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Background: 2C-T-7 (2,5-dimethoxy-4-(n)-propylthiophenethylamine), also known as 'blue mystic,' is a hallucinogen developed around 1980 that purportedly share some of the entheogenic properties of LSD. No information could be found about this drug in the standard medical literature (i.e. MEDLINE, POISINDEX, and toxicology texts). Several Internet 'recreational drug' web sites, however, provide extensive information on 2C-T-7. Case Report: The patient is an 18-year-old college student brought to the ED because of new onset seizure activity. He had been ingesting 2CT-7 on a daily basis for about a month. He was familiar with web sites that discussed this drug and had purchased his supply of 2C-T-7 over the Internet. He had no past medical or psychiatric history and denied alcohol or other drug use. The patient stated that prior to his most recent use of 2C-T-7 he had experienced less vivid hallucinations during his 'drug trips.' In order to intensify the hallucinations he increased the dose. Within a few minutes of ingesting the larger dose, he sustained a witnessed generalized tonic clonic seizure lasting less than a minute. On arrival in the ED he had some visual hallucinations and no recollection of the seizure activity. Vital signs were T: 36.6, RR: 18, P: 125, BP: 132/82. His pupils were about 7 mm bilateral and reactive. The rest of his examination was unremarkable. Over a three-hour observation, he remained stable. His hallucinations resolved, his heart rate slowed gradually to 90, and he was discharged from the ED. Conclusion: We report a case of 2C-T-7 use that resulted in seizure activity. Since the standard medical literature at present has little information about this drug, the health care provider is forced to rely on information garnered from Internet drug web sites. While such information may not have undergone medical peer review, the public, and adolescents in particular, may be quite influenced by their content., Badawy M, Wax P. Department Emergency Medicine, University of Rochester Medical Center, Rochester, [...]

Background: While excessive use of anticholingeric agents has been widely documented among individuals taking neuroleptic agents, cases of diphenhydramine (DPH) abuse and withdrawal are seldom reported. Case Report: A 38year-old female with a history of depression presents to the ED with confusion and refusal to take her medications--olanzapine, gabapentin, mirtazapine, clonazepam. In addition, the patient has a history of escalating DPH use over the past 18 months, secondary to its 'relaxing' effect, reaching a maximum of 100 25 mg tabs qd (2.5 gm) for a 10 month period of time and gradually tapering to 1.25 gm qd over the past 4 wks. She had not taken any of her medications including DPH over the 2 days prior to presentation. During the past 18 months she had not complained of dry mouth, urinary retention, constipation, confusion, sedation, or blurry vision. ED vital signs were T 36.1, P 109, BP 121/75, and R 16. She was calm with a normal exam except for disorientation and confusion. Her CBC and serum chemistries were normal. She was admitted to the hospital for observation of worsening withdrawal symptoms. By day 2 her mental status was clear but she complained of anorexia, nausea, and increased anxiety followed on day 3 by diarrhea, abdominal cramping and episodes of flushing. She was treated only with clonazepam, maintaining normal vitals. All somatic complaints gradually resolved, but she continued to complain of anxiety prior to discharge to outpatient drug rehabilitation on day 6. A DPH level drawn upon initial presentation (48 h after last DPH dose) was 550 ng/mL (ref. avg peak serum DPH level 2h after a single 50 mg oral dose is 66 ng/mL.) Conclusion: This is a case of presumed DPH withdrawal presenting with mild confusion, anxiety and somatic symptoms of mild cholinergic excess without alteration in vital signs and demonstrating a self-limiting course. A remarkable tolerance to DPH characterized this case., Shiuh T, Wax P. Department of Emergency Medicine, University of Rochester Medical Center, Rochester, [...]

