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Introduction: This is the 41st Annual Report of America's Poison Centers® National Poison Data System®. As of 1 January, 2023, all 55 of the nation's poison centers uploaded case data automatically to NPDS. Methods: We analyzed the case data, tabulating specific indices from the NPDS®. The methodology was as in previous years. Where changes were introduced, the differences are identified. Cases with medical outcomes of death were evaluated by a team of medical and clinical toxicologists using an ordinal scale of 1-6 to assess the Relative Contribution to Fatality of the exposure. Results: In 2023, 2,421,251 closed encounters were logged by the National Poison Data System®: 2,080,659 human exposures, 41,857 animal exposures, 293,663 information requests, 5,046 human confirmed nonexposures, and 26 animal confirmed nonexposures. The upload interval was 4.88 [4.43, 9.33] (median [25%, 75%]) minutes, creating a near real-time national exposure and information database and surveillance system. Total encounters showed a 2.49% decrease from 2022 while human exposure cases increased by 0.764% and health care facility human exposure cases increased by 2.38%. All information requests decreased by 19.1%, medication identification (Drug ID) requests decreased by 14.0%, and medical information requests showed a 61.3% decrease, returning to pre-COVID-19 pandemic numbers. Drug Information requests showed a 17.6% decrease, due to continued declining COVID-19 vaccine calls to poison centers, but these still comprised 21.7% of all information contacts. Human exposures with less serious outcomes have decreased by 1.58% per year since 2008, while those with more serious outcomes (moderate, major or death) have increased by 4.25% per year since 2000. Consistent with the previous year, the top 4 substance classes most frequently involved in all human exposures were analgesics (11.00%), household cleaning substances (7.12%), antidepressants (5.58%), and cosmetics/personal care products (5.01%). Cardiovascular drugs (4.97%) replaced antihistamines as the 5th most common substance class. As a class, analgesic exposures increased most rapidly, by 1,260 cases/year (2.72%/year) over the past 10 years for cases with more serious outcomes. The top 5 most common exposures in children aged 5 years or less were household cleaning substances (10.1%), analgesics (9.13%), cosmetics/personal care products (9.10%), foreign bodies/toys/miscellaneous (8.03%), and dietary supplements/herbals/homeopathic (6.88%). The National Poison Data System® documented 3,272 human exposures resulting in death; 2,700 (82.5%) of these were judged as related (Relative Contribution to Fatality of 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory). Conclusions: These data support the continued value of poison center expertise and the need for specialized medical toxicology information to manage the increasing number of more serious exposures. Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality in the US. The near real-time nature of the National Poison Data System® represents a national public health resource for collecting and monitoring US exposure cases and information requests. The continuing mission of the National Poison Data System® is to provide a nationwide infrastructure for surveillance for all types of exposures (e.g., foreign body, infectious, venomous, chemical agent, or commercial product), and the identification and tracking of significant public health events. The National Poison Data System® is a model system for the near real-time surveillance of national and global public health. [ABSTRACT FROM AUTHOR]

The given text is a compilation of case reports and studies related to toxicology and poisoning. It covers a range of topics, including medication overdoses, adverse effects of substances, and the management of toxic exposures. The document provides valuable insights into the complexities of toxicology and highlights the importance of prompt and individualized treatment approaches. It can be a useful resource for library patrons conducting research in this field. [Extracted from the article]

This document is a part of the Pharmacotherapy Self-Assessment Program (PSAP) and provides information on the acute management of prescription and nonprescription drug overdoses. It emphasizes the importance of supportive care, exposure history, and understanding toxidromes in guiding treatment decisions. The article discusses the treatment paradigm in toxicology, including decontamination methods, enhanced elimination techniques, and focused antidotes. It recommends consulting toxicologists or poison centers for guidance in managing drug overdoses and highlights the value of involving poison centers and toxicologists in patient care. The document also provides information on the management and treatment of specific drug overdoses, such as Type 1 antiarrhythmics, diphenhydramine, bupropion, digoxin, and various toxic substances. It covers symptoms, treatment options, and the importance of early toxicologist involvement. Additionally, the document presents clinical cases to guide healthcare professionals in making appropriate treatment decisions. [Extracted from the article]

This article discusses the case of a 45-year-old male who was envenomated by his pet Trimeresurus insularis, a blue Indonesian pit viper. The patient presented to an emergency department in the United States and consultation with a poison center and medical toxicologist was obtained. Although Thai green pit viper antivenom is not approved by the US FDA, it was recommended based on in vitro data. The patient was transferred to another hospital to acquire the antivenom and received multiple doses, resulting in improvement in pain and swelling. Challenges in managing exotic snake envenomation in the US were highlighted, including the need for reimbursement to lending institutions and the regulatory requirements for using foreign antivenoms. Preemptive relationship development between poison centers, hospital pharmacies, IRBs, and venom lending facilities was suggested to navigate these challenges. [Extracted from the article]

