A Case of Severe Lead Encephalopathy with Cardiac Arrest Managed During a Chelation Shortage.

INTRODUCTION: For many years, the standard of care in the USA has been to treat acute lead encephalopathy with a combination parenteral dimercaprol (BAL) and CaNa2EDTA. We present a case of a pediatric patient with severe lead encephalopathy, complicated by cardiac arrest, who was treated with an alternative regimen when CaNa2EDTA was unavailable. CASE REPORT: A 24-month-old male was brought by ambulance to an emergency department (ED) with new onset seizures and sustained a cardiac arrest. An initial blood lead concentration returned at 263 mcg/dl. The hospital was unable to obtain CaNa2EDTA due to the nationwide shortage. For this reason, the patient was chelated with BAL IM for 12 days and dimercaptosuccinic acid (DMSA) for 28 days. He received a second 5-day course of BAL due to rebounding blood lead concentrations. Eight days after cardiac arrest, he was extubated; however, despite ongoing therapy, subsequent follow-up 2 months later demonstrated persistent cognitive deficits. DISCUSSION: The combination of DMSA and BAL was effective in rapidly decreasing whole blood lead concentrations. Drug shortages continue to have implications for the management of poisoned patients. This case highlights how shortages of chelating agents complicate patient care.

Central ECMO cannulation for severe dihydropyridine calcium channel blocker overdose.

Calcium channel blocker (CCB) toxicity carries a high mortality and is the sixth most fatal drug class reported to US poison centers. Amlodipine overdose is characterized by a life-threatening arterial vasodilation that compromises organ perfusion. The management of CCB intoxication is focused on maintaining adequate organ perfusion. In cases refractory to medical therapies, hemodynamic support with extracorporeal membrane oxygenation (ECMO) is warranted necessitating higher flows than usual to compensate for the vasodilation and requiring central cannulation. We present a case of a 12-year-old with severe dihydropyridine CCB ingestion, refractory to medical management and successfully treated with central ECMO cannulation. The patient was discharged home with no significant disability. Central ECMO cannulation may be helpful to facilitate adequate flows in vasodilatory shock such as CCB overdose.

Management of Cerebral Herniation Secondary to Lead Encephalopathy: A Case Report.

Background: Adult lead encephalopathy is a rare but critical condition to recognize in modern healthcare settings. Few reports have described the medical and neurosurgical management of severe adult lead encephalopathy. Case Presentation: A 22 year old woman presented with severe headache, anemia, vomiting, 40-lb weight loss, and constipation. At the time of presentation, she had extensive colonic radiopaque material and a serum lead concentration of 87 mcg/dl (normal <10). She rapidly developed anisocoria requiring emergent ventriculostomy insertion. Following CSF diversion, ICP mitigation, and lead chelation, she considerably improved in <2 weeks. Conclusion: We report one of the few instances of successful surgical and medical management of adult lead encephalopathy. Dedicated neurocritical care and neurosurgical teams are necessary in conjunction with toxicology in order to manage the advanced sequalae of severe lead poisoning.

Characteristics of tianeptine effects reported to a poison control center: a growing threat to public health.

BACKGROUND: Tianeptine is an antidepressant structurally similar to tricyclic antidepressants which is approved abroad but is currently a drug of abuse in the United States since at least 2000. In 2019, our poison center experienced an increase in calls relating to this xenobiotic. The goal of this report is to describe the characteristics of acute tianeptine intoxication and withdrawal. METHODS: All calls to a statewide poison center regarding tianeptine were reviewed from January 1, 2015 to March 15, 2020. Cases were identified using the American Association of Poison Control Centers' substance code for "other types of tricyclic antidepressants." Cases were excluded if they did not involve tianeptine. Date of call, patient demographics, symptoms, cardiac intervals if available, and disposition were recorded. RESULTS: Eighty-four cases of atypical tricyclic antidepressants were identified in the study period. Forty-eight cases involving tianeptine met inclusion criteria and were reviewed. Of these, 37 (77%) occurred from May 2019 to March 2020. Twenty-seven (56%) required medical admission including 17 cases (35%) that were managed in an intensive care unit. Seventeen of the 48 cases resulted from acute tianeptine intoxication. Lethargy was the most common presentation, but some patients also presented with agitation. Thirty-one (65%) of the cases resulted from tianeptine withdrawal, which usually exhibited agitation, anxiety, gastrointestinal distress. Naloxone was used in 4 cases (24%) of the acute intoxication cohort and benzodiazepines were frequently used both in acutely intoxicated patients and in patients experiencing tianeptine withdrawal. No patients in either cohort had cardiac conduction disturbances. CONCLUSION: Our center observed a dramatic rise in tianeptine toxicity, particularly in patients experiencing withdrawal symptoms, beginning in May 2019. More than half of the cases required medical admission including a third who were treated in the intensive care unit. Health care practitioners should be increasingly aware of this xenobiotic as usage may be on the rise.

Utilization of thromboelastograms in management of Crotalus adamanteus envenomation.