Objective: Metallic mercury is commonly used in jewelry manufacturing. We describe two related clusters of mercury exposure cases that resulted from the improper removal of metallic mercury from an abandoned jewelry factory. Methods: Following the report that metallic mercury was found on the ground outside an apartment complex, an epidemiological investigation was initiated to trace the source of the mercury and to perform 24-hour urine mercury testing on residents who may have been exposed to the mercury. Results: Two teenage brothers (Brother A lived with mother, and Brother B lived with father 10 miles apart from Brother A) divided a several kilogram cache of metallic mercury that they had taken from an abandoned jewelry factory. Both brothers brought their mercury allotment home and stored it in their respective residences, intermittently showing it to friends. After several months, Brother A decided to throw the mercury into the trash outside his apartment. Unfortunately, the mercury container broke as he was discarding it, resulting in ground contamination. After the mercury spill was identified and confirmed by positive air sampling, Brother A and residents from his apartment complex were brought to the hospital for mercury testing. Brother A's 24 h urine mercury was 46.6 [micro]g/L. Repeat urine mercury 8 days later was 22.8 [micro]g/dL. Of 11 neighbors tested, 3 had urine mercury levels of 15-20 [micro]g/dL with a mean neighbor mercury level of 9.5 [micro]g/L [+ or -] 5.7. Further investigation revealed that Brother B lived next to the jewelry factory separated by a 50-meter alleyway. The ground adjoining his residence was grossly contaminated with mercury. Brother B's urine mercury was 157.5 [micro]g/dL. His car was secondarily contaminated by his mercury contaminated shoes. Brother B's repeat urine mercury level 15 days later without chelation was 88.8 [micro]g/dL. Brother B's father had a urine mercury of 57.7 [micro]g/L. Two other residents from the second residence had a urine mercury of 37.9 and 15 [micro]g/L respectively. The remaining 5 neighbors of Brother B all had urine mercury [is less than] 7 [micro]g/dL. Neither brother nor any of the other tested individuals had any symptoms of mercury toxicity, and no one received chelation. Cost of the environmental cleanup of the mercury at the two residences and adjacent grounds was approximately $500,000 USD. Conclusions: The improper disposal of mercury from a jewelry plant has the potential to become a public health problem and requires a costly cleanup. Careful tracing of the origin of the spilled mercury is important in order to evaluate all potentially exposed individuals and to make sure all the mercury can be accounted for., Wax P, Salhanick S, Cernichiari E, Doniger A. University of Rochester School of Medicine, Rochester, New York, [...]

Background: Apoptosis represents a genetically programmed and highly selective mechanism of cell death that eliminates redundant or excessively damaged cells in response to a wide array of stimuli (viruses, radiation, toxins, etc.). Previous data have shown that amatoxins induce structural changes in liver and kidney cell nuclei by binding RNA polymerase II, thereby inhibiting DNA transcription and subsequent protein synthesis. The purpose of the present study was to investigate whether apoptosis played a role in the acute fulminant hepatic failure that developed in a patient following amatoxin (Lepiota sp.) ingestion. Methods: Surgically excised liver was formalin-fixed, paraffin-embedded, cut into 4 [micro]m thick sections and mounted onto glass slides. Furthermore, formalin-fixed, paraffin-embedded liver and thymus sections from healthy patients were included in the study and served as a control. Nucleosomal DNA fragmentation was assessed with the Hoescht stain and the fragmented DNA of apoptotic cells was measured by using the terminal transferase deoxynucleotide end labeling (TUNEL) assay. Results: Our results demonstrated a dramatically increased number of cells positive for both the Hoechst stain and the TUNEL assay (p [is less than] 0.001) in the amatoxin exposed liver relative to control as assessed by the unpaired student t-test, indicating that a large number of amatoxin exposed cells underwent apoptosis. Conclusion: The data presented here suggest that amatoxin induced hepatotoxicity is largely mediated by apoptosis. The exact apoptotic pathway mediating this hepatotoxicity remains to be elucidated, however if it involves caspase activation, caspase-based therapeutic strategies may be useful for the management of these patients in the acute setting., Brouxhon S, Ryan C, Wax P, Schneider S. Department of Emergency Medicine, University of Rochester School of Medicine & Dentistry, Rochester, [...]

Objective: Acute pancreatitis in the setting of acetaminophen hepatotoxicity has been reported in isolated case reports, but there are no series investigating the actual incidence. Our goal was to better define the incidence of acute pancreatitis in this setting. Methods: A retrospective review of medical records of 50 consecutive patients consulted on by the medical toxicology service at a tertiary care hospital with a diagnosis of acetaminophen toxicity over a 6-year period was performed. This hospital also serves as a liver transplant center. Acetaminophen hepatotoxicity was defined as AST [is greater than] 1000 IU/L in the setting of excessive acetaminophen use or overdose. Patients who had a serum lipase level three times above the upper limit of normal (upper limit of normal 208 IU/L) were considered to fulfill a commonly used laboratory diagnosis for acute pancreatitis. Results: 28 of 50 (56%) patients had peak AST [is greater than] 1000 IU/L. Serum amylase and lipase data were available for 16 of these 28 patients. Seven of 16 (44%) patients had hyperamylasemia ([is greater than] 130 IU/L), and 13 of 16 (81%) had hyperlipasemia ([is greater than] 208 IU/L). Nine of 16 (56%) had serum lipase [is greater than] 624 IU/L (3 x upper limit of normal), meeting the criteria for acute pancreatitis. Conclusion: Although 12 of 28 patients with AST [is greater than] 1000 IU/L in this study did not have serum lipase determinations, our data suggests that at least 9 of 28 (32%) of our patients with acetaminophen hepatotoxicity had fulfilled the criteria for acute pancreatitis. Acute pancreatitis may be more common in acetaminophen ingestion than previously described. Lipase assay is indicated in patients with significant acetaminophen ingestion for early and accurate diagnosis of pancreatitis, as a number of patients with pancreatitis in our study had serum amylase within the normal range., Yoo H, Witmer R, Wax P. University of Rochester Medical Center, Rochester, [...]

