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Study objective We report botulism poisoning at a state prison after ingestion of homemade wine (pruno). Methods This is an observational case series with data collected retrospectively by chart review. All suspected exposures were referred to a single hospital in October 2011. Results Twelve prisoners consumed pruno, a homemade alcoholic beverage made from a mixture of ingredients in prison environments. Four drank pruno made without potato and did not develop botulism. Eight drank pruno made with potato, became symptomatic, and were hospitalized. Presenting symptoms included dysphagia, diplopia, dysarthria, and weakness. The median time to symptom onset was 54.5 hours (interquartile range [IQR] 49-88 hours) postingestion. All 8 patients received botulinum antitoxin a median of 12 hours post–emergency department admission (IQR 8.9-18.8 hours). Seven of 8 patients had positive stool samples for type A botulinum toxin. The 3 most severely affected patients had respiratory failure and were intubated 43, 64, and 68 hours postingestion. Their maximal inspiratory force values were −5, −15, and −30 cm H 2 O. Their forced vital capacity values were 0.91, 2.1, and 2.2 L, whereas the 5 nonintubated patients had median maximal inspiratory force of −60 cm H 2 O (IQR −60 to −55) and forced vital capacity of 4.5 L (IQR 3.7-4.9). Electromyography abnormalities were observed in 1 of the nonintubated and 2 of the intubated patients. Conclusion A pruno-associated botulism outbreak resulted in respiratory failure and abnormal pulmonary parameters in the most affected patients. Electromyography abnormalities were observed in the majority of intubated patients. Potato in the pruno recipe was associated with botulism.

Study objective: To determine the incidence and risk factors of clinically relevant adverse drug interactions occurring in emergency department patients. Design: This report describes the drug interactions identified in an emergency population. Patients' drug regimens were evaluated prospectively at the time of the emergency evaluation. Setting: University hospital ED. Type of participants: Convenience sample of 341 patients. Interventions: Patients' medications on arrival at the ED (current medications) and medications initiated in the ED were entered into Hansten's computer-based drug interaction program to identify potential drug interactions. All potential drug interactions were brought to the attention of the attending emergency physician, whose subsequent actions were noted. Clinically relevant interactions were determined by a physician panel based on the ED attendings' actions, set criteria, and a review of hospital charts and four-week telephone follow-up of patients with potential drug interactions. Measurements and main results: Three hundred forty patients were enrolled. One hundred thirty-five potential drug interactions were identified in 61 patients. Among these 135 potential drug interactions and 61 patients, we identified 20 clinically relevant interactions in 15 patients. The incidence of clinically relevant interactions was significantly higher ( χ 2 = 3.95, P = .047) among current medication (9.7%) than medication added in the ED (3.1%). Clinically relevant interaction from both current and ED-initiated medication was associated with taking three or more medications on ED arrival ( P = .016 and .045, respectively). Multiple regression showed age of 60 years or older to be the sole predictor of clinically relevant interaction among current medication ( P = .05). Conclusion: Clinically relevant adverse drug interaction was significantly less from medication administered or prescribed in the ED than from current medication.

Breath alcohol analyzers are used to detect ethanol in motorists and others suspected of public intoxication. One concern is their ability to detect interfering substances that may falsely increase the ethanol reading. A 47-year-old-man was found in a public park, acting intoxicated. A breath analyzer test (Intoxilyzer 5000EN) measured 0.288 g/210 L breath ethanol, without an interferent noted. In the emergency department, the patient admitted to drinking HEET Gas-Line antifreeze, which contains 99% methanol. Two to three hours after ingestion, serum and urine toxicology screen results were negative for ethanol and multiple other substances. His serum methanol concentration was 589 mg/dL, serum osmolality 503 mOsm/kg, osmolar gap 193 mOsm/kg, and anion gap 17 mmol/L. The patient was treated with intravenous ethanol, fomepizole, and hemodialysis without complication. This is a unique clinical case of a breath alcohol analyzer reporting methanol as ethanol. Intoxilyzer devices have been shown to indicate some substances (acetone) as interferents in humans but not methanol. Increased serum concentrations of methanol can be reported as ethanol by a commonly used breath alcohol analyzer, which can result in a delayed diagnosis or misdiagnosis and subsequent methanol toxicity if antidotal treatment is not administered in a timely manner.

