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Cannabinoid hyperemesis syndrome (CHS) is typically unresponsive to conventional pharmacologic antiemetics, and patients often require excessive laboratory and radiographic testing and hospital admission. We report 4 cases of CHS that failed standard emergency department therapy but improved significantly after treatment with haloperidol. Although the exact mechanism for CHS remains unclear, dysregulation at cannabinoid type 1 seems to play a role. Recent animal data demonstrate complex interactions between dopamine and cannabinoid type 1 signaling, a potential mechanism for haloperidol success in patients with CHS. Our success with haloperidol in these 4 patients warrants further investigation of haloperidol as an emergency department treatment for CHS.

The aging population of the United States creates pharmaceutical challenges for the practicing emergency physician. Polypharmacy, drug-drug and drug-disease interactions, and other pharmaceutical complications from the pathophysiologic changes associated with aging need to be recognized in order to optimize outcomes in the elderly. Effective strategies that improve patients outcomes include a better understanding of the physiologic and pharmacologic changes that occur with aging, integrated use of clinical emergency department pharmacists, and choosing nonpharmacologic treatment options when possible., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Limited data suggest that heroin worsens asthma severity, but little is known about heroin-dependent patients who seek emergency department (ED) care for asthma., Objectives: To describe what heroin-dependent patients know about their asthma and how they use health care resources., Methods: A prospective study of heroin-dependent patients seeking care for "asthma" at an urban ED with 130000 annual visits was conducted. Eligible subjects were English-speaking heroin-dependent adults seeking care for mild to moderate asthma symptoms. A closed-format survey instrument to assess opioid use, asthma knowledge, and health care use was developed by content experts, piloted for study performance, revised, and then administered to eligible patients prior to ED discharge. Descriptive analysis was done., Results: Thirty subjects participated. Mean age was 47.5 years; 21 (70%) were male. Most used heroin several times weekly. Intranasal was the most common route (93%). Almost half (47%) stated that their asthma was diagnosed in the ED, 13% by a primary care physician, 13% by a lung specialist, and 27% did not know how diagnosed. The ED was used as the primary source for asthma medications in 73% cases; 43% used the ED for breathing issues at least once per month. Most subjects (77%) felt that heroin worsened their asthma symptoms. Only 7 (23%) also abused prescription opioids, and only 7 (23%) knew about prescription naloxone., Conclusion: Patients with heroin dependence frequently use the ED for their health care needs related to asthma. Most do not have other health care providers, most have limited health literacy, and all would benefit from referral to a primary care provider and substance abuse resources., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The purpose of our study was to evaluate the educational value of an annual Senior Scholars Forum (SSF) of graduating Emergency Medicine resident participants and attendees., Description: This study was conducted at an urban academic medical center with a PGY1-4 year residency program. After completion of the 2nd annual SSF, a web-based survey instrument was sent to all resident and faculty attendees. The instrument was a 3-part tool adapted from previous studies on postgraduate scholarship. Data were analyzed using descriptive statistics., Evaluation: Forty-two of the 44 (95%) attendees completed the survey, including 100% of the PGY4 resident presenters. Prior to the SSF, 52% of respondents did not have a full understanding of senior scholarly activities. After the SSF, 67% reported an improved understanding and 88% had a better understanding of the scope of potential scholarly projects. Sixty-four percent reported the SSF introduced them to departmental resources available for completion of their own scholarly projects, and 69% would have liked to have heard the lessons communicated earlier in residency. Most (79%) agreed the SSF demonstrated the value of communal scholarly activities. Most senior residents (67%) felt most of the department would not know about their scholarship if they had not participated in the SSF., Conclusions: Our innovative SSF enhanced the scholarship process by allowing graduating senior residents an opportunity to share their scholarly productivity with a larger audience, provided attendees critical insights into the process of scholarship, and encouraged communal learning. Because the Accreditation Council for Graduate Medical Education and Residency Review Committee require all residents to participate in scholarly activity, other training programs may benefit from a similar educational experience.