Introduction: Chronic and unintentional overdose of acetaminophen (APAP) is an increasingly common cause of acute liver failure. This study examines knowledge and perception about APAP therapeutic usage and toxicity in a convenience sampling of ED visitors. Method: During a 3-month period a questionnaire was distributed to adult visitors found in a ED waiting room. The subjects were asked about demographic data, maximum daily therapeutic APAP dose and dosing intervals, and self-reporting practices regarding APAP use. Results: 103 of 142 (79%) ED visitors approached completed the questionnaire. The respondents were 66% Caucasians, and 31% of African Americans. 17.5% of the subjects believed maximum daily APAP dose is [is greater than or equal to] 5g (5.8% believed that it is [is greater than or equal to] 10 g per day). When asked to identify APAP-containing products among 10 commonly used pain medications, only 12.6% chose Percocet[R], and 5.8% Vicodin[R] respectively. Motrin[R] was the medication respondents most frequently believed to contain APAP(sic). 51.5% did not know that APAP toxicity causes liver damage. Readers (55.5%) of APAP package labeling had comparable knowledge of APAP toxicity to nonreaders (44.5%). No statistically significant difference existed with regard to sex, race and age in responding to these questions. However, more female subjects routinely inform doctors about their APAP use compared to males (64.1% vs 29.7%, p [is less than] 0.005). Conclusion: Some study subjects appear to have very limited knowledge regarding therapeutic dosing of APAP and its toxicity. To reduce the occurrence of chronic and unintentional APAP toxicity from the improper use of this omnipresent medication, optimal education of the public is essential. Regarding self-reporting practice, special attention should be focused on male patients who are less likely to volunteer APAP use history., Chen L, Schneider S, Wax P. University of Rochester, School of Medicine, Rochester, [...]

Background: The abuse of fentanyl is a well described phenomenon. Fentanyl patch smoking has rarely been reported. A case of apnea immediately following one inhalation of fentanyl in this manner is described. Case Report: A 37-year-old female with a history of drug abuse was found unresponsive (GCS = 3), apneic, and with miosis by her friends after smoking a 'pipe with fentanyl.' Upon arrival of EMS, the patient was intubated and given 2 mg naloxone to which she rapidly responded. In the ED, the patient was very agitated but calmed after extubation. Her urine drug screen was positive for benzoylecgonine and negative for opiates. After one additional dose of 2 mg naloxone, the patient remained alert and required no further treatment. Upon further questioning, the patient admitted to past history of nasal insufflation of heroin and fentanyl smoking. She had refrained from opioid abuse during the previous 6 months. She described her fentanyl smoking technique as follows: 'Take a 75 or 100 [micro]g fentanyl patch, cut the edges and peel it apart. Place the gel portion in the oven on 500 [degrees] and bake for approximately 10 minutes until the gel becomes brown and bubbles. Remove from the oven and let it cool and scrape the residue into a glass pipe (eg. crack pipe). Light it and inhale. The high is similar to heroin and peaks within 20 minutes and lasts 60 minutes.' She reports each patch provides enough fentanyl for only one inhalation. Conclusion: We report an unusual case of fentanyl abuse by smoking the fentanyl obtained from a patch. The smoking of fentanyl from a patch may produce apnea., Souders C, Branton T, Wax P. Department of Emergency Medicine, University of Rochester Medical Center, Rochester, [...]

Objective: An increasing number of recreational drug related ED visits appear to be precipitated by drug use suggestions garnered off the Internet. The study objective is to determine the frequency of Internet drug site visitation by students and its association with drug use. Methods: A convenience sample of undergraduate college students (school size = 3800), and a 1st year medical school class (class size = 100) were asked to fill out an anonymous written questionnaire about their own recreational drug use. Specific questions were also asked about whether they had surfed the Internet for drug information and its impact on subsequent drug use. Chi-squared statistics were used as appropriate. Results: 168 students (20% of whom had been to a rave) were surveyed (94 college and 74 1st year medical students). 19% reported that they surfed the Internet for information on recreational drug use (24% college and 14% medical students). Of those who surfed the Internet, 9% said this increased their likelihood of using recreational drug (27% college and 0% medical students), 19% said it decreased likelihood of using recreational drug (27% college and 10% medical students) and 72% stated this had no effect (45% college and 90% medical student). Those who surfed for recreation drug information were much more likely to have used MDMA 53%, 'magic mushrooms' 50%, and LSD 22% than those who had not surfed the internet 7%, 11%, and 6% respectively (p < 0.05). There was no statistical difference between web surfers and nonsurfers regarding their likelihood of having attended a rave. Conclusions: About 1 in 5 students surveyed have visited recreational drug web sites. Comparable numbers of college students reported that web site visitation increased or decreased their drug taking likelihood. The impact on medical students was considerably less. There appears to be an association between hallucinogenic drug use and drug site visitation but causation can not be ascertained., Wax P, Reynolds N. Department of Emergency Medicine & University Health Service, University of Rochester, Rochester, [...]

