in the inpatient wards. Methods We conducted a historical controlled observational study comparing paracetamol-poisoned patients (who received at least 21 hours of IV N-acetylcysteine [NAC]) admitted to the EDOU during 2013-2014 with similar patients admitted to inpatient ward during 2011, 2013-2014.  Results We found 136 patients admitted to the inpatient ward and 95 to our EDOU due to paracetamol poisoning but only 78 and 39 patients respectively fulfilled the inclusion criteria. Between the EDOU and inpatient ward groups, we found similar demographics, poisoning presentation, treatment, and adverse event profiles. There were no fatalities and only two patients (one from each group) developed hepatotoxicity. The "medical" length of stay was 31.9 hours shorter in the EDOU group compared to the inpatient ward group (23.3 versus 55.2 hours). EDOU patients have statistically significant savings (comparing bill size) of S$784 per patient. Conclusions Admission to the EDOU resulted in significant cost savings and 58% decreased LOS when compared to inpatient wards. The EDOU is a cost-effective and safe alternative for the management of selected paracetamol poisonings requiring NAC. Further studies would be needed to verify these results.

Improving telestroke treatment times through a quality improvement initiative in a Singapore emergency department.

INTRODUCTION: Telestroke allows for remote determination of suitability for treatment with thrombolysis in patients with acute ischaemic stroke. However, this approach is time-dependent and most centres have yet to achieve the recommended treatment times. We describe a quality improvement initiative aimed at improving the telestroke workflow and treatment times at our centre. METHODS: A multidisciplinary workgroup comprising clinicians, stroke case managers and radiology staff was formed to oversee the initiative. A phase-by-phase review of the existing workflow was done to identify the reasons for delay. Phase-specific measures were then introduced to address these delays, and a data-monitoring system was established to track the impact of these measures. The initiatives were implemented through four Plan-Do-Study-Act cycles. The door-to-needle (DTN) times for thrombolysis and clinical outcomes before and after the interventions were compared. RESULTS: A total of 104 patients were evaluated. The median DTN time improved from 96 minutes to 78 minutes post implementation of initiatives (p = 0.003). Fewer patients had symptomatic intracranial haemorrhages (8.5% vs. 24.2%; p = 0.03), and more patients had improvements in their National Institutes of Health Stroke Scale score (47.9% vs. 25.0%; p = 0.031) after the initiatives were introduced. CONCLUSION: The quality improvement initiative resulted in a reduction in median DTN time. Our approach allowed for a systematic method to resolve delays within the telestroke workflow. This initiative is part of an ongoing effort aimed at providing thrombolysis safely to eligible patients in the shortest possible time.

Use of a 23-hour emergency department observation unit for the management of patients with toxic exposures.

BACKGROUND: A significant proportion of patients with toxic exposures presenting to the ED require admission. However, most will improve within 24 hours, and so could potentially be managed in a short-stay observation unit. We describe the management and outcomes of these patients in a 23-hour ED observation unit (EDOU). METHODS: A retrospective chart review of all patients with toxic exposures admitted to the EDOU in Singapore between 1 April 2013 and 31 March 2015 was performed. Patient demographics, exposure patterns, clinical presentation and interventions received were abstracted. The poisoning severity score (PSS) was retrospectively determined. Outcomes were length of stay and disposition. RESULTS: A total of 286 patients were analysed, of which 78.0% had intentional self-poisoning, 12.2% had bites/stings and 9.8% had unintentional or occupational toxic exposures. Analgesics (29.4%), sedatives (12.3%) and antidepressants (6.8%) were the most common drugs encountered. The majority of patients had a mild (68.9%) or moderate (15.4%) PSS, but 4.2% were graded as severe. Most patients with deliberate self-poisoning were reviewed by psychiatry (88.8%) and social services (74.9%). Most patients (92.0%) were medically cleared during their stay in EDOU, including all 12 with a severe PSS. Of these, 200 (69.9%) were discharged and 63 (22.0%) were transferred directly to a psychiatric unit. The median length of stay in the EDOU was 18 hours (IQR 13-23). CONCLUSION: Most patients admitted to the EDOU were successfully managed and medically cleared within 23 hours, including those with a severe PSS. The EDOU appears to be a suitable alternative to inpatient admission for selected patients.

Safety profile of snake antivenom (use) in Hong Kong - a review of 191 cases from 2008 to 2015.

