Retrospective chart review of substance abuse in patients with psychiatric emergencies in an emerging urban county.

Objectives: Substance abuse is common in patients with psychiatric emergencies. To further understand the connection between substance abuse and psychiatric disorders, a retrospective chart review was done that included positive drug screens among patients with psychiatric emergencies and to determine whether there was an association between substances used and the psychiatric diagnosis. Methods: A retrospective chart review of patients seen in an emergency department with psychiatric emergencies was conducted. The review comprised 1000 charts with diagnoses of anxiety, depression, schizophrenia, attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, alcohol abuse, or schizoaffective disorder. Data collected included patient demographics, tobacco abuse, chief complaint, arrival mode, voluntary versus involuntary status, suicide attempt on presentation, psychiatric diagnoses, urine drug screen, and ethanol results. Chi-square statistical analysis was conducted to examine the relationship between substances of abuse and psychiatric diagnoses. Results: Approximately 58% of patients with a history of psychiatric illness had a positive urine drug screen. Of 245 patients with schizoaffective disorder, 69 (28%) were positive for tetrahydrocannabinol (THC) and 48 (20%) were positive for cocaine. Of 225 patients with depression, 59 (29%) were positive for THC and 33 (15%) were positive for cocaine. Cannabis was the most commonly reported substance used among patients with depression, schizophrenia, anxiety, schizoaffective disorder, and bipolar disorder, and ethanol was most common in patients with ADHD. No significant correlations were found between psychiatric diagnosis and positive drug screens. A statistically significant secondary end point was found that White people using cannabinoids were more likely to attempt suicide than were African American people (P = 0.02). Conclusions: Positive drug screens were common among patients presenting to an ED with psychiatric emergencies. Cannabis was the most commonly reported substance used among patients independent of diagnosis. Ethanol was the most common in patients with ADHD. Urine drug screens are unlikely to provide insights into relationships between specific substance use and psychiatric emergencies.

Failure of Computed Tomography (CT) in Detecting an Aspirin Pharmacobezoar: A Case Report.

BACKGROUND Prior studies suggest CT can identify bezoars under certain circumstances. Endoscopy provides diagnostic and therapeutic benefit in the setting of suspected aspirin bezoar. Does the absence of findings on CT scan exclude the presence of an aspirin bezoar? CASE REPORT A 64-year-old woman called the police and stated she ingested a bottle of aspirin to harm herself. Upon arrival to the Emergency Department, she was tachypneic with a GCS of 15. Initial laboratory results were: salicylate level of 1143 mcg/mL, respiratory alkalosis, bicarbonate of 9 meq/L, anion gap of 23, and normal renal function. Initial therapeutic intervention included infusions of glucose and bicarbonate, multiple doses of activated charcoal, intubation, and emergent hemodialysis. After hemodialysis, the salicylate level rebounded, and a Gastroenterology (GI) consultation was requested to rule out bezoar. On day 2, GI requested an abdominal CT scan with Gastrografin in place of endoscopy due to hemodynamic instability. A CT scan was negative for bezoar. After multiple hemodialysis sessions and whole-bowel irrigation with rebounding salicylate levels, GI was consulted again for reevaluation for endoscopy. On day 5, an endoscopy discovered a concretion containing pill fragments. Another endoscopy performed on day 7 removed further fragments. Salicylate levels began to consistently decline. Unfortunately, the patient's neurologic status did not improve, and on day 11 she was switched to palliative care and died. CONCLUSIONS Endoscopy with direct visualization is diagnostic and therapeutic in the setting of a possible bezoar. The absence of pharmacobezoar on imaging should not delay endoscopy in a clinical setting suggesting bezoar.

Trending of a falsely elevated serum creatinine after a pediatric nitromethane ingestion: A case report.