Study objective: The need for clinical toxicology resources by emergency physicians is unclear and may have implications for future training and resource availability. This study was designed to assess current emergency physician use of available resources. Design: Prospective evaluation by mail using a 49-item questionnaire. Type of participants: All 170 emergency physicians in Utah. Interventions: None. Results: The response rate was 75.3% (128 of 170). Resources "outside their own fund of knowledge" were consulted "occasionally" to "frequently" by 98.3%. They used the following resources "occasionally" to "frequently" : poison control center (PCC) (93.7%), toxicology textbook (77.6%), "expert colleague" (34.0%), and "in-house POISINDEX ® " (23.9%). They often contacted the PCC for toxicity information (93.7%) and management recommendations (87.3%) and for acute, symptomatic overdose cases (88.3%). They "almost never" contacted the PCC for adverse drug reactions (76.6%), pill identification (70.2%), consultation with physician toxicologist (68.1%), asymptomatic exposures (62.9%), chronic toxicity (50.4%), or solely to report the case to the American Association of Poison Control Centers data base (90.2%). Those who had access to in-house POISINDEX ® often did not consult the PCC (82.6%). Of those who did not have in-house POISINDEX ® , 42.8% contacted the PCC to access it. Providing access to physician toxicologist consultations was thought to be an important role for the PCC by 86.7%, but only 32% of physicians were using this option. Conclusion: The vast majority of emergency physicians in Utah consult the PCC only for acute, symptomatic overdoses. They view access to physician toxicologist consultation as an important role for the PCC but seldom use it. The availability of in-house POISINDEX ® decreases the likelihood of PCC consultations from emergency departments. The frequency of emergency physician consultation with the PCC may decrease as POISINDEX ® becomes available at more hospitals.

Traditionally, about 10% of patients suffering from copperhead (Agkistrodon contortix) envenomation have been treated with antivenom therapy.1-5 Because of the high risk of hypersensitivity reactions associated with the equine-derived product,6 it was usually reserved for patients with systemic signs of toxicity. Antivenom treatment was abandoned entirely by some clinicians because residual disability, tissue loss, or death was considered to be virtually nonexistent.1,2,4 Now, with the availability of the less antigenic and probably safer Crotalidae polyvalent immune Fab (ovine) (CroFab; FabAV),7 antivenom treatment may no longer carry as great a risk to the patient. Are the potential therapeutic benefits worth the lower risks but higher cost of this new antivenom? In this issue of Annals, Lavonas et al8 begin to address this question by reviewing a large case series of patients treated with FabAV. FabAV became available for treatment of Crotalid (rattlesnake, copperhead, and cottonmouth) envenomations in December 2000. Ironically, victims of copperhead envenomation were not included in the clinical trials of FabAV because its venom effects were not deemed serious enough. Now the challenge is to objectively evaluate the potential benefits, risks, and costs of this new antivenom for these patients in a postmarketing environment. The manifestations of copperhead envenomation are predominately mild to moderate local tissue effects. Significant systemic effects are rare.1-4 However, the notion that the local tissue effects are benign has been challenged recently.5 Up to one third of victims reportedly have severe pain, ecchymosis, and swelling of the bitten extremity,5 and local tissue necrosis has been reported in 8% of bites.3 The average time lost from work appears to be about 2 weeks.9 Various periods of “limb dysfunction” have been subjectively reported by patients, ranging from 5 to more than 365 days.3 Unfortunately, the overall incidence of chronic limb dysfunction and whether it correlates with the degree or location of swelling is not known. Until now, reported clinical experience with FabAV treatment for copperhead envenomation has been very limited. Lavonas et al8 retrospectively reviewed 32 cases. The primary outcome for the study was cessation of local swelling, and a majority of patients appeared to respond to initial FabAV therapy. However, this finding must be viewed in the appropriate clinical and costbenefit context. This was a highly selected patient sample, and the results should not be generalized to all victims of copperhead bite. They represented only 8% of patients with copperhead envenomation reported to the poison center during the study period. It is likely they were more severely envenomated than those managed with supportive care alone. In addition, this sample contained a large representation of high-risk victims: children (25%), older adults (22%), and patients with upper-extremity envenomations (75%). Patients with progressive swelling who did not receive FabAV were not evaluated for comparison. Intuitively, swelling should correlate with the degree of tissue injury, and halting its progression should result in an improved outcome and less disability. Yet this relationship has not been proven for Crotaline snakebites. One can easily justify giving expensive antivenom to patients with systemic signs of venom toxicity such as a multicomponent coagulapathy or hypotension. However, what about mild to moderate local tissue swelling alone? Is the potential for a less swollen extremity worth thousands of dollars in drug charges for FabAV? Does FabAV reduce the incidence, severity, or duration of tissue necrosis or limb dysfuncT O X I C O L O G Y / B R I E F C O M M E N T A R Y

