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This article presents two years of billing and collection data for a bedside toxicology consultation service. The collections rate was 34% or $26.19 per hour of consultative time. There was an inverse correlation between collection rates and patient acuity. Keywords Toxicology economics; Reimbursement, INTRODUCTION Very few board certified medical toxicologists are engaged in the private practice of medical toxicology. Furthermore, little has been published regarding the medical economics of the private practice of [...]

Byline: Raquel Gibly, Michelle Williams, Frank G Walter, Jude McNally, Carol Conroy, Robert A Berg Abstract: Study objective: We sought to describe the effects of continuous intravenous midazolam infusion as therapy for severe bark scorpion (Centruroides exilicauda) envenomation. Methods: A retrospective chart review from July 1, 1993, through January 1, 1998, identified all patients treated at a university hospital with International Classification of Diseases, Ninth Revision, codes 989.5 (toxic effect of venom) or E905.2 (scorpion sting causing poisoning). By using standardized collection forms, data were extracted from the medical record of every patient who had a grade III or IV envenomation and was treated with a continuous intravenous midazolam infusion. Results: Our search identified 104 patients; 34 had grade III or IV envenomation. Of these, 33 were treated in the ICU with continuous intravenous midazolam infusion. Median patient age was 4 years (range, 1 to 68 years). Midazolam dosage was adjusted to induce a light sleep state to control agitation and involuntary motor activity. The median amount of midazolam resulting in the first recorded decrease in agitation and involuntary motor activity was 0.30 mg/kg (range, 0.03 to 1.76 mg/kg). This first evidence of clinical improvement was recorded as 1.00 hour (median), with a range of 0.00 to 3.75 hours. The initial midazolam infusion rate was 0.10 mg*kg.sup.-1*h.sup.-1 (median), with a range of 0.01 to 0.31 mg*kg.sup.-1*h.sup.-1. The maximal midazolam infusion rate was 0.30 mg*kg.sup.-1*h.sup.-1 (median), with a range of 0.06 to 1.29 mg*kg.sup.-1*h.sup.-1. The median time until the maximal midazolam infusion rate was 2.5 hours (range, 0.00 to 8.50 hours). The median duration of infusion was 9.50 hours (range, 4.25 to 20.50 hours). The median length of stay in the ICU was 15.17 hours (range, 6.0 to 28.0 hours), and 85% of patients were discharged directly home. All patients had resolution of abnormal motor activity and agitation during their midazolam infusion. Transient hypoxemia without evidence of end-organ dysfunction was documented in 4 patients during midazolam therapy. Conclusion: A continuous intravenous midazolam infusion can be a safe, effective, and readily available treatment option for patients with grade III or IV C exilicauda envenomation. [Gibly R, Williams M, Walter FG, McNally J, Conroy C, Berg RA: Continuous intravenous midazolam infusion for Centruroides exilicauda scorpion envenomation. Ann Emerg Med November 1999;34:620-625.] Author Affiliation: From the Section of Medical Toxicology, Division of Emergency Medicine, Department of Surgery,.sup.* Arizona Poison and Drug Information Center,.sup.a Arizona Emergency Medicine Research Center,.sup.As. the Department of Pediatrics and the Steele Memorial Children's Research Center,.sup.a[yen] the University of Arizona Health Sciences Center, and Emergency Room Associates, Carondelet St. Joseph's Hospital,.sup.A[paragraph] Tucson, AZ Article History: Received 6 August 1998; Revised 11 May 1999; Revised 23 June 1999; Accepted 12 July 1999 Article Note: (footnote) [star] Supported in part by the Maria Mandell Emergency Medicine Research Award given by the Arizona Emergency Medicine Research Center., [star][star] Reprints not available from the authors., a 0196-0644/99/$8.00 + 0 , aa 47/1/101383

Case Report: This is a case of severe intravascular hemolysis, without significant coagulopathy, following envenomation by a North American crotalid. A MEDLINE search from 1966-1997, and a review of older literature, revealed no similar cases. A 4-year-old girl was envenomated in her right foot by a 2.5 foot-long rattlesnake whose description matched that of the Hopi rattlesnake (Crotalus viridis nuntius). The snake was not captured. Her initial hematocrit was 45%. In spite of treatment with antivenin and improvement in her lower extremity pain and swelling, her hematocrit decreased to 20.4%. Laboratory tests and clinical exam showed a Coombs positive hemolytic anemia without significant signs of coagulopathy., INTRODUCTION Snake venoms are a well-known cause of coagulopathy and syndromes of disseminated intravascular coagulation (DIC).[1-12] As many as 40 % of people envenomated by North American crotalids suffer from [...]