Background: Over 90% of fatal mushroom poisonings in the United States are caused by the ingestion of Amanita phalloides. We report the ingestion of a much lesser known amatoxin-containing mushroom for which there is one previous report of ingestion and death in this country. Case Report: A 62-year-old previously healthy woman from upstate New York made a meal of mushrooms she picked from her lawn. She developed nausea and diarrhea the next day but waited until 40 hours after the ingestion before seeking medical care. She was found to have elevated liver transaminases and was transferred to a regional poison treatment center where she rapidly developed fulminant hepatic failure and underwent liver transplantation. The postoperative course was complicated by ARDS, sepsis, and renal failure. The patient died 18 days after transplant. Samples collected from where the patient had picked the mushrooms included 3 known edible species and several small Lepiota which were later identified as Lepiota josserandii. The patient admitted having no knowledge of what species she had picked. Conclusion: Amanita phalloides and other amanitas are well known as causes of amatoxin poisoning. Some species of Galerina and Lepiota are also known to contain amatoxin but are less frequently encountered as toxic ingestions. This case represents only the second reported ingestion and death caused by Lepiota josserandii in this country., Donnelly M, Brouxhon S, Schneider S, Wax P. Department of Emergency Medicine, University of Rochester Medical Center, Rochester, [...]

Background: At times liver transplantation (TXP) may be performed in cases of fulminant hepatic failure (FHF) without a clear understanding of the underlying precipitant. A case of FHF is presented in a patient who 11 weeks earlier had received liver TXP for FHF of unclear etiology. Case Report: A 42-year-old previously healthy female was transferred to a liver TXP center with FHF. She had no history of ETOH abuse, solvent exposure, or mushroom ingestion, and her only medication was thyroxine. Admission labs were AST 4754 IU/L, INR 3.9, ammonia 194 mcmol/L, and lactate 9.1 mmol/L. Although her acetaminophen (APAP) level was 21 mcg/mL, there was no history of APAP OD, and the level was thought to be from occasional APAP use and not the culprit of her FHF. Due to her precarious hemodynamic state, the patient underwent emergency liver TXP. Histology on the native liver demonstrated centrilobular necrosis involving 60% of the liver with no evidence of chronic liver disease. Hepatitis serology was negative. After a stormy postoperative course, the patient recovered and went home. Besides the usual post-TXP medications, she was started on phenytoin for tacrolimus-induced seizures. She was told that she could safely take prescription doses of APAP-containing products for pain. 11 weeks after the initial TXP, she again presented to the hospital with FHF. At this time she had AST 3612 IU/L, INR 3.3, ammonia 195 mcmol/L, and lactate 16.9 mmol/L. Liver biopsy again showed centrilobular necrosis involving 50% of the transplanted liver without evidence of acute rejection. Immunologic and viral studies were all negative. Toxicologic consultation recommended obtaining an initial APAP level from her current admission. The APAP was 68 mcg/mL. Serial APAP levels revealed a 10-hour half-life despite FHF. The patient was started on IV NAC and recovered. Upon awakening the patient admitted to taking at least 3-4 gms of APAP per day both before and after her TXP. Conclusion: APAP use should be strongly discouraged after liver TXP in cases of apparent idiopathic FHF. The combination of APAP and phenytoin may be particularly problematic due to p450 enzyme induction., Wax P, Linden E. University of Rochester Medical Center, Rochester, [...]

Background: Fomepizole (4MP) is predominantly eliminated by hepatic metabolism. We present a patient in fulminant liver failure who had an ethylene glycol (EG) level of 50 mg/dL and was treated with a single dose of fomepizole. Serial serum fomepizole levels were obtained over the next 7 days to investigate the elimination of fomepizole in this virtually anhepatic patient. Case Report: A 38-year-old male presented to the ED with fulminant hepatic failure from chronic acetaminophen (APAP) and ethanol abuse. Upon presentation he was unresponsive and had a pH of 7.15, AST of 8580 IU/L, T Bili of 2.5 mg/dL, ammonia of 119 [micro]mol/L, INR of 6.1, creatinine of 1.8 mg/dL, APAP level of 31 mcg/mL, and ethylene glycol level of 50 mg/dL. The patient was treated with NAC and a single intravenous dose of fomepizole 15 mg/kg (total 1050 mg). Subsequently, the EG level was discovered to be a false positive and no further fomepizole was given. The initial fomepizole level 1 hour after administration was 204 [micro]mol/L. The rate of elimination was 2.9 [micro]mol/L/h. In the recent clinical trial on fomepizole in EG poisoning the rate of elimination was 16.5 [+ or -] 3.1 [micro]mol/L/h. Conclusion: Therapeutic doses of fomepizole (4MP) are eliminated normally by nonlinear or zero order kinetics. These doses produce blood levels in the range of 100-300 [micro]mol/L. Studies in healthy humans have shown that fomepizole is eliminated from the body primarily by hepatic metabolism. The nonlinear elimination probably results because of a saturation of this metabolic pathway. In this patient, the elimination of a single IV dose of 4MP was not saturated, but followed classic first order kinetics, with a half-life of 17.8 hours. In comparison, Phase 1 studies in healthy humans showed that the elimination of 4MP, after the initial saturation phase, was first order, with half-lives about 2 hours. These data suggest that in this patient the metabolism of fomepizole was completely blocked by the loss of liver function. Hence, the elimination occurred by excretory processes (most likely in the urine), which are first order processes., Wax P, McMartin K. University of Rochester, Rochester NY; Louisiana State University Medical Center, Shreveport, [...]

