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New psychoactive substances (NPS) are synthetic alternatives to illicit drug abuse that are not under international control but may pose a public health threat. Moreover, the symptoms and signs of NPS users may be quite variable. This study aimed to figure out the clinical characteristics of NPS users presented to the emergency department (ED).A total of 1385 cases were tested via urine toxicity screening from March 25, 2019, to January 28, 2020, in six medical centers, and ten hospitals, in Taiwan. A total of 123 non-NPS cases and 77 NPS-use cases were enrolled in this study. We compared the patient data-vital signs, presentation, co-morbidities, behaviors, symptoms, electrocardiograms, laboratory data, length of stays-and outcomes of NPS users and non-NPS drug users.NPS users were 5.7 years younger than the non-NPS drug users (37 vs. 42.7 years, p = 0.022). Presently, NPS users had a 2.6-fold (27.2%) higher rate of suicide and a 2.9-fold (11.7%) greater possibility of violence than non-NPS drug users. Moreover, in NPS users, eye-opening was affected at a scale of 3.1 versus 3.4 (p = 0.048) in non-NPS drug users in the evaluation of consciousness and they experienced a 4.3-fold greater feeling of palpitation (p = 0.024) and had 8.1-fold higher chance of presenting facial flush (p = 0.032) than non-NPS drug users.NPS users are relatively younger, are more likely to experience facial flush and palpitation and engage in more self-harm, violence, and suicide than non-NPS drug users. Physicians need to pay attention to people who have altered, bizarre mental statuses with the clinical characteristics described above.

BackgroundEmergency medical service (EMS) personnel have high COVID-19 risk during resuscitation. The resuscitation protocol for patients with out-of-hospital cardiac arrest (OHCA) was modified in response to the COVID-19 pandemic. However, how the adjustments in the EMS system affected patients with OHCA remains unclear.MethodsWe analysed data from the Taichung OHCA registry system. We compared OHCA outcomes and rescue records for 622 cases during the COVID-19 outbreak period (1 February to 30 April 2020) with those recorded for 570 cases during the same period in 2019.ResultsThe two periods did not differ significantly with respect to patient age, patient sex, the presence of witnesses or OHCA location. Bystander cardiopulmonary resuscitation and defibrillation with automated external defibrillators were more common in 2020 (52.81% vs 65.76%, pConclusionEMS response time for patients with OHCA was prolonged during the COVID-19 pandemic. Early advanced life support by EMS personnel remains crucial for patients with OHCA.

Avermectin pesticides are widely used in agriculture, and are thought to have low toxicity in humans. However, information on their toxicity after accidental or deliberate ingestion is limited.The aim of this study was to evaluate the clinical manifestations of avermectin pesticide ingestion and identify factors associated with severe outcomes (death, intubation, or sustained hypotension requiring inotrope therapy).This multicenter retrospective study included patients who visited the emergency departments of six teaching hospitals due to acute avermectin pesticide ingestion between January 2012 and May 2020. Patients who reported ingestion of any other pesticides, drugs, or substances were excluded.In total, 64 patients (median age, 72 years) were included: 60 had ingested emamectin pesticides, and 4 had ingested abamectin. Almost all (98%) were cases of self-harm. The most common presentation was drowsiness (47%), with a median Glasgow Coma Scale (GCS) score of 14, followed by shortness of breath (SOB)/dyspnea (33%) and nausea/vomiting (22%). Concurrent methanol exposure (Most patients who intentionally ingested avermectin pesticides required inpatient treatment. Forty-two percent needed ICU care and 31% had severe outcomes. A GCS score13 and SOB/dyspnea were independently associated with severe outcomes.

Stimulant poisoning frequently causes altered mental status (AMS) and can result in severe cerebral vascular complications. The role of noncontrast brain computed tomography (CT) in acute stimulant-poisoned patients presenting with AMS remains unclear.We examined the results and impacts of brain CT in acute stimulant-poisoned patients with AMS.We performed a retrospective single-center study that included all adult patients who presented to the emergency department with stimulant poisoning and AMS (Glasgow coma scale [GCS] score15) between January 1, 2010 and December 31, 2017. Patients who had concomitant head trauma or who presented with focal neurologic symptoms were excluded. The primary outcome was the rate of acute abnormalities on brain CT. The secondary outcomes were to identify factors that affected the decision to perform brain CT in stimulant-poisoned patients with AMS and whether obtaining the brain CT scan itself affected the patients' prognoses.The analysis included 66 patients, of whom 6 died from the poisoning. Noncontrast brain CT was performed in 31 patients and none had acute abnormalities. Patients who underwent brain CT were found to have worse GCS scores, higher body temperatures, higher intubation rates, higher admission rates, longer admission periods and intensive care unit stays, and a higher mortality rate. After adjusting for the propensity score, performing brain CT itself did not independently affect the patients' clinical outcomes.Nontrauma stimulant-poisoned patients presenting with AMS and without focal neurologic symptoms were unlikely to have acute abnormalities on brain CT. Patients who underwent brain CT scans had worse consciousness and greater disease severity.