Introduction: Nitromethane is a primary nitroalkane used as a solvent and a fuel that may be toxic by ingestion, inhalation, or contact. Its presence can be detected in serum of exposed persons, but levels are not readily available to guide patient care. Nitromethane has been shown to falsely elevate serum creatinine when clinical laboratories use Jaffe assays to measure creatinine; enzymatic assays are not affected. Ex vivo experiments have demonstrated a linear relationship between serum nitromethane and the elevation in Jaffe assay creatinine. This case report demonstrates an elevation of creatinine measured by Jaffe assay with normal creatinine measurement by enzymatic assay after exposure to nitromethane. Case report: A 21-month-old girl ingested an unmeasured quantity of a hobby fuel, a fuel containing methanol, nitromethane (20%), and lubricants used in miniature internal combustion engines, such as remote-controlled cars. She was initially evaluated at a community hospital, treated empirically for methanol toxicity with fomepizole and folic acid, and transferred to a university hospital for further management. By 19 hours after ingestion, methanol was below detection, but a serum creatinine of 2.63 mg/dl raised concern for kidney injury. Toxicology consultation recognized that the creatinine had been measured using a Jaffe assay and recommended a repeat creatinine using an enzymatic assay, which was within normal limits. The patient remained an inpatient for further evaluation, which permitted trending of her Jaffe assay creatinine over a 3-day period. The Jaffe assay creatinine demonstrated a gradual decline; repeat enzymatic assay creatinine remained within normal limits. Discussion: The decline in this pediatric patient's Jaffe assay creatinine is consistent with first-order clearance of nitromethane, which has been previously described in adult exposures. This case demonstrates how Jaffe assay-derived serum creatinine may be useful in the pediatric population to establish, quantify, and trend nitromethane exposure with essential concurrent use of an enzymatic assay to determine actual creatinine.

The toxicity of picaridin containing insect repellent reported to the National Poison Data System.

CONTEXT: While low toxicity is reported, there are sparse data on the safety of acute picaridin (icaridin) exposures in humans. OBJECTIVE: The purpose of this study was to review National Poison Data System (NPDS) data regarding ingestion of insect repellents containing picaridin and compare those to insect repellents containing DEET and other insect repellents not containing DEET. METHODS: NPDS was queried for single agent human insect repellent ingestions reported between 1 January 2000 and 31 May 2015 using the American Association of Poison Control Center generic categories 201048 (Insect Repellents with DEET) and 201049 (Insect Repellents without DEET). Picaridin-containing product exposures were assessed using Poisindex(®) product ID 6744589. Insect repellents of unknown type were not included. RESULTS: 68,429 exposures occurred; 24% were non-DEET-containing products, of which 2% were picaridin-containing products. Among picaridin exposures, 92.9% were managed outside of a health-care facility; there were no reported cases of major effect or death, and only one case of moderate effect. Primary symptoms across all insect repellent exposures included ocular irritation/pain, vomiting, red eye/conjunctivitis, and oral irritation. Treatment primarily included dilution/irrigation/wash. CONCLUSION: Unintentional ingestion of picaridin-containing and other insect repellents was associated only with minor toxicity and was generally managed outside of a health-care facility.

Efficacy of Trypsin in Treating Coral Snake Envenomation in the Porcine Model.

Antivenom is the definitive treatment for venomous snakebites. Alternative treatments warrant investigation because antivenom is sometimes unavailable, expensive, and can have deleterious side effects. This study assesses the efficacy of trypsin to treat coral snake envenomation in an in vivo porcine model. A randomized, blinded study was conducted. Subjects were 13 pigs injected subcutaneously with 1 mL of eastern coral snake venom (10 mg/mL) in the right distal hind limb. After 1 min, subjects were randomized to have the envenomation site injected with either 1 mL of saline or 1 mL of trypsin (100 mg/mL) by a blinded investigator. Clinical endpoint was survival for 72 h or respiratory depression defined as respiratory rate <15 breaths per minute, falling pulse oximetry, or agonal respirations. Fisher's exact t test was used for between group comparisons. Average time to toxicity for the saline control was 263 min (191-305 min). The development of respiratory depression occurred more frequently in control pigs than treated pigs (p = 0.009). Four of the six pigs that received trypsin survived to the end of the 3-day study. No control pigs survived. Two of the trypsin treatment pigs died with times to toxicity of 718 and 971 min. Survival to 12 and 24 h was significantly greater in the trypsin treatment group (p = 0.002, p = 0.009, respectively). Local injection of trypsin, a proteolytic enzyme, at the site of envenomation decreased the toxicity of eastern coral snake venom and increased survival significantly. Further investigation is required before these results can be extended to human snakebites.