Background: Only 2 cases of serotonin syndrome (both mild) have been described in the setting of tramadol and SSRI use. We describe a case of severe serotonin syndrome after a polydrug overdose including tramadol and fluoxetine. Profound hyperpyrexia occurred despite an initial dose of cyproheptadine. Case Report: A 32-year-old female presented to the ED 2 hours after an intentional overdose of her own medications that included tramadol (1.6 g), fluoxetine (80 mg), metaxalone (2.4 g), acetaminophen-oxycodone (20 tabs), etodolac (800 mg), and naproxen (30 g). Vital signs on presentation were BP 181/112 mmHg, HR 100 bpm, and T 100.1 F. A urine drug screen was negative for drugs of abuse. The patient denied other ingestions including MAOIs. Her physical exam and mental status were normal, she received an initial dose of activated charcoal and was admitted for observation. 12 hours after ingestion her mental status declined, and she developed diaphoresis, muscle stiffness and twitching, and required intubation. At this time vital signs were BP 130/70 mmHg, HR 135 bpm and T 98.8 F. Serotonin syndrome was suspected and cyproheptadine 4 mg was given. The patient's symptoms did not improve and less than 2 hours after cyproheptadine, she became more diaphoretic, developed a temperature of 108.8 F, HR 188 bpm, and BP of 86/52 mm Hg. Her vital signs improved with aggressive cooling, lorazepam, and fluid resuscitation. The patient went on to develop ARDS and rhabdomyolysis, but recovered and was discharged 3 weeks after admission. Analysis of the blood from admission showed fluoxetine 143 ng/mL (therapeutic 47-469 ng/mL) and tramadol 800 ng/mL (therapeutic 230-770 ng/mL). Conclusion: Given the relative lack of serotonergic properties of metaxalone, acetaminophen-oxycodone, etodolac, and naproxen, we concluded that the excessive ingestion of tramadol and fluoxetine in a patient already on these medications resulted in the development of severe serotonin syndrome. Single dose cyproheptadine clearly did not prevent deterioration in this case. Because of the late deterioration in this patient, prolonged observation should be considered after ingestion of multiple serotonergic agents., Kious T, Wax P, Cobaugh D. Finger Lakes Regional Poison Center, University of Rochester, Rochester, [...]

Background: We hypothesized that an activated charcoal powder mixed in soda pop (ACSP) has a more rapid time to dose completion in pediatric poisoned patients than to a traditional AC/H20 slurry (AC). Methods: A double-blinded, randomized, prospective study was conducted using subjects enrolled in the emergency department of a university teaching hospital. Subjects aged 1 to 18 years requiring AC as part of their ED management were stratified by age and randomized to receive either ACSP or AC. The container was weighed before and after the dose. Time to dose completion was measured with a stopwatch. Statistical analysis included a two-sided sequential design with time to completion as the end point. The measure of treatment difference was the log hazard ratio. Log hazard ratio was defined as the ratio of the chance of completion per unit time between the AC subjects and the ACSP subjects. Hazard ratio [is less than] 1 indicated a relative benefit for ACSP subjects. Results: 82 subjects were enrolled. Subjects were stratified by age: Group I (16 yrs) included 37 subjects and Group II (7-18 yrs) included 45 subjects. Sequential test efficacy boundary was crossed when 48 dose completions occurred (27 in the ACSP group and 21 in the AC group). In Group I, 10/37 (27%) completed at least 80% of the charcoal dose within 1 hour: 6 received ACSP and 4 received AC. In Group II, 17/23 (74%) subjects who received ACSP completed their dose by a mean time of 10 min (3.4 standard error) and 21/22 (95%) subjects who received ACSP completed their dose by a mean time of 27 min (4.7 standard error). Across age groups, the adjusted (for sequential stopping rule) hazard ratio was 0.33. That is, chance of dose completion at any point in time was 3 times greater in the ACSP group. The ACSP treatment was superior to the AC treatment with an adjusted p-value = 0.0006. In Group I, hazard ratio was 0.629 and in Group II, the hazard ratio was 0.223. Conclusion: Time to completion of an activated charcoal dose is significantly shorter with ACSP when compared to AC. Differences were more significant in children aged 7 to 18., Smith S, Cobaugh D, Dragalin V, Wax P, Lawrence R. Finger Lakes Regional Poison and Drug Information Center, University of Rochester Medical Center, Rochester, [...]

