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Case Presentation: We describe a case of left internal jugular central venous access with rare malpositioning into the internal mammary vein. Despite various confirmatory measures at the time of placement including ultrasonography of the internal jugular vein, as well as blood gas analysis consistent with venous blood by oxygen saturation and good venous flow in all three ports of the catheter, subsequent imaging confirmed misplacement into the internal mammary vein.Discussion: Central venous access is a frequently used procedure by emergency physicians for a variety of indications. Emergency physicians must be facile with both the technical process of central venous catheter placement, as well as possible pitfalls and complications of the procedure. Common complications, such as bleeding, pneumothorax, arterial injury, infection, and hematomas, are usually well known; less frequently encountered is malposition of the catheter despite seemingly appropriate placement.

Objectives: Prevention methods for carbon monoxide (CO) poisoning in Wisconsin address occupational and nonoccupational exposures together, but differences between the settings could inform new approaches to preventing occupational CO poisonings. We described occupational CO poisonings in Wisconsin from July 1, 2018, through July 1, 2021, using surveillance data from the Wisconsin Electronic Disease Surveillance System and Wisconsin Poison Center. Methods: We identified cases of CO poisoning from the Wisconsin Electronic Disease Surveillance System and Wisconsin Poison Center. Occupational CO poisonings were records where "workplace" was recorded as the location of exposure. We excluded records classified as suspect/not a case, those missing laboratory results or information on exposure source/location, and intentional poisonings. We compared characteristics between occupational and nonoccupational settings using odds ratios (ORs), and we estimated crude incidence rates of occupational exposures by occupation. Results: We identified 614 cases of CO poisoning, of which 168 (27.4%) were occupational exposures. When compared with patients with nonoccupational exposures, patients with occupational exposures were more likely to be male (OR = 3.8; 95% CI, 2.4-6.1), Hispanic (OR = 2.4; 95% CI, 1.4-4.2), and younger (mean difference [SD] = 6.6 [20.9]). Several CO sources were significantly associated with occupational poisonings: forklifts (OR = 58.4; 95% CI, 13.9-246.1; P <.001), pressure sprayers (OR = 2.4; 95% CI, 1.3-4.4; P =.003), and other gasoline-powered tools (OR = 3.8; 95% CI, 2.3-6.3; P <.001). The natural resources, construction, and maintenance occupation group had the highest crude incidence rate—45.0 poisonings per 100 000 full-time equivalent employees. Conclusions: Incorporating data from the Wisconsin Poison Center improved data quality, but surveillance is limited by underreporting. Creating strategies to increase reporting would allow for a more comprehensive understanding of occupational CO poisoning. [ABSTRACT FROM AUTHOR]

This letter to the editor discusses a case of delayed peak methemoglobinemia after intentional ingestion of sodium nitrate. The patient, a 63-year-old male with a history of chronic kidney disease and diabetes, ingested a large amount of sodium nitrate and experienced severe diarrhea. The peak methemoglobin percentage did not occur until at least 16 hours after ingestion. The letter highlights the need for more reports on the time course of toxicity after nitrate salt ingestions and emphasizes the importance of monitoring patients until peak methemoglobin levels are observed. [Extracted from the article]