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We report a rare domestic case of exposure to tianeptine and use of a novel, extended-release, six-armed, star-shaped, drug delivery capsule. A 40-year-old male with a history of depression, anxiety, ethanol, opioid, cannabis, and tobacco use disorders presented to the emergency department (ED) from a substance abuse residential recovery treatment program after developing hypertension, tachycardia, and tremor for two day. He used an extended-release, six-armed, star-shaped, drug delivery device he purchased online, filling each arm with 15 mg of tianeptine (90 mg total). His intention was to mitigate the symptoms of kratom/opioid withdrawal through this extended-release method while simultaneously undergoing formal treatment for ethanol withdrawal. Tianeptine is an atypical tricyclic antidepressant that exerts complex mechanisms of action including serotonin (5-HT) neuromodulation as well as full μ-opioid and ∂-opioid receptor agonism. The capsule itself is made of caprolactone, which is a bioabsorbable material similar to absorbable sutures, initially developed as a long-term enteral antimalarial delivery method and is not FDA approved for human use. Over the course of the patients two day hospitalization course he developed symptoms consistent with uncomplicated ethanol withdrawal, which were treated with as-needed phenobarbital. No clinical manifestations of opioid or serotonin toxicity developed. Serial EKGs and telemetry monitoring remained unchanged. The patient was then medically cleared and discharged back to the residential recovery treatment program.

Patients that are taking Ayurvedic supplements have an increased risk of heavy metal toxicity. Lead, arsenic, and mercury are frequently identified in these supplements and can cause clinically significant toxicity. Clinicians should screen patients routinely for use of non-pharmaceutical medications and supplements.

Lithium induced cardiotoxicity is associated with several electrocardiographic (ECG) findings. The most commonly observed cardiac effects include QT prolongation, Twave abnormalities, and to lesser extent SA node dysfunction and ventricular arrythmias. We present a case of a 13-year-old female with acute lithium overdose whodeveloped Mobitz I, a manifestation of lithium associated cardiotoxity not previously reported. The patient had no significant past medical history and presented to the emergency department 1 h after intentional overdose of 10 tablets of unknown drug. Parents reported that the patient had visited her grandmother, who "regularly took many different kinds of medications," earlier that same evening. On physical examination the patient had reassuring vital signs, was in no acute distress,cardiopulmonary examination was normal, had clear sensorium, and no evidence of a toxidrome. On serological examination complete blood count, chemistries panel, and liver function tests did not show significant derangements. 4 h post-ingestion acetaminophen concentration was 28 mcg/ml and below indication for n-acetylcysteine antidote therapy. During her ED course she showed evidence of Mobitz I (Wenckebach) on 12-lead ECG. No prior ECGs were available for comparison. Medical toxicology was consulted at that time given concern for potential cardiotoxicity from an unknown xenobiotic. Serum dioxin and lithium concentrations were subsequently requested. Serum digoxin concentration was undetectable. Serum lithium concentrations was 1.7 mEq/L (0.6-1.2 mEq/L therapeutic range). The patient was treated with intravenous hydration at twice maintenance rate. Repeat lithium concertation 14 h post-ingestion was undetectable. During her admission, the patient remained hemodynamically stable and asymptomatic despite occasional episodes of Mobitz I, lasting seconds to minutes. Repeat 12-lead ECG obtained 20 h post-ingestion showed normal sinus rhythm. Cardiology recommendations included ambulatory Holter monitoring upon discharge and follow-up in clinic within two weeks. The patient was medically cleared after 36 h of monitoring and discharged after psychiatric evaluation. Our case demonstrates that patients who develop a new Mobitz I atrioventricular block of unclear etiology in the setting of acute ingestion should be screened for lithium exposure, even if otherwise free of more typical manifestations of lithium toxicity.