Background: Serum ethylene glycol (EG) determinations are usually performed by glycerol dehydrogenase (GDH) enzyme assay or gas chromatography (GC). An advantage of the enzyme assay is that it is relatively easy to perform particularly when needed 24 hours per day. A recent report suggests that false positive results by enzymatic assay may occur in the presence of elevated LDH and/or lactate resulting in increased production of NADH, the product of the GDH enzymatic reaction. We report on 3 patients who presented with fulminant hepatic failure, a history of chronic acetaminophen abuse, and high anion gap metabolic acidosis. Ethylene glycol levels were obtained in each case. Case Series: Each patient had EG levels by GDH enzyme assay (Hitachi 900) that was [is greater than]-20 mg/dL. In 1 case, serial EG levels were increasing. Treatment was initiated with ethanol infusion in Case 1 and fomepizole in Case 2. The following laboratory analysis was performed: EG Anion AST LDH Lactate (mg/dL) gap pH (IU/L) (IU/L) (mmol/L) Case 1 25 31 6.8 6690 11,000 21 Case 2 50 45 7.15 12,464 39,907 14.6 Case 3 20 33 7.15 3612 12,713 26.5 In all 3 cases the elevated EG by GDH enzyme assay was later determined to be negative by GC. Conclusion: We conclude that the use of the EG assay by GDH enzyme technique in these 3 cases of fulminant hepatic failure from chronic acetaminophen abuse produced false positive results. These findings are most likely due to increases in LDH and/or lactate associated with the liver failure and acidosis. Elevated EG by GDH enzyme assay should trigger the ordering of serum LDH and lactate levels, and if they are elevated, GC confirmation for the presence of EG should be considered. Wax P, Branton T, Cobaugh D, Kwong T. University of Rochester Medical Center, Rochester, NY3, Wax P, Branton T, Cobaugh D, Kwong T. University of Rochester Medical Center, Rochester, [...]

Background: Previous studies have demonstrated that paramedics receive variable amounts of training in treating poisoned patients with AC and they infrequently administer it. The objective of this study was to test paramedics' general knowledge about AC. Methods: A convenience sample of 251 ALS (advanced life support) technicians completed a 5 question multiple choice survey about AC. Questions covered general knowledge appropriate to paramedic practice as determined by a panel of emergency medicine physicians, toxicologists and paramedics. Participants were recruited at EMS (emergency medical services) stations near 4 small to medium sized US cities with poison centers. Data collection was monitored to ensure independent responses without the use of references. Names were not recorded and surveys were not examined until study-blind data entry. Results: Participants worked as ALS technicians for a mean of 9 years (Range: 1-27 years). Overall, 60% of knowledge questions were answered correctly. 47% (108/231) of respondents incorrectly believed that AC was contraindicated in a patient less than 3 years old. 37% (91/246) incorrectly identified the preferred time frame for AC administration as 4 hours, instead of 1 hour, and 25% (61/246) incorrectly believed that single dose AC causes emesis in most patients. 32% (79/246) of respondents agreed and 36% (89/246) disagreed that further training would make them more likely to administer AC in the field. Conclusions: This study demonstrates that there are deficits in some paramedics' knowledge about the indications, contraindications and side effects of activated charcoal., Hoffnung A, Cobaugh D, Wax P, Schneider S, Lawrence R. Department of Emergency Medicine and Finger Lakes Regional Poison & Drug Information Center, University of Rochester Medical Center, Rochester, [...]

Background: Previous studies have reported that AC is infrequently administered to patients in the pre-hospital setting. The objective of this study was to describe how often paramedics administer AC and their perceptions about barriers to its administration. Methods: A convenience sample of 251 ALS technicians completed a 26 question multiple choice questionnaire about their experiences transporting patients with toxic ingestions and their perceptions about barriers to administering AC. Participants were recruited at EMS stations near four small to medium sized US cities with poison centers. Data collection was monitored to ensure independent responses. Names were not recorded and surveys were not examined until study-blind data entry. Results: 62% (152/247) of participants reported transporting patients with toxic ingestions more often than once per month, but only 16% (38/244) administered AC more than once per month, and 72% (176/244) administered AC less than twice per year. 64% (156/243) reported that they required medical command permission to administer AC and 4% (9/243) inaccurately (as later compared to protocol) believed that they were never permitted to administer AC. The three most reported barriers to administering AC were patient resistance to ingest it (39%), risk of spillage and patient emesis (28%), and failure of medical command to advise its use (26%). 60% (147/246) of respondents agreed that the availability of a more palatable form of AC would make them more likely to administer it in the field. Conclusions: These data support previous reports that AC is infrequently administered by paramedics in the pre-hospital setting. Patient non-compliance, risk of emesis, and reliance on medical command were the three most frequently reported barriers to AC administration., Hoffnung A, Cobaugh D, Wax P, Schneider S, Lawrence R. Department of Emergency Medicine and Finger Lakes Regional Poison & Drug Information Center, University of Rochester Medical Center, Rochester, [...]

