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Patients successfully resuscitated from cardiac arrest often have brain injury, myocardial dysfunction, and systemic ischemia-reperfusion injury, collectively termed the post-cardiac arrest syndrome (PCAS). To improve outcomes, potential therapies must be able to be administered early in the post-arrest course and provide broad cytoprotection, as ischemia-reperfusion injury affects all organ systems. Our understanding of the immune system contributions to the PCAS has expanded, with animal models detailing biologically plausible mechanisms of secondary injury, the protective effects of available immunomodulatory drugs, and how immune dysregulation underlies infection susceptibility after arrest. In this narrative review, we discuss the dysregulated immune response in PCAS, human trials of targeted immunomodulation therapies, and future directions for immunomodulation following cardiac arrest.

This study compares maintenance with clinical- and laboratory-triggered (as-needed [PRN]) antivenom dosing strategies with regard to patient-centered outcomes after rattlesnake envenomation.This is a retrospective cohort study of adult rattlesnake envenomations treated at a regional toxicology center. Data on demographics, envenomation details, antivenom administration, length of stay, and laboratory and clinical outcomes were compared between the PRN and maintenance groups. Primary outcomes were hospital length of stay and total antivenom used, with a hypothesis of no difference between the two dosing strategies.A single regional toxicology center PATIENTS:: Three-hundred ten adult patients envenomated by rattlesnakes between 2007 and 2014 were included. Patients were excluded if no antivenom was administered or for receiving an antivenom other than Crofab (BTG International, West Conshohocken, PA).This is a retrospective study of rattlesnake envenomations treated with and without maintenance antivenom dosing.One-hundred forty-eight in the maintenance group and 162 in the PRN group were included. There was no difference in demographics or baseline envenomation severity or hemotoxicity (32.7% vs 40.5%; respectively; p = 0.158) between the two groups. Comparing the PRN with the maintenance group, less antivenom was used (8 [interquartile range, 6-12] vs 16 [interquartile range, 12-18] vials, respectively; p0.001), and hospital length of stay was shorter (27 hr [interquartile range, 20-44 hr] vs 34 hr [interquartile range, 24-43 hr], respectively; p = 0.014). There were no differences in follow-up outcomes of readmission, retreatment, or bleeding and surgical complications.Hospital length of stay was shorter, and less antivenom was used in patients receiving a PRN antivenom dosing strategy after rattlesnake envenomation.

Audiovisual streaming technologies allow detailed remote patient assessment and have been suggested to change management and enhance triage. The advent of wearable, head-mounted devices (HMDs) permits advanced teletoxicology at a relatively low cost. A previously published pilot study supports the feasibility of using the HMD Google Glass® (Google Inc.; Mountain View, CA) for teletoxicology consultation. This study examines the reliability, accuracy, and precision of the poisoned patient assessment when performed remotely via Google Glass®.A prospective observational cohort study was performed on 50 patients admitted to a tertiary care center inpatient toxicology service. Toxicology fellows wore Google Glass® and transmitted secure, real-time video and audio of the initial physical examination to a remote investigator not involved in the subject's care. High-resolution still photos of electrocardiograms (ECGs) were transmitted to the remote investigator. On-site and remote investigators recorded physical examination findings and ECG interpretation. Both investigators completed a brief survey about the acceptability and reliability of the streaming technology for each encounter. Kappa scores and simple agreement were calculated for each examination finding and electrocardiogram parameter. Reliability scores and reliability difference were calculated and compared for each encounter.Data were available for analysis of 17 categories of examination and ECG findings. Simple agreement between on-site and remote investigators ranged from 68 to 100 % (median = 94 %, IQR = 10.5). Kappa scores could be calculated for 11/17 parameters and demonstrated slight to fair agreement for two parameters and moderate to almost perfect agreement for nine parameters (median = 0.653; substantial agreement). The lowest Kappa scores were for pupil size and response to light. On a 100-mm visual analog scale (VAS), mean comfort level was 93 and mean reliability rating was 89 for on-site investigators. For remote users, the mean comfort and reliability ratings were 99 and 86, respectively. The average difference in reliability scores between on-site and remote investigators was 2.6, with the difference increasing as reliability scores decreased.Remote evaluation of poisoned patients via Google Glass® is possible with a high degree of agreement on examination findings and ECG interpretation. Evaluation of pupil size and response to light is limited, likely by the quality of streaming video. Users of Google Glass® for teletoxicology reported high levels of comfort with the technology and found it reliable, though as reported reliability decreased, remote users were most affected. Further study should compare patient-centered outcomes when using HMDs for consultation to those resulting from telephone consultation.