Phenibut is an unregulated supplement that acts primarily as a gamma-aminobutyric acid type B receptor agonist. Use of phenibut can lead to dependence and subsequent withdrawal when use is stopped. Phenibut withdrawal can cause severe symptoms such as delirium, hallucinations, and seizures. The purpose of this systematic review is to characterize the natural history of phenibut withdrawal and summarize treatment strategies published in the literature. A systematic review was conducted using the preferred reporting items for systematic reviews and meta-analyses checklist. English language peer-reviewed articles or conference abstracts in humans describing phenibut withdrawal after cessation of use were included. Databases (Ovid/MEDLINE, Web of Science, and Science Direct) and references of included articles were searched. Case reports were appraised using the Joanna Briggs Institute critical appraisal checklist for case reports. Patient demographics and key outcomes, including withdrawal characteristics and treatment characteristics, were collected into a predefined data collection sheet by six independent reviewers. Search results yielded 515 articles of which 25 were included. All articles were case reports or published conference abstracts. All of the cases (100 percent) involved male patients and the median age was 30 years, (interquartile range 23.5–34 years, range 4 days−68 years). The median daily phenibut dose prior to experiencing withdrawal was 10 g (interquartile range 4.75–21.5 g, range 1–200 g). The shortest duration of phenibut use (2–3 g daily) prior to withdrawal was one week. Withdrawal symptoms occurred as quickly as two hours after the last phenibut dose. Sixteen patients (64 percent) reported progression of withdrawal severity within the first 24 hours of healthcare contact. Seizures were reported in two patients (8 percent), intubation in six patients (24 percent), and intensive care unit admission in 11 patients (44 percent). Withdrawal patterns and outcomes were similar in those using phenibut alone and those with comorbid polysubstance use. Withdrawal treatment strategies varied widely. Only three cases (12 percent) were managed outpatient and all three utilized a phenibut tapering strategy. All patients undergoing medication-assisted abstinence were admitted inpatient for symptom management and received a drug that acts on gamma-aminobutyric acid receptors. The most commonly used medication was a benzodiazepine, reported in 17 cases (68 percent). Nineteen patients (76 percent) required at least two drug therapies to manage symptoms. Baclofen was used in 15 cases (60 percent), primarily in conjunction with gamma-aminobutyric acid type A agonists (12 of 15 cases) or as monotherapy during a phenibut taper (two of 15 cases). Two patients using baclofen monotherapy outpatient, after initial stabilization with multiple drug classes, reported adverse effects. One patient had a seizure and the other experienced recurrent withdrawal symptoms, returned to using phenibut, and was admitted to a hospital for withdrawal symptom management with benzodiazepines. This review is subject to several limitations. Due to the manual nature of article selection, it is possible relevant articles may not have been included. As the entire data set is comprised of case reports it may suffer from publications bias. Outcomes and meaningful conclusions from specific treatment strategies were rarely available because of the heterogeneous nature of case reports. It is possible those reporting only phenibut use were actually using multiple substances. The doses of phenibut a user believed they were taking may be different from what was present in the unregulated product. Phenibut withdrawal appears to have a range of severity. It is important to recognize that patients undergoing phenibut abstinence may have progressive symptom worsening during early withdrawal. All published cases of abrupt phenibut abstinence were admitted inpatients for symptom management. Benzodiazepines or barbiturates with adjunctive baclofen appear to be the most commonly used drugs for moderate to severe withdrawal. Outpatient management via slow phenibut tapers with or without adjunctive gamma-aminobutyric acid agonist therapy may be successful. However, there is no standard treatment, and consultation with experts (e.g., toxicologists, addiction specialists) experienced in managing withdrawal syndromes is recommended. Significant study is warranted to develop methods of triaging phenibut withdrawal (e.g., severity scoring, inpatient versus outpatient management) and creating optimal treatment regimens. [ABSTRACT FROM AUTHOR]