Intravenous fat emulsion (IFE) therapy is a novel treatment that has been used to reverse the acute toxicity of some xenobiotics with varied success. We sought to determine how US Poison Control Centers (PCCs) have incorporated IFE as a treatment strategy for poisoning. A closed-format multiple-choice survey instrument was developed, piloted, revised, and then sent electronically to every medical director of an accredited US PCC in March 2011. Addresses were obtained from the American Association of Poison Control Centers listserv, and participation was voluntary and remained anonymous. Data were analyzed using descriptive statistics. The majority of PCC medical directors completed the survey (45 out of 57; 79 %). Of the 45 respondents, all felt that IFE therapy played a role in the acute overdose setting. Most PCCs (30 out of 45; 67 %) have a protocol for IFE therapy. In a scenario with "cardiac arrest" due to a single xenobiotic, directors stated that their center would "always" or "often" recommend IFE after overdose of bupivacaine (43 out of 45; 96 %), verapamil (36 out of 45; 80 %), amitriptyline (31 out of 45; 69 %), or an unknown xenobiotic (12 out of 45; 27 %). In a scenario with "shock" due to a single xenobiotic, directors stated that their PCC would "always" or "often" recommend IFE after overdose of bupivacaine (40 out of 45; 89 %), verapamil (28 out of 45; 62 %), amitriptyline (25 out of 45; 56 %), or an unknown xenobiotic (8 out of 45; 18 %). IFE therapy is being recommended by US PCCs; protocols and dosing regimens are nearly uniform. Most directors feel that IFE is safe but are more likely to recommend IFE in patients with cardiac arrest than in patients with severe hemodynamic compromise.

Introduction: The use of synthetic drugs of abuse in the United States has grown in the last few years, with little information available on how much physicians know about these drugs and how they are treating patients using them. The objective of this study was to assess emergency physician (EP) knowledge of synthetic cannabinoids (SC)., Methods: A self-administered internet-based survey of resident and attending EPs at a large urban emergency department (ED) was administered to assess familiarity with the terms Spice or K2 and basic knowledge of SC, and to describe some practice patterns when managing SC intoxication in the ED., Results: Of the 83 physicians invited to participate, 73 (88%) completed surveys. The terms "Spice" and "K2" for SC were known to 25/73 (34%) and 36/73 (49%) of respondents. Knowledge of SC came most commonly (72%) from non-medical sources, with lay publications and the internet providing most respondents with information. Among those with previous knowledge of synthetic cannabinoids, 25% were not aware that SC are synthetic drugs, and 17% did not know they are chemically most similar to marijuana. Among all participants, 80% felt unprepared caring for a patient in the ED who had used synthetic cannabinoids., Conclusion: Clinically active EPs are unfamiliar with synthetic cannabinoids. Even those who stated they had heard of synthetic cannabinoids answered poorly on basic knowledge questions. More education is needed among EPs of all ages and levels of training on synthetic cannabinoids.

Cannabinoid hyperemesis syndrome (CHS) is a condition characterized by cyclical vomiting without other identifiable cause in patients with chronic cannabis use. Patients with CHS report that compulsive bathing and hot showers are the only reliable treatments to improve symptoms. Cannabinoid hyperemesis syndrome is usually unresponsive to conventional pharmacologic antiemetics, and patients often require hospital admission. We report a case of CHS that improved significantly after treatment with haloperidol in the emergency department.

Approximately 7% of the US population abuses or is dependent on alcohol. Patients with alcohol disorders often seek medical attention in Emergency Departments (EDs) for complications directly related to alcohol use or due to other medical issues associated with alcohol use. Because of increasing lengths of stay in EDs, alcohol-dependent patients are at high risk of developing alcohol withdrawal syndrome (AWS) during their ED visit. This article reviews the physiology of alcohol withdrawal as well as the symptoms of this potentially deadly illness for the practicing emergency physician (EP). We provide evidence-based guidelines for the appropriate ED treatment of moderate to severe AWS, including pharmacologic interventions, adjunctive therapies, and disposition of these patients., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Poisoning is a leading cause cause for injury and death in pediatric patients. For this reason, β-blocker ingestion has been an indication for emergency department (ED) referral and evaluation in pediatric patients even though significant clinical effects are uncommonly reported. We sought to determine whether an evidence-based triage guideline developed jointly by the American Association of Poison Control Centers, American Academy of Clinical Toxicology, and American College of Medical Toxicology safely reduces unnecessary pediatric ED visits after unintentional small dose β-blocker overdose. This was a prospective study of patients aged 0-6 years with a β-blocker ingestion managed by a regional poison center pre and postimplementation of the triage guideline. One hundred fifty-three cases met inclusion criteria. Before implementation of an evidence-based triage guideline for out-of-hospital management, 52 (67%) cases were referred for ED evaluation, and 26 (33%) cases were recommended for home observation. After guideline implementation, 38 (51%) cases were referred for ED evaluation, and 37 (49%) were recommended for home observation. No deaths occurred in either group. The triage guideline was accurately followed by poison center staff in 96% of cases after implementation. An out-of-hospital triage guideline for pediatric β-blocker overdose was accurately followed by poison center staff and safely reduced unnecessary ED referrals with a 50% increase in home observation.