Study objective: We compared the efficacies of cimetidine (an H 2 -receptor antagonist) and diphenhydramine (an H 1 -receptor antagonist) alone and in combination for alleviation of symptoms of acute allergic reactions. Study design and interventions: In this prospective, randomized, double-blind study, patients and examiners assessed the severity of symptoms and signs of acute allergic reactions using a visual-analog scale before treatment and 30 minutes after treatment with 300 mg IV cimetidine and placebo, 50 mg IV diphenhydramine and placebo, or diphenhydramine plus cimetidine. Setting and participants: Thirty-nine patients with acute allergic reactions presenting to two emergency departments of teaching hospitals. Results: Of the 35 patients with pruritus, all 12 receiving diphenhydramine placebo had clinically significant relief compared with six of ten (60%) receiving cimetidine plus placebo ( P = .03). Twelve of 13 (92%) receiving diphenhydramine plus cimetidine had relief, which was not a significant difference from the single drugs. Comparison of mean differences in pretreatment and post-treatment symptom scores (relief scores) among groups of patients with pruritus detected significantly more relief in the group receiving diphenhydramine plus placebo (80.3 ± 7.4) than in those receiving cimetidine plus placebo (48.8 ± 13.4) ( P = .022). Of the 33 patients with urticaria, five of 11 (46%) receiving diphenhydramine plus placebo had clinically significant relief compared with eight of ten (80%) receiving cimetidine plus placebo ( P = .18). Eleven of 12 patients (92%) receiving diphenhydramine plus cimetidine had relief, which is a significant difference from those receiving diphenhydramine plus placebo ( P = .027). Comparison of mean relief scores in patients with urticaria detected significantly more relief in the group receiving diphenhydramine plus cimetidine (55.3 ± 6.5) than in the group receiving diphenhydramine plus placebo (30.7 ± 6.1) ( P = .006). Conclusion: For treatment of pruritus from acute allergic reactions, diphenhydramine is more effective than cimetidine, and the combination offers no additional benefit. For treatment of acute urticaria, the combination of cimetidine and diphenhydramine is more effective than diphenhydramine alone.

We developed recommendations for antidote stocking at hospitals that provide emergency care.An expert panel representing diverse perspectives (clinical pharmacology, clinical toxicology, critical care medicine, clinical pharmacy, emergency medicine, internal medicine, pediatrics, poison centers, pulmonary medicine, and hospital accreditation) was formed to create recommendations for antidote stocking. Using a standardized summary of the medical literature, the primary reviewer for each antidote proposed guidelines for antidote stocking to the full panel. The panel used a formal iterative process to reach their recommendation for the quantity of an antidote that should be stocked and the acceptable period for delivery of each antidote.The panel recommended consideration of 24 antidotes for stocking. The panel recommended that 12 of the antidotes be available for immediate administration on patient arrival. In most hospitals, this period requires that the antidote be stocked in the emergency department. Another 9 antidotes were recommended for availability within 1 hour of the decision to administer, allowing the antidote to be stocked in the hospital pharmacy if the hospital has a mechanism for prompt delivery of antidotes. The panel identified additional antidotes that should be stocked by the hospital but are not usually needed within the first hour of treatment. The panel recommended that each hospital perform a formal antidote hazard vulnerability assessment to determine the need for antidote stocking in that hospital.The antidote expert recommendations provide a tool to be used in creating practices for appropriate and adequate antidote stocking in hospitals that provide emergency care.