Learning Objectives: To survey graduating EM residents on their perceptions of the EM job market and its effect on their desire to pursue fellowship training.Background: The COVID-19 pandemic has resulted in changes to the emergency medicine (EM) workforce which pose challenges to residents graduating from EM training programs. New graduates face increasing uncertainty in the search for their first job. EM graduates in 2020 and 2021 saw a notable decrease in opportunities compared to years prior. ACEP’s Workforce Study (April 2021) predicts a surplus of emergency physicians by 2030. Objectives: To survey graduating EM residents on their perceptions of the EM job market and its effect on their desire to pursue fellowship training.Methods: We surveyed senior residents (PGY2 and above) at three- and four-year EM residency programs in the greater NYC area. Paper surveys were mailed out to each of the programs with a return envelope; a virtual link to complete the survey was also made available. Surveys were distributed from August 2021 to November 2021 to 22 EM residency programs (695 residents). Participation was voluntary and anonymous. The only demographic information gathered was program name and PGY level.Results: A total of 412 senior residents from the 22 EM residency programs completed the survey. Of the 412 seniors, 183 were PGY2s, 174 were PGY3s, and 55 were PGY4s and 5s (we included responses from residents in combined EM/IM programs). Survey questions and results are summarized in Table 1. Compared to colleagues in previous years, graduating EM residents anticipated broadening their job search. 58% of those considering fellowship after residency stated that their interest in fellowship has increased due to anticipated challenges in the job market (difficulty securing a full-time attending position).Conclusions: The majority of senior residents expressed concern about the current and future EM job market. How and where EM graduates apply for jobs may be impacted as a result. These data may prove valuable to residency programs, institutions, physician groups, and EM-bound medical students.

Tranexamic acid is a commonly used hemostatic agent with broad clinical uses across multiple specialties. Systemic toxicity is due to gamma-aminobutyric acid type A and glycine receptor competitive antagonism and has been reported by multiple routes, but toxicity after pulmonary administration via nebulization and BAL has not yet been described. A 44-year-old man with a history of congenital pulmonary arteriovenous malformations underwent routine bronchoscopy for hemoptysis. He received preprocedure nebulized tranexamic acid 500 mg three times daily for 48 h. An additional 1,000 mg was given via BAL for intraprocedural hemostasis. One hour after the procedure, he developed altered mental status, myoclonus, and hyperthermia, which was ultimately controlled with propofol and vecuronium. As the use of pulmonary tranexamic acid increases, toxicity from this agent should be considered. Dose reductions and alternate treatment modalities should be considered in patients with advanced age, arteriovenous malformations, and renal insufficiency. [ABSTRACT FROM AUTHOR]

The duration of ascorbic acid interference on point-of-care blood glucose measurements is unknown, but there exists a case of pseudohyperglycemia with erroneous measurements that persisted for 48 h after the infusion was stopped [[6]]. Ascorbic acid interference occurred with this patient and has been reported in a similar case in which it contributed to the misdiagnosis of diabetic ketoacidosis leading to subsequent patient death [[6]]. [Extracted from the article]

Draining the chest cavity with two chest tubes after thoracotomy for trauma is controversial. This article aims to determine whether using two tubes after thoracotomy for trauma is more effective than using a single tube. A 9-year retrospective review (2007-2015) was performed at our academic level I trauma center. All patients who underwent trauma thoracotomy (unilateral and bilateral) were included for analysis (n = 99). Patients with incomplete data, pediatric patients (age < 18), pregnant patients, and early deaths (<24 hours) were excluded. When analyzed by chest cavity, dual tubes have increased drainage bilaterally (P = 0.008) and require more days to clear the right chest (P = 0.002). Patients with dual tubes bilaterally are associated with increased intensive care unit length of stay (P = 0.05) and ventilator days (P = 0.04). Although dual chest tube insertion achieves greater drainage, it comes at the cost of increased time to clear the chest and is associated with worse outcomes in bilateral injuries. One chest tube may be sufficient post-trauma thoracotomy; routine placement of two chest tubes is not recommended. [ABSTRACT FROM AUTHOR]