Ziprasidone has been rarely associated with QT prolongation especially in patients (1) with no underlying cardiac or metabolic disorders, (2) who are receiving no concomitant medications known to prolong the QT interval, and (3) whom therapy is being initiated at a low dose. We report a 47-year-old patient who was agitated with suicidal ideation. He had a history of cocaine use, the last time being 72 hours before emergency department (ED) presentation. His electrocardiogram (ECG) on arrival in the ED showed a QT of 484 milliseconds and a QTc of 475 milliseconds with a pulse of 58 beats per minute. The patient was given 20 mg intramuscular (IM) ziprasidone for agitation. He reported feeling palpitations and weakness 45 minutes after receiving ziprasidone. His QT interval was prolonged on ECG and returned to baseline after 72 hours. Clinicians should consider obtaining an ECG before ziprasidone administration.

Background: Emergency medical services (EMS) traditionally administer naloxone using a needle. Needleless naloxone may be easier when intravenous (IV) access is difficult and may decrease occupational blood-borne exposure in this high-risk population. Several studies have examined intranasal naloxone, but nebulized naloxone as an alternative needleless route has not been examined in the prehospital setting., Objective: We sought to determine whether nebulized naloxone can be used safely and effectively by prehospital providers for patients with suspected opioid overdose., Methods: We performed a retrospective analysis of all consecutive cases administered nebulized naloxone from January 1 to June 30, 2010, by the Chicago Fire Department. All clinical data were entered in real time into a structured EMS database and data abstraction was performed in a systematic manner. Included were cases of suspected opioid overdose, altered mental status, and respiratory depression; excluded were cases where nebulized naloxone was given for opioid-triggered asthma and cases with incomplete outcome data. The primary outcome was patient response to nebulized naloxone. Secondary outcomes included need for rescue naloxone (IV or intramuscular), need for assisted ventilation, and adverse antidote events. Kappa interrater reliability was calculated and study data were analyzed using descriptive statistics., Results: Out of 129 cases, 105 met the inclusion criteria. Of these, 23 (22%) had complete response, 62 (59%) had partial response, and 20 (19%) had no response. Eleven cases (10%) received rescue naloxone, no case required assisted ventilation, and no adverse events occurred. The kappa score was 0.993., Conclusion: Nebulized naloxone is a safe and effective needleless alternative for prehospital treatment of suspected opioid overdose in patients with spontaneous respirations.

The elderly are particularly sensitive to delirium-inducing medications. We report a case of a 93-year-old woman who developed anticholinergic delirium from subcutaneous diphenhydramine that she received in the emergency department. This patient was reportedly allergic to “caine” anesthetic agents, and thus, subcutaneous diphenhydramine was administered as an alternative local anesthetic, as recommended in emergency medicine textbooks. Within 20 minutes of administration, the patient developed agitation, tachycardia, dilated pupils, and dry skin, consistent with a classic anticholinergic toxidrome. Diphenhydramine use is associated with a high incidence of anticholinergic adverse effects, especially in the elderly. Clinicians should carefully consider using diphenhydramine in this vulnerable population.

The combative or uncooperative patient is a growing problem in the emergency department. Restrained patients are at especially high risk of adverse outcomes. Particular attention has been given to de-escalation techniques to reduce the need for patient restraint. This article examines these techniques and the need for and risks of physical and chemical restraints in managing patients in the emergency department.