Background Historically, anticoagulants and antiplatelet agents included warfarin and aspirin, respectively. In recent years, numerous novel anticoagulants (eg, direct thrombin inhibitors and factor Xa inhibitors) as well as the adenosine diphosphate receptor antagonists have increased significantly. Little information on the bleeding risk after exploratory ingestion of these agents is available. The primary purpose of this study is to evaluate the bleeding risk of these agents after an exploratory ingestion in children 6 years or younger. Methods This retrospective multicenter poison control center study was conducted on calls between 2005 and 2014. The following agents were included: apixaban, clopidogrel, dabigatran, edoxaban, prasugrel, rivaroxaban, or ticagrelor. Bleeding characteristics and treatment rendered were recorded. Results A total of 638 cases were identified. Most cases involved antiplatelet agents. No patient developed any bleeding complication. The administration of charcoal was independent of the amount of drug ingested. Conclusion Accidental, exploratory ingestions of these agents seem well tolerated, with no patient developing bleeding complications.

Under physiologic conditions, the acid-base balance of the body is maintained via changes in ventilation that eliminate carbon dioxide, buffering of acid loads, and renal excretion of hydrogen ions. Failure to maintain the pH of the blood between 7.35 and 7.45 can result in life-threatening conditions. This review details the pathophysiology, stabilization and assessment, diagnosis and treatment, and disposition and outcomes of acid-base disorders. Figures show the relationship between hydrogen ions and blood pH, proximal tubular bicarbonate reabsorption, the secretion of hydrogen ions, renal ammonia production, ammonium diffusion, metabolic alkalosis, electrocardiographic changes in hypokalemia and hyperkalemia, pseudoinfarction caused by hyperkalemia, and an algorithmic approach to suspected acid-base disorders. Tables list causes of high–anion gap metabolic acidosis, metabolic acidosis with a normal anion gap, type 1 renal tubular acidosis, type 4 renal tubular acidosis and aldosterone resistance, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis; treatment of hyperkalemia; and a stepwise approach for the evaluation of suspected acid-base disorders. This review contains 9 highly rendered figures, 9 tables, 64 references, and a list of pertinent Web sites.

Wearable smart glasses like Google Glass provide real-time video and image transmission to remote viewers. The use of Google Glass and other Augmented Reality (AR) platforms in mass casualty incidents (MCIs) can provide incident commanders and physicians at receiving hospitals real-time data regarding injuries sustained by victims at the scene. This real-time data is critical to allocation of hospital resources prior to receiving victims of a MCI. Remote physician participation in real-time MCI care prior to victims' hospital arrival may improve triage, and direct emergency and critical care services to those most in need. We report the use of Google Glass among first responders to transmit real-time data from a simulated MCI to allow remote physicians to complete augmented secondary triage.

A 21-month-old boy presented to the emergency department because of lethargy, respiratory distress, and abdominal distention. Initial laboratory evaluation was notable for anion-gap metabolic acidosis. A diagnostic test result was received.