Byline: Frank G Walter, Raquel L Gibly, Robert K Knopp, Denise J Roe Abstract: Study objective: To determine whether squamous cells in urine indicate bacterial contamination. Methods: We prospectively studied 105 consecutive women who presented to the emergency department with symptoms suggestive of a urinary tract infection. Two urine samples were collected from each woman, a midstream clean-catch (MSCC) sample and a catheterized (CATH) sample. Microscopic urinalyses to assess for squamous cells and urine cultures to assess for bacterial contamination were performed on all samples. Bacterial contamination was defined as growth of fewer than 10,000 colonies of a single species per milliliter or growth of three or more species of commensal bacteria (mixed flora) in a urine sample. Results: Squamous cells were found in 99 of 105 CATH samples (94%); however, no CATH samples had bacterial contamination. Squamous cells were found in 101 of 105 MSCC samples (96%); however, only 22 MSCC samples (21%) had bacterial contamination. Conclusion: The presence of squamous cells in CATH urine samples obtained from women is not indicative of bacterial contamination. The presence of squamous cells in MSCC urine samples obtained from women also is not a good indicator, with an overall predictive value for bacterial contamination of 21%. [Walter FG, Gibly RL, Knopp RK, Roe DJ: Squamous cells as predictors of bacterial contamination in urine samples. Ann Emerg Med April 1998;31:455-458.] Article History: Received 10 October 1996; Revised 25 June 1997; Revised 4 November 1997; Accepted 16 November 1997 Article Note: (footnote) [star] From the Department of Emergency Medicine, Valley Medical Center, Fresno, * and the Department of Medicine, University of California San Francisco School of Medicine, San Francisco,a CA; and the Division of Emergency Medicine, Department of Surgery,As. and Department of Family and Community Medicine, II The University of Arizona College of Medicine, Tucson, AZ., [star][star] Supported by a grant from the Medical Research Committee of Valley Medical Center, Fresno, CA., a Address for reprints: Raquel L Gibly, MD, Division of Emergency Medicine, 1501 North Campbell Avenue, Tucson, AZ 85724-5057, 520-626-6312, Fax 520-626-2480, E-mail raquel@aemrc.arizona.edu, aa 47/1/88631

Background: Animal and human laboratory studies suggest marijuana may cause hyperthermia. However, there are no clinical case reports of life-threatening hyperthermia associated with use of marijuana alone. Case Re o : We report a patient who developed severe hyperthermia after smoking a marijuana cigarette and jogging on a warm day. He presented with delirium: hot, red, dry skin; and a rectal temperature of 41.7[degrees]C Historical and laboratory data indicated he had used cannabinoids and no other drugs. This is the first report of life-threatening hyperthermia temporally associated with use of marijuana alone., INTRODUCTION Heatstroke can be defined as a combination of an elevated body temperature of 40.0[degrees]C or more; central nervous system dysfunction such as delirium, coma, or seizures; and an exogenous [...]

Antidotal therapy for acetaminophen poisoning is routinely based on a single acetaminophen level obtained four or more hours after ingestion. Some experts recommend additional acetaminophen levels if there are coingestants. This case report describes a 20-year-old woman who ingested acetaminophen 13 g, propoxyphene napsylate 2 g and naproxen sodium 3.75 g. A 4.5 h acetaminophen level was 83.5 mg/L (nontoxic). A 6.75 h acetaminophen level was 124.6 mg/L (toxic). The patient was treated with N-acetylcysteine and recovered without sequelae. This is the first published report of a delayed toxic acetaminophen level occurring after an initial nontoxic level. Although rare, the possibility of a delayed peak acetaminophen level merits consideration, particularly with coingestions that delay gastric emptying., INTRODUCTION Antidotal therapy for acetaminophen (APAP) poisoning is routinely based on a single APAP level obtained four or more hours after ingestion[1,2]. Additional APAP levels have been recommended if there [...]

This case report describes seizures and encephalopathy in a nine year-old boy treated with iodoquinol for amebiasis. The toxicity of iodoquinol and other 8-hydroxyquinolines is discussed. The radiopacity of this medication, used worldwide for the treatment of diarrheal illnesses and dermatitis, may be diagnostically useful., INTRODUCTION Neurotoxicity from the 8-hydroxyquinolines, such as iodoquinol, is well documented[1,2], but seizures in man have not been reported during use of these medications. A number of ingested medications can [...]