INTRODUCTION: The mainstay of treatment for significant envenoming from snakebites is antivenom. However, there is insufficient data regarding the safety of antivenom used in Hong Kong. We describe the incidence of hypersensitivity reactions from antivenom use and review the frequency and reasons for intensive care unit (ICU) admission. METHODS: The Hong Kong Poisons Information Centre database was reviewed. All patients given snake antivenom between 2008 and 2015 were included. Patient demographics, species of snake involved, details of antivenom used, treatment location, use of pre-treatment, reasons for ICU admission (where applicable) and details of early and late antivenom reactions were extracted. RESULTS: There were 191 patients who received snake antivenom. Most (93%) were treated with either the green pit viper antivenom from Thailand or the Agkistrodon halys antivenom from China. The incidences of early hypersensitivity reactions to green pit viper antivenom and Agkistrodon Halys antivenom were 4.7% and 1.4%, respectively. Most patients (69%) were managed in the ED observation ward or general ward. There were 59 patients managed in ICU, most (90%) of whom were admitted for close monitoring during antivenom administration. There were no cases of significant morbidity from antivenom administration. Eight patients (5.6%) had features suggestive of mild serum sickness. CONCLUSIONS: The incidence of immediate hypersensitivity reaction to antivenom commonly used in Hong Kong is low. Majority of patients were managed safely in the emergency department observation ward or general ward. Serum sickness appears to be uncommon and possible cases presented with mild features.

Snakebite by the Shore Pit Viper (Trimeresurus purpureomaculatus) Treated With Polyvalent Antivenom.

Although snakebites are uncommon, there are several species of medically important venomous snakes native to Singapore. We present a case of envenoming by the shore pit viper (Trimeresurus purpureomaculatus) that showed clinical improvement when treated with the Indian (Haffkine) polyvalent antivenom. A 40-year-old man was bitten on his right hand by a snake, which was identified through photos and his description to be a shore pit viper, which is native to the local mangrove area. Severe swelling and pain developed immediately after the bite, which progressed up the arm. Because of the progression of local swelling, antivenom was started. He was given a total of 6 vials (60 mL) of polyvalent antivenom, with the first vial started 3 hours after the bite. He showed clinical improvement within 24 hours. His subsequent recovery was uneventful, with no other complications as a result of envenomation or antivenom use. Severe envenoming by the shore pit viper can lead to marked local effects such as extensive swelling and tissue necrosis. Antivenom is indicated in the presence of severe local envenomation. Antivenom against the shore pit viper is however not available locally. The Indian (Haffkine) polyvalent antivenom contains antibodies against 4 common venomous snakes in India, namely the Indian cobra, common krait, Russell's viper, and sawscaled viper. The improvement seen in this patient suggests possible cross-neutralizing activity of the Indian vipers' antivenom against the local shore pit viper venom. Further in vivo and in vitro studies should be performed to verify this clinical case.

Scorpion stings presenting to an emergency department in Singapore with special reference to Isometrus maculatus.

OBJECTIVE: We describe the epidemiology and clinical features of scorpion stings presenting to an emergency department in Singapore, including that of the venomous species Isometrus maculatus. A management approach to scorpion stings is proposed. METHODS: A retrospective study was done for patients from 2004 to 2009. Cases were identified by searching through emergency department records with ICD code E905, inpatient records, and the hospital toxicology service records. Identification of species was assisted by the Venom and Toxin research program at the National University of Singapore. RESULTS: A total of 13 cases of scorpion stings were identified. Eleven stings occurred locally, and the remaining 2 stings occurred in neighboring countries. The most common presenting symptoms were pain (92%), numbness (31%), and weakness (23%) confined to the region of the sting. The most common clinical signs recorded were redness (77%), tenderness (77%), and swelling (46%). Only 2 patients had significant alterations of vital signs: 1 had hypertension and the other had hypotension from anaphylaxis. Three patients experienced complications (abscess formation, anaphylaxis, cellulitis) requiring inpatient management. There were no fatalities, and all patients made a good recovery. Three cases were identified to be stings from I maculatus. These cases occurred locally, and mainly had clinical features of pain, redness, and mild regional numbness. CONCLUSIONS: Scorpion stings are uncommon presentations to the emergency department. Most stings cause local reactions that can be managed with supportive treatment. Stings by I maculatus were observed to cause mild, self-limiting effects.