Objective: To investigate demographics and practice patterns that may impact medical toxicology billing practices. Methods: Data from a recent written survey to ACMT members regarding workforce issues in medical toxicology was analyzed with respect to how the demographics and practice patterns of medical toxicologists may impact their billing practices as they pertained to 2 patient scenarios: inpatient evaluation of a hypotensive CCB overdose and outpatient evaluation of steelworker presenting with multisystem complaints. Billing practices were assessed with regard to geographic location, primary specialty, and % of professional time devoted to medical toxicology. Results: 150 of 236 ACMT members completed the survey. 133 of 150 are currently practicing medical toxicology. Mean inpatient bill was Western States $628 (collected $354), Midwest $309 ($190), Northeast $270 ($127), and South $188 ($138). Mean outpatient bill was West $768 ($697), Midwest $281 ($181), Northeast $243 ($179), and South $125 ($75). Regarding primary specialty: mean inpatient bill was EM $427 (collected $235), Peds $157 ($85), and OM $650 ($463). Mean outpatient bill was EM $421 ($355), Peds $149 ($96), and OM $908 ($875). Those with 100% Med Tox practice had mean inpatient bill of $1160 (collected $600), 50-99% Med Tox practice $354 ($190), and [is less than] 50% Med Tox practice $272 ($180). Mean outpatient bill for 100% Med Tox practice was $847 ($847), 50-99% Med Tox practice was $276 ($206), and those with [is less than] 50% Med Tox practice was $267 ($203). Conclusions: These billing scenarios suggest that medical toxicologists from the West bill more and collect more than in other parts of the U.S. Those from OM bill and collect the most revenue, and those from pediatrics bill and collect the least. Billings and collections appear to be significantly greater for full-time medical toxicologists than those who practice toxicology part-time. Collection to billing ratio is best for outpatient consultations, especially for full-time and OM medical toxicologists., Wax P. University of Rochester Medical Center, Rochester, [...]

Background: Specialists in Poison Information (SPIs) in U.S. poison centers obtain CE through a combination of internal and external programs. The purpose of this study was to describe existing educational programs and to characterize the CE needs of SPIs. Methods: A 13-item self administered survey was mailed to the managing directors of 72 US poison centers and a 17-item self administered survey was mailed to 948 SPIs. Only one mailing was completed for each survey. Results: Completed surveys were received from 65/72 (90%) centers. A mean 13.6 hours (range 0-150 hours) of CE were provided per year by the centers. 21/65 (32%) centers indicated that CE is not required for SPIs. 51/65 (79%) of the centers indicated that formal evaluation methods are not included in their CE programs and 49/64 (75%) indicated that CE credits are not available for poison center based CE. The return rate for the SPI needs assessment survey was 430/948 (45%). SPI demographics were: RN 252/430 (59%), RPh 170/430 (40%), MD 5/430 (1%), other 3/430. Mean length of poison center experience was 7 years and 336/430 (78%) of the respondents were CSPIs. Respondents reported a mean of 38.9 hours per year are spent on CE. 133/430 (30.9%) of respondents indicated that attendance at a poison center based conference is not required for their job. 68/430 (15.8%) of respondents indicated that poison center based conferences are not provided. 369/430 (86%) believed that CE was very important. Both the SPIs and the centers identified mushrooms, drugs of abuse, herbals and heavy metals as preferred CE topics. Conclusion: SPIs regard CE as very important to their professional practice. There is inconsistency across US poison centers in provision of CE., Fishman C, Cobaugh D, Ciancaglini P, Wax P, Lawrence R. Finger Lakes Regional Poison & Drug Information Center, University of Rochester Medical Center, Rochester, [...]