This is the 40th Annual Report of America's Poison Centers National Poison Data System (NPDS). As of 1 January, 2022, all 55 of the nation's poison centers (PCs) uploaded case data automatically to NPDS. The upload interval was 4.72 [4.40, 9.27] (median [25%, 75%]) minutes, effectuating a near real-time national exposure and information database and surveillance system. We analyzed the case data tabulating specific indices from NPDS. The methodology was similar to that of previous years. Where changes were introduced, the differences are identified. Cases with medical outcomes of death were evaluated by a team of medical and clinical toxicologist reviewers using an ordinal scale of 1-6 to assess the Relative Contribution to Fatality (RCF) of the exposure. In 2022, 2,483,183 closed encounters were logged by NPDS: 2,064,875 human exposures, 50,381 animal exposures, 363,099 information requests, 4,790 human confirmed nonexposures, and 38 animal confirmed nonexposures. Total encounters showed a 12.9% decrease from 2021, and human exposure cases decreased by 0.771%, while health care facility (HCF) human exposure cases increased by 0.214%. All information requests decreased by 48.4%, medication identification (Drug ID) requests decreased by 21.2%, and medical information requests showed a 76.92% decrease, although these remain twice the median number before the COVID-19 pandemic. Drug Information requests showed a 52.4% decrease, due to declining COVID-19 vaccine calls to PCs but still comprised 5.55% of all information contacts. Human exposures with less serious outcomes have decreased 1.70% per year since 2008, while those with more serious outcomes (moderate, major or death) have increased 4.41% per year since 2000. Consistent with the previous year, the top 4 substance classes most frequently involved in all human exposures were analgesics (11.5%), household cleaning substances (7.23%), antidepressants (5.61%), and cosmetics/personal care products (5.23%). Antihistamines (4.81%) replaced sedatives/hypnotics/antipsychotics as the 5th substance class. As a class, analgesic exposures increased most rapidly, by 1,514 cases/year (3.26%/year) over the past 10 years for cases with more serious outcomes. The top 5 most common exposures in children age 5 years or less were household cleaning substances (10.3%), analgesics (9.54%), cosmetics/personal care products (9.49%), dietary supplements/herbals/homeopathic (6.65%), and foreign bodies/toys/miscellaneous (6.61%). NPDS documented 3,255 human exposures resulting in death; 2,622 (80.6%) of these were judged as related (RCF of 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory). These data support the continued value of PC expertise and the need for specialized medical toxicology information to manage the increasing number of more serious exposures. Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality in the US. The near real-time status of NPDS represents a national public health resource to collect and monitor US exposure cases and information requests. The continuing mission of NPDS is to provide a nationwide infrastructure for surveillance for all types of exposures (e.g., foreign body, infectious, venomous, chemical agent, or commercial product), and the identification and tracking of significant public health events. NPDS is a model system for the near real-time surveillance of national and global public health. [ABSTRACT FROM AUTHOR]

Management of patients with salicylate toxicity frequently requires urine alkalinization to enhance excretion of salicylate. One strategy for determining when to stop urine alkalinization is to wait for two consecutive serum salicylate concentrations to be less than 300 mg/L (2.17 mmol/L) and declining. When alkalinization of the urine ceases, a rebound in serum salicylate concentration can occur from tissue redistribution or delayed gastrointestinal absorption. Whether this can lead to rebound toxicity is not well understood. This was a single-center, retrospective review of cases with a primary ingestion of acetylsalicylic acid reported to the local poison center over a five-year period. Cases were excluded if the product was not listed as the primary ingestion or if there was no serum salicylate concentration documented after discontinuation of intravenous sodium bicarbonate infusion. The primary outcome was the incidence of serum salicylate rebound to a concentration greater than 300 mg/L (2.17 mmol/L) after discontinuation of intravenous sodium bicarbonate infusion. A total of 377 cases were included. Of these, eight (2.1%) had a serum salicylate concentration increase (rebound) after stopping the sodium bicarbonate infusion. All these cases were acute ingestions. Five of the eight cases had rebound serum salicylate concentrations that were greater than 300 mg/L (2.17 mmol/L). Of these five patients, only one reported recurrent symptoms (tinnitus). Prior to stopping urinary alkalinization, the last or the last two serum salicylate concentrations were less than 300 mg/L (2.17 mmol/L) in three and two cases, respectively. In patients with salicylate toxicity, the incidence of rebound in serum salicylate concentration after cessation of urine alkalinization, is low. Even if serum salicylate rebounds to supratherapeutic concentrations, symptoms are often absent or mild. Routine repeat serum salicylate concentrations after urine alkalinization is stopped may be unnecessary unless symptoms recrudesce. [ABSTRACT FROM AUTHOR]

The article addresses several issues regarding the treatment of phenibut withdrawal. Topics include the inaccuracy of statements about baclofen's safety in withdrawal management, the need for different treatment strategies for tapering versus abstinence, and concerns over the suggested dosing regimen for baclofen in comparison to phenibut.

This letter to the editor discusses a case involving the application of 17 lidocaine 4% patches to a patient's thigh. The patient did not experience any signs or symptoms of lidocaine toxicity, despite the large number of patches applied. However, it is important to note that this is a single case report and caution should be exercised when applying these findings to other exposure scenarios. The authors emphasize the need for further research and data on lidocaine patch absorption. [Extracted from the article]

