Podcast #378: Is That a Brown Recluse Spider Bite?

Author:  Michael Hunt, MD

Educational Pearls:

  • Use the mnemonic NOT RECLUSE to rule out a brown recluse spider bite:
  • Numerous bites (recluse spiders will bite once)
  • Occurence (recluse bites between April- October)
  • Timing (recluse spiders are… get this…  reclusive)
  • Red (recluse bites are white/pale)
  • Elevated (recluse bites are flat)
  • Chronic (recluse bites are acute)
  • Large (recluse wounds are small)
  • Ulceration, early (recluse bites ulcerate between 7-14 days)
  • Swollen (recluse bites are flat)
  • Exudative (recluse bites are dry)

 

References:

Stoecker WV, Vetter RS, Dyer JA. NOT RECLUSE-A Mnemonic Device to Avoid False Diagnoses of Brown Recluse Spider Bites. JAMA Dermatol. 2017 May 1;153(5):377-378. doi: 10.1001/jamadermatol.2016.5665. PubMed PMID: 28199453.

Check out this episode!

Podcast #376: Alcohol Intoxication

Educational Pearls:

  • Blood concentrations over 0.4 mg/dL  is associated with respiratory depression and possible death in alcohol naive patients
  • Alcohol overdose accounts to 2,200 deaths per year
  • Don’t forget about checking for hypoglycemia in severe alcohol intoxication
  • Consider ketamine for agitation to prevent further respiratory depression

 

Editor’s note: check out our podcast on ketamine for alcohol withdrawal here

References:

Jung YC, Namkoong K. Alcohol: intoxication and poisoning – diagnosis and treatment. Handb Clin Neurol. 2014;125:115-21. doi: 10.1016/B978-0-444-62619-6.00007-0.

Centers for Disease Control and Prevention (CDC). “Vital signs: binge drinking prevalence, frequency, and intensity among adults-United States, 2010.” MMWR. Morbidity and mortality weekly report 61.1 (2012): 14.

Podcast # 369: Five powerful toxins – the definitive list?

Author: Michael Hunt, MD

Educational Pearls:

Here is a list of some very toxic natural substances:

#5: Tetrodotoxin: Found in pufferfish and other aquatic species

#4: Ricin: made from castor beans

#3: Mercury: natural element absorbable through skin and gloves

#2: Batrachotoxin: found on poison dart frogs

#1: Botulinum toxin: produced by Clostridium botulinum and causes a descending paralysis

Editor’s note: batrachotoxin is thought to be accumulated by the beatles and other insects dart frogs eat – those in captivity therefore are not poisonous

References

https://theconversation.com/handle-with-care-the-worlds-five-deadliest-poisons-56089

 

Podcast # 343: Snake Bites

Educational Pearls:

  • Snake bites commonly occur between April and October.
  • Rattlesnake bites are the most common.
  • Venom contains proteins/enzymes that cause local inflammation, coagulopathy, and systemic effects (hypotension, angioedema, renal failure, etc.) along with neurotoxins may cause fasciculations, ptosis, drooling, or hyporeflexia.
  • Management:
  • Mark site for swelling.
  • Monitor progression.
  • Elevate and immobilize injured limb and treat pain.
  • Check basic labs including coagulation studies, and update tetanus.
  • Antidote is CroFab and use if patient has systemic symptoms.  Anaphylaxis is a known complication of CroFab
  • Avoid: ice, tourniquets, and incision and drainage.

 

References

Hifumi T et. al.. Venomous snake bites: clinical diagnosis and treatment. J Intensive Care. 2015 Apr 1;3(1):16. doi: 10.1186/s40560-015-0081-8.

Warrell DA. Snake bite. Lancet. 2010. 375(9708):77-88. doi: 10.1016/S0140-6736(09)61754-2.

Warrell DA. Envenoming and injuries by venomous and nonvenomous reptiles worldwide. In: Wilderness Medicine, 6th Edition, Auerbach PS (Ed), Elsevier Mosby, Philadelphia 2012. p.1040.

Podcast #316: Abnormalities in Alcohol Intoxication

Author: Michael Hunt, M.D.

Educational Pearls:

  • 1% of patients presenting to ED with alcohol intoxication end up going to the ICU.
  • Most common critical illnesses were acute hypoxic respiratory failure, sepsis, and intracranial hemorrhage.
  • Predictive markers: Vital abnormalities (hypoxia, tachycardic, tachypneic, hypothermic, hyperthermia, hypoglycemia) and patients receiving parenteral sedatives had higher incidence of ICU admission.

