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Five cases of illegitimate bite by captive specimens of the Gaboon viper (Bitis gabonica) snake have demonstrated the dangers of keeping exotic African snakes in captivity.Four cases necessitated hospitalization for the bite and were characterized by progressive swelling of the affected limb, local necrosis and hemorrhagic edema near the wound, chest tightness and prolonged coagulation times. However, platelet counts were not altered. All patients received antivenom and had uneventful recovery, except for one who underwent amputation of a distal phalanx and one who required debridement. In the fifth case, the patient died without being able to summon help.The results of this case series emphasize the need for extreme care to be exercised with the captivity of exotic snakes, such as the Gaboon viper. The increasing popularity of this snake as a captive pet predicates the need for private collectors to have a pre-existing treatment strategy with their local emergency centers. Such arrangements may facilitate the treatment of envenomation by this snake.

Although intentional and unintentional rodenticide poisoning is common, most readily available agents are of relatively low acute toxicity. A four-year long epidemic of severe toxicity from rodenticide exposure continues among patients predominantly of Dominican descent living in New York City. This study characterizes the ongoing epidemic of acute cholinesterase inhibitor poisoning due to an illicit rodenticide and identifies its etiology.A prospectively collected case series of poisoned patients referred to the New York City Poison Control Center. The main outcome measures include the clinical characteristics upon presentation, antidotal and other therapeutic requirements, and patient outcome. Product analysis was performed with paper chromatography, gas chromatography/mass spectrometry, and high-performance liquid chromatography. A murine model assessing both clinical effect and cholinesterase activity was also performed.Thirty-five patients were referred following exposure to Tres Pasitos. Patients developed signs of cholinergic hyperactivity and many required high doses of atropine (10 mg) to control these symptoms. The source was identified as a rodenticidal compound sold illicitly in local groceries primarily within the Dominican community. Murine cholinesterase activity fell significantly following exposure to the rodenticide. High-performance liquid chromatography identified aldicarb, an extremely potent carbamate-type cholinesterase inhibitor, not licensed for rodenticidal use in this country.Illicit sale of undocumented compounds poses a substantial public health threat. Despite several public health interventions, the epidemic continues.

Study objectives: To determine which adult patients with new-onset seizures require admission and whether those who require admission can be identified in the emergency department. Design: Retrospective chart review of patients seen during a 5-yearperiod. Setting: Urban county teaching hospital in southern California. Participants: Three hundred thirty-three adult patients with new-onset seizures. Patients were excluded if they had acute head trauma, hypoglycemia from diabetic therapy, or alcohol- or recreational drug-related seizures. Interventions: Standardized medical evaluation including physical examination, CBC, SMA-7 (electrolytes, blood urea nitrogen, creatinine, glucose), calcium, cranial computed tomography (CT), lumbar puncture if indicated, and admission to the hospital. Results: Forty-six percent of patients (136 of 294) admitted toour hospital required admission as judged by a retrospective evaluation of the ED and hospital course. The numbers of patients who had a clinically significant result with each part of the evaluation were: physical examination, 75 of 333 (23%); CBC, 25 of 319 (8%); SMA-7, 21 of 329 (6%); calcium, 2 of 208 (1%); CT, 134 of 325 (41%); and lumbar puncture, 19 of 227 (8%). Ninety-five percent of patients requiring admission (129 of 136) were detected by the standardized medical evaluation. Conclusion: One half of patients with new-onset seizures require admission. Patients with new-onset seizures who require admission can usually be detected by a standardized medical evaluation in the ED.

Internet access and online pharmacies are a resource for purchasing medications. It is unclear if this venue is being used by emergency department (ED) patients to obtain medications.We sought to determine the frequency of and to characterize online pharmacy use by ED patients. We hypothesized that students and younger patients would be more likely than others to obtain medications via online pharmacies due to their familiarity with the Internet.This prospective, cross-sectional survey occurred in an urban university ED. We enrolled a convenience sample of adult patients. The study was Institutional Review Board approved, and informed consent was obtained. To determine differences between online pharmacy users and non-users, chi-squared or Fisher's exact tests were used for categorical data, and t-test or Wilcoxon rank sum tests were used for continuous variables.There were 1657 patients who completed the survey. The mean age was 39 years, standard deviation 16 years; 947/1657 (57%) reported awareness of online pharmacies; 89/1657 (5.4%) patients used the Internet to order medications. More patients with prescription plans ordered medications from online pharmacies (94.3% vs. 70%; p0.0001), and Internet users were more commonly on multiple medications (median 3 vs. 1; p0.0001). There was no difference in age (39.4 vs. 41 years; p=0.2) or student status (13.8% vs. 14.9%; p=0.8) between the two groups.Approximately 5% of ED patients used the Internet to obtain medications. Contrary to our hypothesis, younger patients were not more likely to use the Internet for medications. Patients on multiple medications and those with prescription plans used online pharmacies more frequently.