This is the 39th Annual Report of America's Poison Centers' National Poison Data System (NPDS). As of 1 January, 2021, all 55 of the nation's poison centers (PCs) uploaded case data automatically to NPDS. The upload interval was 4.87 [4.38, 8.62] (median [25%, 75%]) minutes, effectuating a near real-time national exposure and information database and surveillance system. We analyzed the case data tabulating specific indices from NPDS. The methodology was similar to that of previous years. Where changes were introduced, the differences are identified. Cases with medical outcomes of death were evaluated by a team of medical and clinical toxicologist reviewers using an ordinal scale of 1-6 to assess the Relative Contribution to Fatality (RCF) of the exposure. In 2021, 2,851,166 closed encounters were logged by NPDS: 2,080,917 human exposures, 62,189 animal exposures, 703,086 information requests, 4,920 human confirmed nonexposures, and 54 animal confirmed nonexposures. Total encounters showed a 14.0% decrease from 2020, and human exposure cases decreased by 2.22%, while health care facility (HCF) human exposure cases increased by 7.20%. All information requests decreased by 37.0%, medication identification (Drug ID) requests decreased by 20.8%, and medical information requests showed a 61.1% decrease, although these remain about 13-fold higher than before the COVID-19 pandemic. Drug Information requests showed a 146% increase, reflecting COVID-19 vaccine calls to PCs. Human exposures with less serious outcomes have decreased 1.80% per year since 2008, while those with more serious outcomes (moderate, major or death) have increased 4.56% per year since 2000. Consistent with the previous year, the top 5 substance classes most frequently involved in all human exposures were analgesics (11.2%), household cleaning substances (7.49%), cosmetics/personal care products (5.88%), antidepressants (5.61%), and sedatives/hypnotics/antipsychotics (4.73%). As a class, antidepressant exposures increased most rapidly, by 1,663 cases/year (5.30%/year) over the past 10 years for cases with more serious outcomes. The top 5 most common exposures in children age 5 years or less were cosmetics/personal care products (10.8%), household cleaning substances (10.7%), analgesics (8.16%), dietary supplements/herbals/homeopathic (7.00%), and foreign bodies/toys/miscellaneous (6.51%). Drug identification requests comprised 3.64% of all information contacts. NPDS documented 4,497 human exposures resulting in death; 3,809 (84.7%) of these were judged as related (RCF of 1-Undoubtedly responsible, 2-Probably responsible, or 3-Contributory). These data support the continued value of PC expertise and the need for specialized medical toxicology information to manage more serious exposures. Unintentional and intentional exposures continue to be a significant cause of morbidity and mortality in the US. The near real-time status of NPDS represents a national public health resource to collect and monitor US exposure cases and information contacts. The continuing mission of NPDS is to provide a nationwide infrastructure for surveillance for all types of exposures (e.g., foreign body, infectious, venomous, chemical agent, or commercial product), and the identification and tracking of significant public health events. NPDS is a model system for the near real-time surveillance of national and global public health. [ABSTRACT FROM AUTHOR]

In July 2020, an outbreak of methanol-contaminated hand sanitizers in the United States prompted our regional poison center to implement a more conservative triage guideline for hand sanitizer exposures. All pediatric hand sanitizer ingestions of more than a "taste" were referred to a healthcare facility for assessment. We then evaluated the effect of this change on identifying patients with methanol poisoning. This was a single-center, retrospective review of pediatric (<19 years) hand sanitizer ingestions reported to our poison center from May 1, 2020 through January 28, 2022. Methanol and ethanol concentrations were collected if available. During the study period, we received 801 calls regarding hand sanitizer exposure, of which 140 children were referred to a healthcare facility for hand sanitizer ingestions. Of those, 88 (63%) had methanol and/or ethanol concentrations measured. No child had a detectable methanol concentration, 78 had ethanol testing, and 12 had a detectable ethanol concentration. In this sample, no patient tested had a detectable methanol concentration. Children who consumed enough to have a detectable ethanol concentration were symptomatic or had an intentional ingestion. Asymptomatic children with unintentional ingestion of hand sanitizer were at low risk for methanol toxicity. [ABSTRACT FROM AUTHOR]

Study objective: The objective of this study was to evaluate clinical outcomes associated with time to administration and dose of four‐factor prothrombin complex concentrate (4F‐PCC) in patients with ICH on warfarin. Design: This was a single‐center retrospective analysis of patients with ICH on warfarin who received 4F‐PCC. Setting: The site of the study was a large, Level I trauma, academic medical center with a dedicated neurologic intensive care unit and an emergency department (ED) that has approximately 72,000 visits annually. Patients: Patients were included if they were ≥18 years of age, diagnosed with ICH, had an INR >1 due to warfarin use, and received both 4F‐PCC and IV vitamin K for anticoagulation reversal. Exclusion criteria included patients who were less than 18 years of age, were not currently taking warfarin, had a bleeding site other than ICH, were pregnant or incarcerated, had an inadequate medical record, had a left ventricular assist device, had known liver disease with Child‐Pugh Class C, received anticoagulation with heparin therapy within 24 h of anticoagulation reversal, or did not receive vitamin K within 24 h of hospital admission. Intervention: Our primary outcome was a composite of hematoma expansion or death due to neurologic injury. Treatment groups were defined as receipt of 4F‐PCC within 0–30, 31–60, 61–90, 91–120 min, or greater than 120 min. Hematoma expansion was defined as any increase in hematoma size as assessed by a radiologist via standard 6‐h CT. Death due to neurologic injury was defined as death prior to a repeat CT being performed or documentation of a neurologic cause of death. Adequate INR reversal (INR ≤1.3 on repeat INR) vs. inadequate INR reversal and weight‐based vs. fixed‐dose 4F‐PCC were also assessed. Measurements and Main Results: A total of 94 patients met the inclusion criteria. Forty‐one patients (43.6%) met the composite endpoint, including 60% of the 31–60 min group, 47.6% of the 61–90 min group, 71.4% of the 91–120 min group, and 30.6% of the >120‐min group. A significant difference in primary outcome occurred between the 91–120 min and >120‐min groups (71.4% vs. 30.6%; p= 0.005), but this difference was not observed when accounting for disparities in Glasgow Coma Scale (GCS). Patients with adequate INR reversal were less likely to meet the primary endpoint than those with inadequate INR reversal (28.1% vs. 58.6%; p= 0.0059). There was less failure of anticoagulation reversal with weight‐based dosing compared with fixed dosing (24.2% vs. 65.0%; p< 0.001). Conclusions: No difference in clinical outcomes among 4F‐PCC dosing strategies or time windows to administration was observed in patients with GCS <15. Rates of repeat INR ≤1.3 were higher with weight‐based dosing, suggesting investigation of populations in which fixed dosing may be inappropriate is warranted. [ABSTRACT FROM AUTHOR]