References:

Klein, LR; et al. (2018). Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication. Annals of Emergency Medicine. 71(3):279-288

Podcast #296: Synthetic Cannabinoids

Author: Rachael Duncan, PharmD

Educational Pearls

  • A NEJM study report in July 2016 discussed a situation in New York during which 30 people became “zombie-like” after ingesting synthetic cannabinoids (aka “Spice).
  • The ER managed to coordinate with the CDC to evaluate  blood samples from 18 patients who were transported to the hospital.
  • Of those who went to the ER, the mean age was 36.8, many  of them were homeless, all of them were male. Mass spectrometry was used to confirm the presence of synthetic cannabinoid in their blood.
  • Compared to normal THC, synthetic cannabinoids have a much lower EC50 and LD50.
  • Spice intoxication presents in a variety of ways -patients may be hyperthermic, combative, delirious and/or seizing.
  • Treatment  is supportive, including fluids, cooling, electrolyte management, and sedatives.

References: Adams, A. J., Banister, S. D., Irizarry, L., Trecki, J., Schwartz, M., & Gerona, R. (2017). “Zombie” Outbreak Caused by the Synthetic Cannabinoid AMB-FUBINACA in New York. New England Journal of Medicine, 376(3), 235-242. doi:10.1056/nejmoa1610300

Podcast #289: Cannabinoid Hyperemesis

Author: Dylan Luyten, M.D.

Educational Pearls

  • Cannabinoid Hyperemesis syndrome is a relatively new diagnosis that presents with vomiting and abdominal pain without a clear etiology in the setting of daily marijuana use.
  • The pathophysiology is not well-understood well, but may involve cannabinoid receptors in the gut.
  • Treatment is abstinence from marijuana, fluids, dextrose, and antiemetics (haldol, ondansetron, etc). Opioids should be avoided.
  • Capsaicin cream on the abdomen may be helpful, as it can distract from the pain and vomiting. Milk can be used to reverse its effects.

References:  Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid Hyperemesis Syndrome. Current drug abuse reviews. 2011;4(4):241-249.

Podcast #275: Battery Ingestions

Author: Nick Hatch, M.D.

Educational Pearls

  • Unlike coin ingestions, button batteries can cause necrosis of the GI tract.
  • If lodged in the esophagus, removal within 2 hours is important, because they can cause problems such as strictures or esophago-aortic fistula.
  • If the battery is in the stomach or beyond, it may be ok to let it pass but give strict return precautions.
  • Small hearing aid batteries are not as dangerous, but still require close follow-up to ensure the battery passes.
  • Delayed effects (after passage of the battery) are possible.

References: https://www.poison.org/battery/guideline

Podcast #265: The 2017 Flu Vaccine

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist – Emergency Medicine

Educational Pearls

  • CDC recommends using the inactivated, injectable flu vaccine in those 6 months and older. The live attenuated vaccine is not used because of low efficacy.
  • Pregnant women should be vaccinated, and can receive the vaccine at any stage of their pregnancy.
  • The vaccine is contraindicated ONLY in those with a history of a severe anaphylactic reaction to the injection in the past.
  • Antivirals (oseltamivir, zanamivir) are useful for Flu A and B. Their dosing needs to be adjusted for renal function, and it is contraindicated in those with ESRD who are not receiving dialysis. It should be used for prophylaxis in those with exposure and/or for the very young, very old, morbidly obese, nursing home residents, and those who are immunocompromised. They may be effective as long as 72 hours after symptom onset.

References: https://www.cdc.gov/flu/professionals/index.htm

Podcast #251: Cyanide Poisoning

Author: Rachel Beham, PharmD, Advanced Clinical Pharmacist – Emergency Medicine

Educational Pearls

  • Cyanide poisoning is suspected in patients who present with lactic acidosis after being trapped around burning household objects. It affects our ability to metabolize and can quickly lead to CV collapse and death.  
  • Because cyanide blood levels are not quickly available, the diagnosis is made by history and lactic acidosis on ABG.
  • The cyanokit is the key treatment. It contains hydroxocobalamin, which binds to cyanide so it can be excreted.
  • One side effect to be aware of is that the cyanokit will turn everything red, including mucous membranes, saliva, urine, and skin. This will interfere with some lab values, so make sure to get labs before administration.

References: Mégarbane B, et al. Antidotal treatment of cyanide poisoning. J Chin Med Assoc. 2003