Author: Katie Sprinkle, MD
- Carbon monoxide (CO) is the leading cause of death from poison world-wide
- CO forms from the combustion of any carbon based product
- Patients often present with non specific symptom like headache, vomiting, and malaise
- Consider this diagnosis with multiple people presenting with similar symptoms from a single location
- Treatment is with high flow oxygen (i.e. non-rebreather)
- Hyperbaric therapy is controversial and up for debate – discussion with local consultants may help guide this management/transfer
- Tobacco smokers typically have elevated levels of carbon monoxide at baseline
Editor’s Note: smoking hookah for one hour may be the equivalent of smoking nearly 100 cigarettes
Jacob P, Abu Raddaha AH, Dempsey D, et al. Nicotine, carbon monoxide, and carcinogen exposure after a single use of a water pipe. Cancer Epidemiol Biomarkers Prev. 2011;20(11):2345-53.
Ng PC, Long B, Koyfman A. Clinical chameleons: an emergency medicine focused review of carbon monoxide poisoning. Intern Emerg Med. 2018 Mar;13(2):223-229. doi: 10.1007/s11739-018-1798-x. Epub 2018 Feb 12. Review. Erratum in: Intern Emerg Med. 2018 Mar 22;:. PubMed PMID: 29435715.
American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Carbon Monoxide Poisoning:., Wolf SJ, Maloney GE, Shih RD, Shy BD, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Carbon Monoxide Poisoning. Ann Emerg Med. 2017 Jan;69(1):98-107.e6. doi: 10.1016/j.annemergmed.2016.11.003. PubMed PMID: 27993310.
Guzman JA. Carbon monoxide poisoning. Crit Care Clin. 2012 Oct;28(4):537-48. doi: 10.1016/j.ccc.2012.07.007. Review. PubMed PMID: 22998990.
Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD
Author: Katie Sprinkle, MD
- Medication Assisted Treatment (MAT) is the treatment of addiction with medications, commonly used for opioid use disorders
- A long held belief is MAT simply replaces one addiction for another, which is patently false
- MAT is one of the most affective methods to treat a patient with opioid addiction
- Unfortunately, outdated requirements for prescribers along further prevent its widespread use
Salsitz E, Wiegand T. Pharmacotherapy of Opioid Addiction: “Putting a Real Face on a False Demon.” Journal of Medical Toxicology. 2016;12(1):58-63. doi:10.1007/s13181-015-0517-5.
Duber HC, Barata IA, Cioè-Peña E, Liang SY, Ketcham E, Macias-Konstantopoulos W, Ryan SA, Stavros M, Whiteside LK. Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2018 Oct;72(4):420-431. doi: 10.1016/j.annemergmed.2018.04.007. Epub 2018 Jun 5. Review. PubMed PMID: 29880438.
Summary by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD
Author: Michael Hunt, MD
- 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)
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!
- 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
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.
Author: Michael Hunt, MD
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
- Recent study has shown adjunctive ketamine can be useful in setting of alcohol withdrawal.
- Ketamine was associated with a decrease in the amount of benzodiazepines needed, likelihood of intubation, and a decrease in ICU length of stay by 3 days.
- For patients with benzodiazepine resistance, ketamine was shown to have symptom relief in an hour and decreased rate of benzodiazepine infusion.
Pizon A, Lynch M, Benedict N, et al. 2018. Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal. Critical Care Medicine. 46(8):e768-e771.
Shah, P., McDowell, M., Ebisu, R. et al. J. Med. Toxicol. (2018). https://doi.org/10.1007/s13181-018-0662-8
Author: John Winkler, MD
- Tall flowering plant with phototoxic sap
- Direct skin contact with the sap can cause the skin to become photosensitive
- Severe blisters and even burns can result
Diebel, Matthew (18 June 2018). “Giant Hogweed, a Plant That Can Cause Burns and Blindness, Found in Virginia”. USA Today.
- 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.
- 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.
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.
Author: Michael Hunt, M.D.
- 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.
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
Author: Rachael Duncan, PharmD
- 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