This is a case of a potentially fatal mercuric chloride ingestion with elevated blood mercury concentrations resulting in only mild symptoms after early chelation with BAL. We describe a patient with potentially fatal ingestion of mercuric chloride who made a full recovery following the early initiation of chelation therapy. To the Editor Acute ingestion of mercuric chloride can lead to serious and life-threatening events. [Extracted from the article]

The high prevalence of fentanyl in the illicit drug supply has generated concern among first responders regarding occupational exposure. Social media sharing of unconfirmed first responder overdoses after brief exposure to fentanyl may be contributing to an inappropriate risk perception of brief dermal fentanyl exposure. This case details a dermal exposure to a large dose of analytically confirmed pharmaceutical fentanyl (fentanyl citrate, 10 microgram fentanyl base per ml), over a large skin surface area. Additionally, the exposure occurred at a site with some skin barrier compromise, a factor that can increase fentanyl absorption. The patient underwent appropriate decontamination and underwent a brief medical assessment with no clinical effects of opioid exposure observed. This information is of value to first responders and other health care workers who are at risk of occupational fentanyl exposure. Findings are consistent with in vitro and ex vivo data supporting low risk of rapid absorption after brief dermal fentanyl exposure. [ABSTRACT FROM AUTHOR]

Background: Exposures to bromethalin rodenticides have increased since restrictions were placed on long acting anticoagulant rodenticide (LAAR) registrations in 2008. Bromethalin works, in part, by uncoupling mitochondrial oxidative phosphorylation. Toxicity in humans is not well characterized and no antidote is available. Methods: This retrospective observational study analyzed data from the National Poison Data System (NPDS). The data set was derived from single substance bromethalin ingestions followed to a known medical outcome that were reported to US poison centers from 01/01/2008 to 12/31/2017. Results: There were 2674 bromethalin exposures in the NPDS database that met inclusion criteria. Of these exposures 2227 (83.28%) were pediatric, aged 16 days–12 years. Within this population, no effects were seen in 2143 (96.38%) of the exposures, 74 (3.32%) had minor effects, and 10 (0.45%) had moderate effects. No major clinical effects or deaths occurred in pediatric patients, although one patient with a major effect was of unknown age. Exposures in patients >12 years encompassed 391 patients aged 13–94 years. No effect was seen amongst 257 (65.73%) of the patients, 100 (25.58%) had minor effects, 23 (5.88%) had moderate effects, nine (2.30%) had major effects, and two (0.51%) patients died. Intentional ingestions among these patients accounted for one (0.25%) death and four (1.02%) major effects. Case details of the intentional ingestion death suggest the possibility of a miscoded long acting coagulant rodenticide. Conclusions: No major effects or deaths were seen in pediatric exposures. A majority of the possible bromethalin exposures involving adults reported to poison centers resulted in minor or no effects, though seizures, death and one questionable case of coagulopathy were documented. This dataset suffers from its retrospective nature, reliance on caller information, selection bias, information bias, and miscoding. It is possible that one or both deaths attributed to bromethalin exposure were not actually due to bromethalin. [ABSTRACT FROM AUTHOR]

Dear Editor In recent years, much discussion surrounds higher dosing of intravenous (IV) n-acetylcysteine (NAC) in acetaminophen toxicity [[1]]. Commonly, this is described as a "three-bag" method for IV NAC administration, implying that, over each dosing interval a separate NAC dose is injected into its own bag of IV fluid and then given as a separate infusion. For example, a hospital may be instructed to administer the "one-bag" NAC regimen and logically conclude they should administer the three-bag regimen's daily dosing as a single, continuous infusion. [Extracted from the article]