What is known and objective Although the risk of major bleeding with non-vitamin K antagonist oral anticoagulant (NOAC) is low, life-threatening bleeding can occur. Case summary We report a case of an 81-year-old female with deep vein thrombosis who developed bilateral spontaneous haemothorax and haemopericardium after rivaroxaban therapy. Diagnostic thoracentesis revealed a grossly bloody pleural effusion. She was treated with factor eight inhibitor bypassing agent, but the result was not satisfactory. What is new and conclusion To our knowledge, this is the first case report of a concomitant presentation of spontaneous bilateral haemothorax and haemopericardium due to rivaroxaban use. This case highlights the potential risk of major haemorrhagic complication of NOAC, which could be life-threatening and require emergent reversal.

What is known and objective Hexavalent (VI) chromium is a powerful oxidant that can produce cellular oxidative stress and multi-organ system dysfunction. The role of antioxidants such as N-acetylcysteine (NAC) and ascorbic acid in alleviating organ damage in humans remains unclear. Case description We present a 47-year-old male who ingested 30 mL of plating solution and developed hepatic injury. He was treated with NAC and ascorbic acid with improvement in hepatic function. However, his clinical conditions and jaundice worsened again after discontinuing these therapies. What is new and conclusion Our findings suggest a potential role for antioxidant therapy for acute hexavalent chromium poisoning.

Accidental ingestion of foxglove (Digitalis purpurea) can cause significant cardiac toxicity. We report a patient who ingested foxglove mistaking it for comfrey and developed refractory ventricular arrhythmias. The patient died despite treatment with digoxin-specific antibody fragments (DSFab) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).A 55-year-old woman presented to the emergency department with nausea, vomiting and generalized weakness eight hours after drinking "comfrey" tea. She had bradycardia (54 beats/min) and hyperkalemia (7.6 mEq/L). Electrocardiogram revealed a first-degree atrioventricular conduction block with premature atrial contractions, followed by polymorphic ventricular tachycardia three hours after arrival. A serum digoxin level was 151.2 ng/mL. The patient developed ventricular fibrillation while waiting for Digibind infusion. Resuscitation was performed and an emergent VA-ECMO was set up. A total of eight vials of Digibind were given over the next 16 hours. She temporarily regained consciousness, but remained hemodynamically unstable and subsequently developed lower limb ischemia and multiple organ failure, and she expired on hospital day seven. A botanist confirmed that the plant was foxglove.The diagnosis of cardiac glycoside plant poisoning can be difficult in the absence of an accurate exposure history. In facilities where DSFab is unavailable or insufficient, early VA-ECMO might be considered in severely cardiotoxic patients unresponsive to conventional therapy.

Dear editor, Matsum (Coriaria intermedia) is a neurotoxic plant indigenous to Taiwan and the Philippines. Human poisonings from the ingestion of Coriaria species have been rarely reported in Europe...

A 64-year-old woman presented with coma, seizure, and lactic acidosis after ingesting 80 yam bean seeds. This rotenone-containing seeds cause cellular asphyxia via blockage of the mitochondrial electron transport. Subsequent oxidative stress results in the formation of lipid peroxidation (LPO). Rotenone analysis via liquid chromatography mass spectrometry revealed the following: 31,590 ng/mL in cooked yam bean seed and 100 ng/mL in the blood. We attempted to use N-acetylcysteine to alleviate oxidative stress and documented the continuous decline in the plasma concentration of LPO.

The risks of intravenous (IV) lidocaine before rapid sequence induction (RSI) have become a great concern. No study has investigated the hemodynamic effects of IV lidocaine during endotracheal intubation in patients with severe traumatic brain injury.We investigated whether the use of IV lidocaine before RSI was associated with postintubation hemodynamic changes in patients with severe traumatic brain injury.In this retrospective cohort study, adults who presented with isolated traumatic brain injury and definite intracranial hemorrhage were included. Patients who presented with other major injuries received prehospital intubation, had initial mean arterial pressure (MAP) less than 70 mm Hg, and/or had incomplete medical records were excluded.A total of 101 patients (82.2% men; mean age, 48.6 ± 19.6 years) were enrolled. Forty-six patients received IV lidocaine in addition to RSI before intubation (group 1), and 55 received RSI without IV lidocaine before intubation (group 2). There were no significant intergroup differences in baseline characteristics, the number of RSI doses, or the RSI dose used, with the exception of sex, diagnosis of subarachnoid hemorrhage, and diagnosis of subdural hemorrhage. Our results demonstrated no significant intergroup differences in MAP changes or the proportion of patients with hypotension (MAP70 mm Hg) after intubation. Intravenous lidocaine remained unrelated to significant hypotension after adjusting for variables by logistic regression analysis.Intravenous lidocaine in addition to RSI before endotracheal intubation was not associated with significant hemodynamic changes in patients with severe traumatic brain injury.

Sir,Ketamine, an N-methyl-d-aspartic acid (NMDA) receptor antagonist, is commonly used as a recreational drug for its hallucinogenic and dissociative properties [1]. In some southeast Asian countri...