Background: A regional AAPCC certified poison center developed an electronic CE program for Specialists in Poison Information (SPIs). The program was distributed to participants via one of three electronic mediums including the www, E-mail, and fax. Participants chose the most appropriate electronic medium for delivery of their CE modules. Each two-week module provided information on a toxicology-related topic, in a brief question/answer format followed by a discussion of the answer. Following each module, participants were asked to respond to a test question and a satisfaction survey. Thirteen modules were completed at the time of analysis. The purpose of this analysis was to describe the participants' response to the program. Methods: 948 SPIs from 72 poison centers were included in the educational program. Responses to the satisfaction survey were to be indicated by marking strongly agree, agree, disagree, or strongly disagree, and were then to be submitted via fax or E-mail along with the completed test question. Results: As of the completion of the 13th module, 2,134 visitors logged onto the website. 553 responses to test questions and 456 satisfaction surveys have been received. Response to individual test questions ranged from 7.7% (73/948) for Module I (AACT/EAPCCCT Gastric Decontamination Guidelines) to 2.0% (19/948) for Module 13 (Herbal/Dietary Supplements Part II). Response rate steadily declined over the duration of the program. 97% agreed that the activity met its stated objectives. 95% agreed that the content was at an appropriate level for the audience. 97% said they would apply the information/skills learned from this activity to their clinical practice. 90% agreed that the overall quality of the activity was excellent. Conclusion: Although responders were generally satisfied with the activity, the response rate for both the test questions and satisfaction surveys was much lower than anticipated. This analysis was limited because we were unable to determine the number of participants who completed the module but elected not to respond., Ciancaglini P, Cobaugh D, Wax P, Lawrence R. Finger Lakes Regional Poison & Drug Information Center, University of Rochester Medical Center, Rochester, [...]

Introduction: Of the 40 scorpion species found in the United States, envenomation by Centruroides exilicauda (also known as the bark scorpion because of its predilection of residing in or near [...]

Background: Serum acetaminophen (APAP) levels are often obtained in cases of unexplained liver failure. However, serum APAP levels in jaundiced patients may be potentially misleading. The GDS Diagnostic[R] enzymatic assay package insert cautions bilirubin levels >25 mg/dL may result in falsely elevated APAP levels in the presence of APAP. We present 2 jaundiced patients in whom serially elevated APAP levels were detected using GDS Diagnostic assay when APAP wasn't present by GC/MS. Case Reports: A 36 year-old man with alcoholism/Hepatitis C presented with jaundice without history of APAP ingestion. Initial bilirubin level was 19.5 mg/L, and serial serum APAP/bilirubin levels were drawn (see table). A 31-year-old woman with alcoholism presented after an acute APAP overdose (unknown time) with an initial APAP level of 178 mg/L and bilirubin of 9.9 mg/dL. Serial APAP/bilirubin levels were drawn (Table). Conclusions: Despite complete absence of APAP, hyperbilirubinemia was associated with measurable APAP concentrations using the GDS Diagnostics assay, even with bilirubin concentrations below 25 mg/dL. The mechanism and threshold of this interference are unknown. Clinicians must realize elevated APAP levels in jaundiced patients using the GDS assay may not reflect APAP use. Pt 1 (hrs after admit) Laboratory Values 16 41 210 282 Bilirubin, mg/dL 17.7 23.3 21.0 26.5 APAP, mg/L (GDS) 22 16 22 26 APAP (GC/MS) None None None None Pt 2 (hrs after admit) Laboratory Values 306 346 Bilirubin, mg/dL 32.7 40.1 APAP, mg/L (GDS) 28 26 APAP (GC/MS) None None Abstract 142. Beuhler M, Katz K, Curry S, Ruha A, Wax P, Holubek W, Nadir A. Good Samaritan Regional Medical Center, Phoenix AZ, Beuhler M, Katz K, Curry S, Ruha A, Wax P, Holubek W, Nadir A. Good Samaritan Regional Medical Center, Phoenix [...]

Background: While the King College Criteria utilizing pH, PT, creatinine and degree of encephalopathy has been advocated for determining patient selection for orthotropic liver transplantation (OLT) in the setting of acetaminophen (APAP) induced fulminant hepatic failure (FHF), some transplant centers may include liver biopsy as a key determinant. Reports suggest that [greater than or equal to] 70% hepatic necrosis is predictive of poor outcome without OLT. We report a case of chronic APAP-induced FHF who recovered completely without OLT despite an initial percutaneous liver biopsy (PLB) showing >80% necrosis. Case Report: A 32 yo woman presented after long-term hydrocodone/APAP use for chronic pain with AST 2398 IU/L, PT 35.8 sec, APAP 67.2 ug/mL and negative viral serologies. By hospital day (HD) 2 she progressed to grade IV encephalopthy and worsening coagulopathy. Treatment included IV NAC, factor VII and DDAVP. Serum pH and creatinine remained normal. Given her clinical deterioration OLT was considered and a PLB was performed on HD 3 demonstrating [greater than or equal to] 80% centrilobular necrosis. Transplant arrangements were made. By the time the donor liver arrived (HD 5) the patient's clinical and laboratory status had somewhat improved. A second PLB showed 40-50% necrosis. OLT was not performed and the patient swiftly recovered and was discharged on HD 7. Conclusion: The use of PLB for OLT patient selection in patients with APAP induced FHF may be misleading. PLB results should be interpreted with caution, as the procedure samples a very small, potentially misrepresentative fraction of the entire organ. Until the use of PLB in this setting is validated, the Kings College criteria should be relied upon for patient selection., Brooks D, Wallace K, Wax P, Watts D, Holubek W. Department of Medical Toxicology, Good Samaritan Regional Medical Center, Phoenix, Arizona, [...]