Dear Editor, Ethosuximide (ESM) is an antiepileptic used for the treatment of absence seizures. A single case series in patients with chronic renal disease who underwent iHD after one therapeutic dose of ESM showed a reduction in drug concentration by 38.8-52.4% [[6]]. [Extracted from the article]

The fungi Paecilomyces variotii is a potential pathogen in immunocompromised and immunocompetent patients. Their rare association with clinical disease results in scarce literature regarding susceptibility and treatment. Here, we discuss a case involving successful treatment of probable P. variotii pneumonia with posaconazole after treatment failure with voriconazole. The current literature related to antifungal susceptibility profiles, microbiological identification methods and clinical management of infections caused by this organism is also reviewed. [ABSTRACT FROM AUTHOR]

Background: Alkyl nitrite analogs known as "poppers" have been inhaled recreationally for decades. They are available to be purchased from gas stations marketed as "nail polish remover not for human consumption". These rapid-onset, short-acting, vasodilators cause the user to experience euphoria, dizziness, tachycardia and flushing. While chronic use may lead to problems such as methemoglobinemia or neuropathy, nitrites rarely lead to acute life-threatening side effects such as ventricular dysrhythmias.Case Report: We report a case of ventricular fibrillation cardiac arrest in a 21-year-old male after inhaling from a solution labeled to contain isobutyl nitrite, a rarely reported adverse effect of "popper" use. The product was analytically confirmed to contain mainly isobutyl alcohol, volatile hydrocarbons, and isobutyl nitrite, as well as smaller quantities of other substances. The patient was also prescribed escitalopram and hydroxyzine may have contributed. Return of spontaneous circulation was achieved in the field after initiation of CPR and defibrillation. He was found to have no clear predisposition to arrythmias during his care or on follow up.Conclusion: Alkyl nitrite "popper" users and clinicians should be aware that products labeled to contain nitrites may contain volatile hydrocarbons along with nitrites and have the potential to cause arrhythmia. [ABSTRACT FROM AUTHOR]

Introduction: Yohimbine, an alpha-2 adrenoreceptor antagonist found in a variety of supplements, has been historically used to treat libido, erectile dysfunction, xerostomia, and as a weight loss enhancement. Yohimbine toxicity causes a sympathomimetic syndrome as demonstrated by the case below of a female who developed an intracranial hemorrhage (ICH) following an ingestion of yohimbine.Case: This case follows a 39-year-old female who presented to the emergency department (ED) with complaints of nausea, emesis, and flushing following the ingestion of a female sexual enhancement supplement labeled to contain yohimbine (BioXgenic Nature's Desire) one hour prior. The patient took her prescribed 0.1 mg clonidine when the symptoms commenced. Upon arrival, the patient's blood pressure was 198/93. She developed neurological sequelae including a left-sided facial droop and weakness of her right extremities. A computed tomography scan demonstrated an acute basal ganglia hemorrhage with mild mass effect and mild subarachnoid hemorrhage. She was transferred to a regional referral hospital and discharged 16 days later to a rehabilitation center with persistent neurological sequelae.Discussion: This patient exhibited sympathetic toxicity temporally associated with yohimbine ingestion. Our patient also had a variety of risk factors that increased the likelihood of a poor outcome with yohimbine. Chronic use of clonidine is known to down-regulate alpha-2 receptors. This leads to dependence of clonidine to maintain adrenergic homeostasis and could potentiate the effects of yohimbine. To compound effects, our patient was also taking bupropion and desvenlafaxine, which inhibit norepinephrine reuptake, likely worsening our patient's sympathomimetic response. Despite the temporal relationship of our patient's ICH and ingestion of yohimbine, a definitive relationship cannot be inferred due to our lack of confirmatory testing of yohimbine content and possibility of adulterants. The U.S. Food and Drug Administration (FDA) does not regulate the supplement market strictly, with multiple studies illustrating variation among ingredients of supplements despite stated quantities on the labels.Conclusion: Dietary supplements are not required by the FDA to undergo efficacy or safety testing, necessitating clear post-marketing communication regarding potential adverse events from various supplements. Users should be aware of yohimbine-containing products and the possible side effects of toxicity. It is crucial that physicians and patients be aware of possible drug-supplement interactions of yohimbine and the presentation of sympathomimetic syndromes. [ABSTRACT FROM AUTHOR]

This report describes a case of hemolysis in a patient injecting deoxycholic acid and benzyl alcohol for aesthetic benefit without medical supervision. The concentration and dose injected by the patient resulted in a 10-fold overdose of deoxycholic acid in comparison to the FDA-recommended dosing for the approved indication. Providers should be aware of medically unsupervised use of DCA and other injectables and the potential risks associated with this practice. [ABSTRACT FROM AUTHOR]

