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
Author: Dylan Luyten, M.D.
- 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.
Author: Nick Hatch, M.D.
- 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.