Background: Historically, females had delays to definitive diagnosis of appendicitis when compared to males. In this current millennium, appendicitis is now most commonly diagnosed by computed tomography (CT) in the emergency department (ED) rather than at surgery., Objective: The aim of the study was to assess if female gender is still associated with delays to diagnosis of appendicitis in the CT era., Methods: A retrospective cohort analysis of adult patients with appendicitis at a university teaching hospital ED was conducted. Inclusion criteria was age of more than 18 years and an International Classification of Diseases, Ninth Revision (ICD-9), diagnosis of appendicitis. Patients were excluded from analysis if they were pregnant, no CT scan was obtained in the ED, or had incomplete outcome data., Results: One hundred thirty-seven patients met inclusion criteria; 65 female, 72 males. Time from triage to CT order was 138 minutes in females and 95 minutes in males (P = .0012). Time from initial physician evaluation to CT order was 45 minutes in females and 28 minutes in males (P = .0012). Nonclassic symptoms were more common in females and pelvic evaluation did not delay the CT order., Conclusion: Female gender is still associated with delays to CT acquisition and diagnosis of appendicitis.

Introduction: Our objective was to examine gender, racial, and age differences in door-to-EKG time in patients diagnosed with non-cardiac chest pain., Methods: This was a prospective cohort study of adult patients with an explicitly stated chief complaint of chest pain at an urban, academic ED. Primary study outcome variable was time to initial EKG. Predictor variables included gender, race, and age., Results: The final sample consisted of 214 patients. The overall median time to EKG in this cohort of patients was 29 minutes. No difference in time to EKG was found between gender or racial category. Time to EKG was significantly greater for patients in age categories 18-39 and 40-59 when compared with subjects greater than 60 years old., Discussion: In this prospective cohort study of non-STEMI/ACS patients with a chief complaint of chest pain, there were no gender or racial disparities in door-to-EKG time.

Study Objective: The aim of this study was to examine the characteristics and outcomes of patients seeking treatment for abuse of supplemental caffeine., Methods: This was a 3-year analysis conducted of all consecutive cases involving caffeine abuse in patients 10 years and older reported to a regional poison center. Excluded were suicide attempts, therapeutic errors, and cases involving only a coffee or tea product., Results: Two hundred fifty-four cases met inclusion criteria. Mean age was 20.5 years, 50% were women. Caffeine was in the form of a nondietary medication in 201 cases, a dietary supplement in 35 cases, and a caffeine-enhanced beverage in 35 cases. Caffeine was abused alone in 174 (68%), with alcohol in 7, illegal drugs in 6 cases, and with other pharmaceutical products in 81 (29%) cases. Thirty-four patients (13% of total) were hospitalized for medical complications from caffeine. Only concomitant abuse of other pharmaceutical products was associated with hospitalization (odds ratio, 3.8; 95% CI, 1.8-8.8; P = .0004)., Conclusion: In this cohort, supplemental caffeine was abused primarily by young adults. Concomitant recreational abuse of other pharmaceuticals was associated with hospitalization and warrants further investigation.

Unlabelled: We conducted a retrospective cohort study to compare the effects of metoclopramide versus hydromorphone for the initial emergency department treatment of migraine headache at an urban teaching hospital. The primary outcome measure was the mean difference in the subjects' self-reported pain scores before and after the administration of the initial medication treatment. We also estimated crude and adjusted relative risks (using Poisson multivariate regression modeling) to assess and control potential confounding by age, gender, race, and pain score before initial medication. Two hundred subjects were included, with 51 (25.5%) receiving intravenous or intramuscular hydromorphone, 95 (47.5%) receiving intravenous metoclopramide, and 54 (27.0%) receiving 1 of several other medications. Using a standardized pain scale of 0 to 10, mean pain score reductions were 2.3 points for hydromorphone, 3.7 points for metoclopramide, and 2.8 points for all other medications combined (P < .001). When comparing metoclopramide versus hydromorphone, the crude relative risk for pain reduction of 3 or more points was 1.76 (95% CI, 1.12-2.75, P = .01), and the adjusted relative risk was 1.60 (95% CI, 0.84-3.03, P = .15). Metoclopramide also resulted in less use of rescue medications, faster times to discharge, and no difference in the frequency of adverse reactions., Perspective: Metoclopramide appears to be an effective initial medical treatment for migraine headaches in the emergency department setting, but its pharmacologic mechanism remains incompletely understood. A double-blinded, randomized, controlled trial comparing standard dosages of hydromorphone versus metoclopramide will be needed to definitively determine which medication is more effective.