Purpose Vasoactive medications are used during advanced cardiac life support (ACLS) to shunt oxygenated blood to vital organs and after return of spontaneous circulation (ROSC) to maintain hemodynamic goals. However, limited evidence exists to support vasoactive medication recommendations in such scenarios, and it is unknown how practices vary among emergency departments across the US. Methods A survey questionnaire (15 questions) was electronically distributed to emergency medicine pharmacists (EMPs) in the US through various professional listservs. Demographic information, American Heart Association ACLS algorithm medication use, and use of continuous vasopressor infusions and adjunct medications following ROSC were assessed and are reported descriptively. Results The survey was distributed to 764 EMPs, with a 23% response rate from a wide geographic distribution and 48% of respondents practicing in academic medical centers. Epinephrine dosing and administration during cardiac arrest were reported by most to be in accordance with ACLS cardiac arrest algorithms. Calcium, magnesium sulfate, and sodium bicarbonate were the most common adjunct intravenous medications given during cardiac arrest. Norepinephrine was the first-choice vasopressor (81%) for post-ROSC hypotension, while epinephrine was preferred less frequently (17%). Antibiotics and sodium bicarbonate were the most frequently administered post-ROSC adjunct medications. Conclusion This survey of a geographically diverse group of EMPs demonstrated high ACLS algorithm adherence for epinephrine during cardiac arrest with frequent additional administration of nonalgorithm medications. Sodium bicarbonate and calcium were the most frequently administered adjunct medications during cardiac arrest, while sodium bicarbonate and antibiotics were the most frequently used adjunct medications following ROSC. Norepinephrine was the most commonly used vasopressor following ROSC. [ABSTRACT FROM AUTHOR]

Purpose To streamline workflow of the culture review process in the emergency department (ED), a transition from a nurse-driven to a pharmacist-initiated process was implemented. Methods This was a single-center retrospective study conducted at an adult urban level 1 trauma academic medical center. The pharmacist-initiated culture review process was compared to the previous nurse-initiated process. The primary objective was time from final culture result to patient contact by an advanced practice provider. Secondary objectives included incidence of treatment failure and hospital admission within 30 days of ED visit. Results A total of 283 patients met inclusion criteria: 144 patients in the pre-intervention group and 139 patients in the postintervention group. Patients were contacted a median time of 15.7 hours (95% confidence interval [CI], 9.88-18.83) earlier for definitive urinary tract infection antibiotic therapy and 46.7 hours (95% CI, 33.34-61.62) earlier for definitive sexually transmitted infection therapy in the pharmacist-initiated workflow compared to the nurse-initiated workflow (P < 0.001). Treatment failure occurred in 0.01% of patients in the postintervention group and 6.3% in the pre-intervention group (P = 0.01). Hospital admission within 30 days of the ED visit occurred in 0% of patients in the postintervention group and 4.2% in the pre-intervention group (P = 0.03). Conclusion Pharmacist-initiated culture review in the ED at an academic medical center reduced time from final culture to patient contact for optimal antibiotic therapy and decreased hospital admission and treatment failure rates. A change in the culture review workflow involving pharmacists appears to have a positive impact on clinical outcomes. [ABSTRACT FROM AUTHOR]

Cardiac arrest occurs in approximately 350,000 patients outside the hospital and approximately 30,000 patients in the emergency department (ED) annually in the United States. When return of spontaneous circulation (ROSC) is achieved, hypotension is a common complication. However, optimal dosing of vasopressors is not clear. The objective of this study was to determine if initial vasopressor dosing was associated with cardiac re-arrest in patients after ROSC. This was a retrospective, single-center analysis of adult patients experiencing cardiac arrest prior to arrival or within the ED. Patients were assigned to one of four groups based on starting dose of vasopressor: low dose (LD; < 0.25 µg/kg/min), medium dose (MD; 0.25–0.49 µg/kg/min), high dose (HD; 0.5–0.99 µg/kg/min), and very high dose (VHD; ≥ 1 µg/kg/min). Data collection was performed primarily via manual chart review of medical records. The primary outcome was incidence of cardiac re-arrest within 1 h of vasopressor initiation. Multivariate logistic regression analysis was conducted to identify any covariates strongly associated with the primary outcome. No difference in cardiac re-arrest incidence was noted between groups. The VHD group was significantly more likely to require a second vasopressor (p = 0.003). The HD group had lower survival rates to hospital discharge compared with the LD and MD groups (p = 0.0033 and p = 0.0147). In the multivariate regression, longer duration of pre-vasopressor re-arrests and hyperkalemic cardiac arrest etiology were significant predictors of cardiac re-arrest after vasopressor initiation. Initial vasopressor dosing was not found to be associated with risk of cardiac re-arrest or, conversely, risk of adverse events. [ABSTRACT FROM AUTHOR]