BACKGROUND: Crotalinae (pit viper) envenomations are frequently encountered in North American emergency departments. Cases can be complicated by ambiguity in initial species identification as well as timing and duration of current antivenin treatment. Recently, thromboelastography (TEG) has emerged as an enhanced real-time monitoring parameter for snake envenomations that may aid in management of venom-induced consumptive coagulopathy. CASE: A 61-year-old snake handler presented with severe coagulopathy and hypofibrinogenemia following envenomation from her pet eastern diamondback rattlesnake (Crotalus adamanteus). Her coagulopathy transiently improved with Crotalidae Polyvalent Immune Fab (Ovine) (FabAV) but would repeatedly rebound following cessation of antivenin over the next 10 days. Serial TEGs were successfully utilized to identify and corroborate fibrinolysis while predicting clot formation prior to routine coagulation studies. DISCUSSION: Traditional coagulation parameters have not always been ideal when treating severe coagulopathy from pit viper envenomations and may not identify active fibrinolysis for several hours. In this case of C. adamanteus envenomation, TEG proved to be useful in demonstrating improvements in clotting function prior to standard laboratory measures, which further guided antivenin therapy.

Novel Psychoactive Substances and Trends of Abuse.

The purpose of this paper is to review the most common and quickest growing classes of novel, or new, psychoactive substances. Abuse of novel psychoactive substances continues to increase, resulting in subsequent increases in hospitalizations. Furthermore, the chemical structures are ever-changing and substances are increasing in potency. Reviewing the chemistry behind these agents will facilitate a better understanding of the toxicity associated with them and allow for successful identification of and management in the critical care unit. Being familiar with the most common psychoactive substances and trends of abuse, as well as the challenges health care providers face when managing intoxication, is essential to the overall understanding and care of these critically ill patients.

Negative predictive value of excluding an embedded snake foreign body by ultrasonography.

OBJECTIVE: Numerous reputable sources for healthcare providers advocate routine imaging to rule out an embedded tooth or fang after a snake bite. The objective of this study was to determine whether these foreign bodies can be reliably excluded by bedside ultrasonography. METHODS: All emergency medicine (EM) residents and faculty at a single institution were invited to participate. Two sets of 5 ultrasound gel phantoms were prepared using a method previously validated to have the same density as human tissue. In the first set of 5 phantoms, 1 snake fang was embedded to simulate a retained foreign body. Similarly, in the second set of 5 phantoms, 1 snake tooth was also embedded. Participants were asked to identify the presence or absence of a foreign body in each phantom using bedside ultrasonography. Year of training and confidence in excluding a snake foreign body were also recorded. RESULTS: Each participant (n=27) performed ultrasound imaging on 10 phantoms for a total of 270 samples. Range of experience included postgraduate year 1 (25.9%), postgraduate year 2 (29.6%), postgraduate year 3 (33.3%), and graduates of EM residency (11.1%). The sensitivity and negative predictive value for ruling out an embedded fang was 92.6% and 98.1%, respectively. The sensitivity and negative predictive value for ruling out an embedded tooth was 77.8% and 93.7%, respectively. Among all the phantoms, there was a sensitivity of 85.2% and a negative predictive value of 96%. CONCLUSION: Bedside ultrasonography performed by an EM physician is a feasible option to rule out embedded foreign bodies after a snake bite if imaging is warranted.

Dexmedetomidine in the treatment of serotonin syndrome.

OBJECTIVE: Patients suffering from moderate to severe serotonin syndrome frequently present with autonomic instability and altered mental status. Management of serotonin syndrome can be complex and may be refractory to treatment with benzodiazepines alone. The objective of this series is to present 3 cases of serotonin syndrome that demonstrated clinical improvement with initiation of dexmedetomidine. CASE SERIES: We present 3 cases of severe serotonin syndrome in adolescents requiring intubation that were refractory to midazolam and/or propofol. Dexmedetomidine, an α-2 receptor agonist, was used in all 3 cases with temporal stabilization of the autonomic nervous system and improvement of agitation, and aided in successful extubation. DISCUSSION: Although no human studies exist, rat and mouse models offer evidence that dexmedetomidine can reduce serotonin excess and stabilize signs of serotonin neurotoxicity. CONCLUSION: Accordingly, health care providers may consider using dexmedetomidine as adjunctive therapy for cases of severe serotonin syndrome that are refractory to standard treatment.

Evaluation of the initiation of urine drug screens intended for use in transfer patients.

OBJECTIVE: The objective of this study was to determine if signs of clinical intoxication were present in patients who had transfer urine drug screens (UDS) performed and to determine the proportion of patients with UDS orders who were actually transferred to another facility. METHODS: Of all emergency department (ED) patient visits who had a transfer UDS ordered from November 19, 2011, to December 31, 2012, 54% of the population was randomly selected for review by 1 of 3 study investigators. For quality assurance, a random sample of 100 patient charts was independently reviewed by all 3 investigators to assure consistency in interpreting data. Demographics, clinical characteristics and history, disposition, and laboratory results were recorded. RESULTS: Of the 639 patients included in this study, only 18% were transferred to another psychiatric facility. Pediatric patients and those with presenting with suicidal ideation were more likely to be transferred to an outside facility. Thirty-six percent of the UDS were positive for at least one substance. Marijuana was the most common substance (23%), followed by cocaine (7%) and opiates (7%). There was no evidence that the UDS changed acute management decisions. CONCLUSIONS: Few (<6%) patients demonstrated any clinical characteristics that were consistent with an acute intoxication. Less than 20% of patients who had a transfer UDS were actually transferred to an outside facility corresponding with more than 80% not ordered appropriately according to the ED established guidelines. This number of inappropriate tests represented more than $152 000 of avoidable UDS cost during the study period.