Background: Coca tea, derived from the same plant that is used to synthesize cocaine, is commonly consumed in South America and easily obtained in the United States., Objectives: To determine whether consumption of coca tea would result in a positive urine toxicology screen for cocaine metabolites., Methods: Five healthy adult volunteers consumed coca tea and underwent serial quantitative urine testing for cocaine metabolites by fluorescence polarization immunoassay. The cutoff for a positive assay was chosen at 300 ng/ml, the National Institute on Drug Abuse standard., Results: Each participant's urine cocaine assay was positive (level exceeding 300 ng/ml) by 2 h after ingestion. Three out of five participants' samples remained positive at 36 h. Mean urine benzoylecgonine concentrations in all postconsumption samples was 1777 ng/ml (95% confidence interval: 1060-2495)., Conclusions: Coca tea ingestion resulted in a positive urine assay for cocaine metabolite. Healthcare professionals should consider a history of coca tea ingestion when interpreting urine toxicology results.

We sought to examine hospital compliance with poison center antidotal alcohol dehydrogenase inhibition recommendations in cases of ethylene glycol (EG) and methanol (ME) ingestion. A 2-year analysis of all potential EG and ME ingestion cases reported to a regional poison center was conducted. Excluded from analysis were exposures without an ingestion, without a confirmatory EG or ME serum assay, or without complete medical charting. During the study period, 579 EG or ME exposures were reported to the poison center: 133 cases met study eligibility as an ingestion. Of the 133 cases, 102 (77%) had complete data and were included in the analysis. Immediate alcohol dehydrogenase inhibition was recommended by the poison center in 79 of the 102 cases. Fomepizole was recommended in 61/79 (77%); ethanol was recommended as an alternative therapeutic choice in 32/61 (52%) of these cases if fomepizole was not immediately available. Ethanol alone was recommended in 18/79 (23%). Fomepizole was eventually administered in 39/61 (64%) cases where recommended. The mean time to antidote administration was 3 times longer in cases where a choice in antidote was given [57 min (95% confidence interval, 43-70) vs. 146 min (95% confidence interval, 93-200)]. Despite its ease of administration, fomepizole is used less frequently than recommended by poison center staff. Delays to antidote administration occurred more commonly in cases where the poison center gave a choice in antidotal therapy.

Introduction: Lithium concentrations analyzed from blood collected in inappropriate tubes may lead to misdiagnosis and lead to unnecessary hospitalization and intervention. We sought to assess the magnitude of falsely elevated lithium levels in green top lithium heparin-containing blood tubes., Methods: Serum lithium concentrations from two types of commonly used standard green top tubes were evaluated against a control tube. Blood samples obtained from 5 healthy volunteers who have never ingested pharmaceuticals containing lithium were aliquoted into a control serum separator tube (SST), a light green heparin-containing tube, and a dark green heparin tube at the following volumes: full draw, 2cc, and 1cc. Serum lithium levels in lithium heparin blood tubes were compared to standard blood tubes., Results: All levels are reported as mmol/L. Mean serum lithium level for the control was 0.16 [range: 0.1-0.2]. Levels for the light-green tubes at full-draw, 2cc, and 1cc were 1.05 [1.0-1.1], 1.99 [1.68-2.3], and 3.31 [2.8-4.2] respectively. Levels for the darkgreen tubes at full-draw, 2cc, and 1cc were 1.07 [1.0-1.14], 2.35 [2.1-2.55], and 4.04 [3.8-4.4] respectively., Conclusions: Falsely elevated lithium levels may occur when using green-top lithium containing blood tubes and may contribute as much as 4 mmol/L to the level in tubes not completely filled.

Purpose: Adverse drug events (ADEs) at a hospital before and after the weekly work hours of medical residents were limited to 80 were studied., Methods: The study population included all adults admitted to a 750-bed academic tertiary care hospital where resident physicians provide direct care under the supervision of faculty attending physicians. The six-month period after implementation of the 80-hour work limit (July 1 to December 31, 2003) was compared with the same six-month period one year before implementation (July 1 to December 31, 2002)., Results: There were no significant differences between study periods in any measured variables, including number of confirmed ADEs (194 before, 172 after), number of ADEs per 1000 patient days (1.3 before, 1.1 after), and number of preventable ADEs (21 before, 22 after)., Conclusion: Hospitalwide ADEs remained constant despite limiting of resident physician weekly work hours to 80.