Study Objective: The primary objective of our study was to compare the effectiveness of oral cephalosporins versus fluroquinolones and trimethoprim/sulfamethoxazole (TMP-SMX) for the treatment of pyelonephritis in patients discharged home from the emergency department (ED)., Methods: This was a multicenter, retrospective, observational cohort study of 11 geographically diverse US EDs. Patients aged ≥18 years diagnosed with pyelonephritis and discharged home from the ED between January 1, 2021 and October 31, 2023 were included. The primary outcome was treatment failure at 14 days defined as a composite outcome of the following: (1) recurrence of urinary symptoms, (2) repeat ED visit or hospitalization for a urinary tract infection, (3) receipt of a new antibiotic prescription for urinary tract infection. Secondary outcome was appropriateness of empiric treatment based on urine culture susceptibility., Results: Among the 851 patients who met inclusion criteria, 647 patients received a cephalosporin, and 204 patients received an Infectious Diseases Society of America guideline-endorsed first-line treatment (fluroquinolones, TMP-SMX). Overall, baseline characteristics were similar between the 2 cohorts. Rates of treatment failure were not significantly different in the cephalosporin group compared with the fluroquinolone/TMP-SMX groups (17.2% of cephalosporin vs 22.5% of fluroquinolone/TMP-SMX group, difference=5.3%, 95% confidence interval -0.118 to 0.01). After adjusting for potential confounders, cephalosporin use was not associated with treatment failure (odds ratio=0.22, 95% confidence interval 0.03 to 1.95). There was no difference in rates of appropriate empiric treatment based on urine culture susceptibility., Conclusion: Oral cephalosporins were associated with similar treatment failure rates compared with Infectious Diseases Society of America guideline-endorsed treatments for the treatment of pyelonephritis in ED patients discharged home., (Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Introduction: There is controversy over the existence of a metronidazole-induced disulfiram-like reaction. Uncontrolled case reports suggest metronidazole can cause a severe disulfiram-like reaction in combination with ethanol. Criticism of these cases suggest the observed effects appear to be as likely caused by ethanol as by a drug interaction. Controlled experimental data refute these reports, demonstrating metronidazole does not increase acetaldehyde and cannot reliably produce disulfiram-like reactions. The purpose of this study is to retrospectively assess the incidence of clinical effects consistent with a disulfiram-like reaction in a population of patients with confirmed ethanol use who received metronidazole. As alcohol may also be responsible for the effects seen, the incidence of effects is assessed against a control group matched for age, sex, and ethanol concentration., Methods: A retrospective chart review was performed from December 1, 2010, through December 31, 2020 on emergency department patients with ethanol use confirmed via detectable ethanol concentration who received metronidazole while ethanol was predicted to still be present in the serum. A matched comparator group with the same ethanol concentrations, as well as sex and age, was generated for comparison. The incidence of disulfiram-like reaction symptoms documented in the medical record was compared between groups., Results: Thirty-six patients were included in the study: 18 in the metronidazole group and 18 in the ethanol concentration matched control group. The mean age in both groups was 46 years. The metronidazole group was 50% male, and the mean ethanol concentration was 0.21 g/dL. The control group was 44.4% male. There was significantly less hypertension in the metronidazole group compared to the control group (16.7% vs 61.1%, P $lt;  0.0001). There were no other significant difference in disulfiram-like effects between the two groups. No patients who received metronidazole and had a detectable ethanol concentration had a suspected disulfiram-like reaction documented in the medical record., Conclusions: This data set further supports the lack of a disulfiram-like reaction when metronidazole is used in patients with recent ethanol use in the acute care setting. Additionally, it highlights that the clinical effects of a disulfiram-like reactions may be present at baseline from ethanol ingestion or underlying disease regardless of metronidazole use. These findings are consistent with well-controlled human and animal data demonstrating no increase in acetaldehyde concentrations or disulfiram-like symptoms when metronidazole is co-administered with ethanol. In patients where metronidazole is indicated as the superior agent, its use should not be avoided due to concern about an interaction with ethanol., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

Introduction: Prehospital medical teams encounter patients with varying states of shock that require the use of vasopressors for hemodynamic support during transport. Selection of a vasopressor is challenging due to the absent comparative literature in prehospital medicine, as well as practical limitation of use in an ambulance., Areas Covered: This article discusses specific challenges in the delivery of vasopressor support for hemodynamically compromised patients in the prehospital environment. Discussion includes the current state of vasopressor use in prehospital medicine, use of a patient-specific agent selection or "one-vasopressor-fits-all" modality, as well as considerations for each vasopressor based on practical, pharmacologic, and comparative evidence-based evaluations., Conclusions: There are currently many limitations to assessment of shock etiology in the prehospital setting. A "one-vasopressor-fits-all" strategy may be most feasible for most prehospital emergency medical services (EMS) systems. No clear difference in extravasation exists amongst agents. Based on current evidence, norepinephrine may be more efficacious and have a better safety profile than other vasopressors in cardiogenic, distributive, and neurogenic shocks. Due to its suitability for most shocks, norepinephrine is a reasonable agent for EMS systems to employ as a "one-size-fits-all" vasopressor., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)