Rattlesnake envenomations account for many of the Crotalid envenomations in the United States annually. Two antivenoms are currently available to treat Crotalid envenomation in this country: Crotalidae-polyvalent ovine immune Fab antivenom (CroFab®; FabAV) and Crotalidae equine immune F(ab')₂ antivenom (ANAVIP®; F(ab')₂AV). Few studies have compared the adverse effect rates for each. We performed a retrospective chart review of rattlesnake envenomations called to the California Poison Control System from October 2018 to August 2022. Those treated at healthcare facilities with either antivenom were included. Those treated with both antivenoms were excluded. Records were obtained from the poison center electronic medical records system. Demographic and clinical data were abstracted. "Severe" adverse events were defined as multi-organ system involvement, swelling of the patient's airway, and/or hemodynamic instability. All others were categorized as "non-severe." A total of 481 cases were included with 360 treated with FabAV and 121 with F(ab')₂AV. The median age was 47 and 46 years, and 72 % and 73 % were male, respectively. Clinical signs and symptoms of envenomation were similar in each group. The FabAV group received a median of six vials. The F(ab')₂AV group received a median of 10 vials, based on the recommended loading doses of FabAV and F(ab') 2 AV. Following antivenom administration, 18 individual acute non-severe AEs were reported in 12 FabAV-treated patients. Two acute non-severe AEs were reported in two F(ab')₂AV-treated patients. Rash or urticaria was the most commonly reported adverse effect in both groups after antivenom administration. Five patients (1.5 %) had severe adverse events reported in the poison center records following FabAV administration, and none were reported following F(ab')₂AV administration (p = 0.025). Overall, our poison center data suggests the rate of adverse events is low following the use of either antivenom. Our findings are limited by the lack of consistent timing data, a smaller F(ab')₂AV cohort, retrospective format, and use of poison center data., Competing Interests: Declaration of competing interest The authors report there are no competing interests to declare., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: Rattlesnake envenomations are uncommon, and the majority occur in adults. Although Crotalidae equine immune F(ab') 2 antivenom (F(ab') 2 AV; trade name ANAVIP) was introduced in 2018, no pediatric specific studies of F(ab') 2 AV have been reported to date. The objective of this study was to evaluate the clinical performance and adverse effects of F(ab') 2 AV in children., Methods: A single-center, retrospective chart review was performed on patients with rattlesnake envenomation presenting to a children's hospital between October 2018 and August 2022. Inclusion criteria were age younger than 18 years and F(ab') 2 AV use. Exclusion criteria were other antivenom use at any time and presentation beyond 24 hours postenvenomation.Demographic characteristics, hemoglobin, platelet count, fibrinogen, international normalized ratio, number of F(ab') 2 AV vials used, infusion-related complications, and clinical outcomes were collected., Results: Twenty-six patients, 19 males and 7 females, with a mean age of 7.7 years (0.67 to 16 years) met inclusion criteria. Fourteen (54%) were treated with only the initial 10 vial F(ab') 2 AV doses. Twelve patients were given additional doses with a median additional vials of 10 (4-34 vials; interquartile range, 8.75-12 vials). The median total vials given for all patients was 10 (10-44 vials; interquartile range, 10-20 vials).Two patients developed acute infusion reactions. Both were treated by slowing the infusion rate and with medications (diphenhydramine, corticosteroids). No delayed reactions were noted. No patients required blood products or surgical interventions.After discharge, no complications, recurrent symptoms, return visits, or readmissions were reported. Follow-up by chart review or phone was obtained for 18 patients, and no postdischarge complications were noted. Seven patients had postdischarge hematologic laboratory evaluations and all were normal., Conclusions: Although limited by small sample size and postdischarge follow-up, F(ab') 2 AV was well tolerated in our series of pediatric patients, consistent with prior studies of all age groups., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)