Objective: To describe the results of combined exchange transfusion and chelation therapy in a neonate with an elevated blood lead level (BLL)., Case Summary: A 34-year-old Latina woman with a long history of pica (eating glazed pottery) gave birth to a healthy-appearing girl at 40 weeks of gestation. The mother's preconception BLL was 117 microg/dL and remained elevated throughout pregnancy. At parturition, the mother's BLL was 87 microg/dL and the infant's cord BLL was 100 microg/dL. The infant underwent single-volume exchange transfusion within 12 hours of birth. BLL was 28 microg/dL following the exchange, and a 5-day course of chelation with dimercaprol and CaNa2 ethylenediamine tetraacetic acid was initiated at 36 hours of life. The infant's BLL was 37 microg/dL at the end of inpatient chelation., Discussion: Long-term neurologic disability from in utero lead exposure is well described, but the optimal treatment of elevated neonatal BLLs in healthy-appearing infants at the time of birth is not established. This strategy of combined chelation and exchange transfusion therapy was well tolerated and resulted in decreased lead levels, but the long-term neurologic efficacy of our combination strategy remains to be seen., Conclusions: Combined exchange transfusion and chelation therapy resulted in rapidly decreased lead levels in a neonate with chronic in utero lead exposure.

Background: A significant number of patients seek medical evaluation for chronic subjective symptoms they presume to be associated with a single toxic trigger. This report describes our clinic experience with these patients., Case Series: Twenty patients (of a total of 261 patients) with a mean age of 41 years (median age 42 years; range: 4 to 65 years) were evaluated over an 8 month period. All describe a single past toxic exposure triggering their nonspecific (usually vaguely neurologic) symptoms. Zero of 20 (0%) describe other chemical sensitivities; 2/20 (10%) report ongoing exposure, 18/20 (90%) had a limited exposure dating 1 month to 6 yrs prior to toxicology clinic evaluation; 9/20 (45%) are currently employed; 6/20 (30%) sought alternative medical therapy prior to toxicologist evaluation; 6/20/(30%) have attempted litigation., Conclusion: Despite repeatedly normal toxicologic and medical evaluations, all data refuting an underlying toxic cause are not accepted by this series of patients, and their search for a diagnostic linkage persists. Specific toxin identification or treatment for these patients is unlikely to occur.

CoricidinHBP (Schering-Plough Health Care Products, Inc, Memphis, TN) is a popular over-the-counter product abused by teenagers for its potent euphoric properties. Clinically significant signs and symptoms after ingestion are usually short-lived and commonly include tachycardia, hypertension, somnolence, and agitation. We report 2 cases of severe toxicity from CoricidinHBP in adolescents that required prolonged hospitalization. The first case demonstrates prolonged anticholinergic complications from a suicidal attempt with CoricidinHBP. The second case demonstrates significant acetaminophen-induced hepatotoxicty from recreational use of CoricidinHBP Maximum Strength Flu. Adolescent abuse of these products is encouraged because of the easily accessible medium of the Internet. The significant morbidity seen in our cases clearly demonstrates the need for vigilance by health care professionals regarding the abuse of over-the-counter products.

We describe a patient who developed facial nerve injury following significant exposure to UV radiation. A 49-y-old construction worker developed erythema and edema on the left side of his face (exposed side) 12 h after working within 18 in of a compromised metal halide incandescent light bulb for a total of 2 h. One month later, the patient noted a painful burning sensation over the left side of his face associated with marked left facial weakness and inability to close his eye (peripheral VIIth nerve palsy). Two months later, synkinetic left facial movements were consistent with aberrant regeneration. Over the next several months, forceful episodic spasmodic activity developed in the muscles of facial expression on the left, identical to that seen in hemifacial spasm. Rarely has UV radiation been implicated in damage to subcutaneous nerves. This case demonstrates that significant neurologic morbidity may follow high exposure to UV radiation.