Byline: Tareg A Bey, Frank G Walter, William Lober, Justin Schmidt, Ronald Spark, Patrick M Schlievert Abstract: Envenomation by the brown recluse spider (Loxosceles reclusa) is associated with shock, significant hemolysis, renal insufficiency, and disseminated intravascular coagulation (DIC). Shock has never been associated with envenomation by L arizonica, a related species indigenous to Arizona, southern California, and northwestern Mexico. We report the case of a 13-year-old girl, bitten by a specimen of L arizonica (the spider was identified by an entomologist), in whom shock and a typical cutaneous lesion developed. She did not experience renal insufficiency or disseminated intravascular coagulation. Infectious causes of shock were excluded. She recovered completely with supportive care. [Bey TA, Walter FG, Lober W, Schmidt J, Spark R, Schlievert PM: Loxosceles arizonica bite associated with shock. Ann Emerg Med November 1997;30:701-703.] Article History: Received 28 August 1996; Revised 14 January 1997; Accepted 12 April 1997 Article Note: (footnote) [star] From the Medical Toxicology Fellowship, Section of Emergency Medicine, Department of Surgery, University of Arizona Health Sciences Center,* the Department of Pathology, Tucson Medical Center,a the Carl Hayden Bee Research Center, US Department of Agriculture, Tucson, AZ,As. and the Department of Microbiology, University of Minnesota Medical School, Minneapolis, MN.a[yen] , [star][star] Reprint no. 47/1/85424 , a Address for reprints: Tareg A Bey, MD, University of Arizona Health Sciences Center, Section of Emergency Medicine, 1501 North Campbell Avenue, Tucson, AZ 85724-5057, 520-626-6312, Fax 520-626-2480, E-mail tareg@aemrc.arizona.edu

Case Report: A suicidal, epileptic patient ingested ethanol, valproic acid, and gabapentin, a new antiepileptic drug. He did well clinically despite elevated blood gabapentin, valproic acid, and ethanol. Conclusions: Preliminary data from this case and one previous report indicate relatively mild clinical signs and symptoms with gabapentin poisoning., INTRODUCTION In 1993 the FDA approved gabapentin (GBP) as add-on therapy for adults with unsatisfactory control of partial seizures.[1] To date, five GBP overdoses have been published but only one [...]

Table of Contents Abstract Introduction Materials and Methods Results Discussion References Abstract This is a prospective, descriptive, feasibility study to determine whether an interdisciplinary group of healthcare experts could design [...]

Abstract This is a prospective, descriptive, feasibility study to determine whether an interdisciplinary group of healthcare experts could design and successfully deliver an international, life support, continuing education program that [...]

Backgrounds Coagulation abnormalities following crotaline (pit viper) snakebite have traditionally been considered short-lived, but laboratory studies have rarely been reported beyond the first few days of treatment for envenomation. During the course of an antivenom clinical trial, we observed coagulation defects as late as 2 weeks following envenomation. Objectives: To document and characterize the recurrence or persistence of coagulopathy among patients envenomed by pit vipers and treated with a Fab antivenom. Methods: Patients with moderate pit viper envenomation were enrolled in a multicenter, prospective clinical trial. A Fab-based antivenom preparation, antivenom polyvalent crotalid (ovine) Fab, was administered in all cases. Platelet count, fibrinogen level, presence of fibrin split products, prothrombin time, and partial thromboplastin time were determined before treatment and at standard intervals during the following 2 weeks. Results: Of 38 patients completing the study, 20 (53%) had recurrent, persistent, or late coagulopathy 2 to 14 days after envenomation. Thrombocytopenia occurred in patients with prior thrombocytopenia; hypofibrinogenemia occurred only in those with prior hypofibrinogenemia or positive fibrin split products. No patient experienced significant spontaneous bleeding. One patient with coagulopathy developed minor bleeding following minor surgery 12 days after envenomation. Conclusions: Prolonged or recurrent coagulopathy may occur after envenomation by North American pit vipers. Patients treated with Fab-based antivenom may benefit from periodic rather than single-bolus dosing. Patients with coagulopathy should undergo close monitoring during the first 2 weeks after snakebite. Arch Intern Med. 1999;159:706-710