We report six cases of acute carbon monoxide poisoning during pregnancy. All of the women survived with good outcomes, but three cases were associated with fetal mortality. Two fetuses were delivered stillborn within 36 hours of exposure. One fetus remained alive in utero for 20 weeks and was delivered nonviable at 33 weeks gestation with multiple morphologic anomalies. Three pregnancies were carried to term and resulted in normal neonates. Maternal blood carboxyhemoglobin levels did not correlate with the concurrent severity of symptoms in the woman. Maternal symptoms at the site of exposure seemed to predict the risk of associated morbidity to the fetus. A single maternal carboxyhemoglobin level cannot be used to estimate fetal carboxyhemoglobin if the exposure pattern is not known.

Pain from ureteral stones is believed to be due to spasm and hyperperistalsis of the involved ureter. Nifedipine has been shown to decrease human ureteral spasm in vitro . Conflicting results have been reported concerning the clinical efficacy of nifedipine in relieving acute renal colic. This prospective, double-blind, crossover clinical trial evaluated the acute pain relief obtained in 30 patients who had ureteral stones. All patients had ureteral stones documented either by plain abdominal radiograph (six), intravenous pyelogram (16), or passage of the stone(s) in the urine (eight). Each patient served as his own control. The mean pain relief scores for placebo versus 10 to 20 mg oral nifedipine were 0.7 ± 1.8 and 1.2 ± 2.5, respectively, as measured on a visual analogue scale ( P = .404). Seven patients received clinically significant relief associated with nifedipine, and three patients received relief from placebo ( P = .300). Twenty patients (66%) did not experience clinically significant relief from either treatment. We conclude that nifedipine does not differ significantly from placebo in providing relief from acute renal colic.

Tricyclic antidepressant (TCA) poisoning has been reported to cause a right-axis deviation of 130 degrees to 270 degrees in the terminal 40-ms frontal plane QRS axis (T40-ms axis) of the ECG. This retrospective cohort study was designed to determine if the T40-ms axis could discriminate TCA-toxic patients from other overdose patients and whether a correlation exists between TCA plasma concentration and T40-ms axis rotation. Only symptomatic overdose patients with plasma and urine drug screens and an ECG obtained within two hours of each other were included in the study. Patients were divided into two groups: TCA overdose patients (TCA OD, n = 48) and nonTCA overdose patients (nonTCA OD, n = 30). The mean T40-ms axis was significantly more rightward in the TCA OD group compared with the nonTCA OD group (179 +/- 74 vs 86 +/- 87, P less than .001). A TCA OD patient was 8.6 times more likely to have a T40-ms axis of more than 120 degrees than was a nonTCA OD patient (odds ratio, 8.6; 95% confidence interval, 2.7 to 29.1). Eight of the TCA poisoned patients (17%) did not demonstrate a T40-ms axis between 120 degrees and 270 degrees. Receiver operating characteristics demonstrated that the T40-ms axis was a better indicator of TCA toxicity than the QRS interval (P less than .05). A T40-ms axis of 120 degrees or more was 83% sensitive and 63% specific for TCA overdose. A correlation between plasma TCA concentration and T40-ms axis deviation was not found (r = .04).(ABSTRACT TRUNCATED AT 250 WORDS)

A case of infant clonidine poisoning from a transdermal patch that had been worn for five days by an adult and then discarded is described. The infant became hypotensive with a systolic blood pressure of 38 mm Hg, and a dopamine infusion was required for six hours to maintain adequate blood pressure. The infant was discharged 24 hours after admission. Clonidine toxicity, transdermal delivery system pharmacokinetics, and poison prevention are discussed.

A 64-year-old man ingested a phosphoric acid solution in a suicide attempt. He subsequently developed hyperphosphatemia, hypocalcemia, and systemic metabolic acidosis. Local caustic effects of the acid were mild. The patient recovered and was lost to follow-up.