Delayed treatment of ethylene glycol or methanol poisoning can result in life-threatening complications, but obtaining quantitative levels is delayed by several hours in most hospitals. Calculating the anion gap and the osmol gap are recommended to hasten identification and treatment in cases of suspected toxic alcohol poisoning. However, relying on the anion and osmol gap calculations without understanding the temporal relationship between these 2 gaps can lead to delayed identification and increased morbidity in cases of toxic alcohol poisoning. Our "Mountain" schematic illustrates the presence of an elevated osmol gap found early in toxic alcohol poisoning and the presence of an elevated anion gap found later in the course of poisoning. Using the "Mountain" diagram as a clarification of the temporal relationship between the anion and the osmol gap can improve the diagnostic use of these screening assays.

A 46-year-old woman presented to the Emergency Department with lethargy and respiratory depression after ingesting methadone. Initial oxygen saturation of 61% on room air did not improve with supplemental oxygenation. As venous access was initially unobtainable, naloxone was administered by nebulizer. Within 5 min oxygen saturation was 100% and mental status was normal. The patient did not develop severe withdrawal symptoms. Naloxone hydrochloride has been administered by various routes to treat opioid toxicity. Our report describes the successful use of nebulized naloxone for methadone toxicity.

Objective: To report the occurrence of hemorrhagic gastritis after topical isopropanol application in an infant., Case Summary: A 2-year-old Hispanic boy developed coffee-ground emesis during emergency department evaluation for lethargy and fever. After an initial inconclusive workup for sepsis, further history revealed an isopropanol rubdown for fever reduction. Isopropanol concentrations and acetone metabolites were elevated, the patient recovered with supportive therapy, and other causes for hemorrhagic gastritis were excluded., Discussion: Isopropanol sponge bathing is commonly used as a home remedy for infants with fever. Topical absorption of isopropanol has previously been reported to cause mental status changes, ketosis, and metabolic acidosis. We report a case of hemorrhagic gastritis as a complication of topical isopropanol absorption in a febrile infant. An objective causality assessment revealed that the adverse event was probably caused by the isopropanol. Previous reports of pediatric isopropanol poisoning and its management are discussed., Conclusions: Severe morbidity from topical isopropanol exposure may occur in young children.

A 33-y-old male developed severe acidosis, renal failure, and profound neutrophilia after ingesting ethylene glycol. Workup for his neutrophilia excluded infectious and malignant causes. An elevated leukocyte alkaline phosphatase (LAP) level confirmed a leukemoid response, and the neutrophila resolved. Although several leukemoid reactions have been published due to therapeutic agents these reports are often incomplete or inaccurate; this is the first case of leukemoid response to a toxin. Leukemoid response is distinguishable from leukemia by the absence of clonally derived cells, although this is not easily apparent in extreme neutrophilia. Elevated LAP is useful in identifying leukemoid reaction from leukemia in cases of extreme neutrophila. If a patient develops extreme neutrophila in association with drug or toxin exposure, a leukemoid reaction should be considered and an LAP obtained.

Veterinarians commonly prescribe medications to treat a variety of companion animal clinical conditions. Many pet medications are pharmacologically the same product prescribed for human use. We report 2 cases in which pet medications were used for self poisoning. Obtaining a pet history may provide critical information in the assessment of a patient with a suspected overdose.

A 38-y-old male with occult inhalant abuse underwent an 18-mo evaluation for presumed seizure disorder. Although past medical history was significant for alcohol abuse, his wife confirmed a 6-y histoy of abstinence. His seizures were characterized as episodes of unconsciousness preceded by a feeling of "things slowing down". No muscular activity was witnessed during these episodes, and upon regaining consciousness the patient had slurred speech, disorientation, dissociative amnesia, and bizarre behavior that resolved spontaneously. Despite 4 emergency department visits, 4 hospital admissions, 5 neurologic and 7 psychiatric outpatient evaluations, extensive work-up was non-diagnostic. These episodes recurred until his wife found him huffing trichloroethylene. Questioning of the patient revealed that huffing always preceded these episodes and that he started huffing after discontinuing alcohol. The patient underwent addiction treatment. Toxic inhalants should be suspected as a substitute drug of abuse in patients attempting abstention. Disorientation clinically similar to dissociative amnesia can occur following loss of consciousness during an episode of trichloroethylene use.