Serotonin syndrome is a potentially life-threatening entity associated with pro-serotonergic medications in therapeutic use, in overdose, or when co-administered with other drugs. A broad range of drugs and drug combinations have been associated with serotonin syndrome. Metaxalone overdose associated with serotonin syndrome has not been previously reported.(Case 1) A 23-year-old female overdosed on tramadol and metaxalone. She developed dysautonomia, diaphoresis, lower extremity rigidity and spontaneous clonus, flaccid upper extremities, and hyperthermia 5 h after ingestion. Her course was complicated by status epilepticus. (Case 2) A 56-year-old female overdosed on metaxalone and was found unresponsive. She developed dysautonomia, lower extremity rigidity and spontaneous clonus, flaccid upper extremities, rhabdomyolysis, acute renal failure, and hyperthermia. Non-depolarizing neuromuscular blockade and cooling blankets were required to control hyperthermia in both cases. Serum metaxalone levels were markedly elevated in both cases.These are the first reported cases of metaxalone overdose associated with serotonin syndrome, which may be related to monoamine oxidase inhibition.

In recent years, synthetic cathinones, often labeled as "bath salts" in an attempt to evade drug laws, have emerged as substances of abuse. Sympathomimetic drugs are well known to cause rhabdomyolysis but are rarely associated with acute compartment syndrome. In this case series, we describe 3 patients who presented with sympathomimetic signs or symptoms including hyperthermia and agitation and had confirmed synthetic cathinone use. All 3 patients had severe rhabdomyolysis with delayed development of an acute compartment syndrome. Two patients developed paraspinal compartment syndromes, whereas 1 developed bilateral forearm compartment syndromes. Management included fasciotomy in 2 patients and medical management in the third. Two of the 3 patients made a complete recovery before hospital discharge; the third patient was hemodialysis dependent at 5-month follow-up.

Study objective In recent years, the use of novel anticoagulants and antiplatelet agents has become widespread. Little is known about the toxicity and bleeding risk of these agents after acute overdose. The primary objective of this study is to evaluate the relative risk of all bleeding and major bleeding in patients with acute overdose of novel antiplatelet and anticoagulant medications. Methods This study is a retrospective study of acute ingestion of apixaban, clopidogrel, ticlopidine, dabigatran, edoxaban, prasugrel, rivaroxaban, and ticagrelor reported to 7 poison control centers in 4 states during a 10-year span. The prevalence of bleeding for each agent was calculated, and hemorrhage was classified as trivial, minor, or major. Results A total of 322 acute overdoses were identified, with the majority of cases involving clopidogrel (260; 80.7%). Hemorrhage occurred in 16 cases (4.9%), including 7 cases of clopidogrel, 6 cases of rivaroxaban, 2 cases of dabigatran, and 1 case of apixaban. Most cases of hemorrhage were classified as major (n=9). Comparing the novel anticoagulants with the P2Y12 receptor inhibitors, the relative risk for any bleeding with novel anticoagulant was 6.68 (95% confidence interval 2.63 to 17.1); the relative risk of major bleeding was 18.1 (95% confidence interval 3.85 to 85.0). Conclusion Acute overdose of novel anticoagulants or antiplatelet agents is associated with a small risk of significant hemorrhage. The risk is greater with the factor Xa inhibitors and direct thrombin inhibitors than with the P2Y12 receptor antagonists.

Bupropion inhibits the uptake of dopamine and norepinephrine. Clinical effects in overdose include seizure, status epilepticus, tachycardia, arrhythmias, and cardiogenic shock. We report two cases of severe bupropion toxicity resulting in refractory cardiogenic shock, cardiac arrest, and repeated seizures treated successfully. Patients with cardiovascular failure related to poisoning may particularly benefit from extracorporeal membrane oxygenation (ECMO). These are the first cases of bupropion toxicity treated with veno-arterial EMCO (VA-ECMO) in which bupropion toxicity is supported by confirmatory testing. Both cases demonstrate the effectiveness of VA-ECMO in poisoned patients with severe cardiogenic shock or cardiopulmonary failure.

One of the medical toxicologists in our group was recently asked a shocking question. She was providing recommendations via telephone to a rather upset and flustered emergency physician, when the caller interrupted her by asking, “Excuse me, are you even a clinician?” Working on a toxicology service that admits and consults on more than 1,200 patients per year, my colleague was understandably taken aback. Hearing the story later, I was dismayed but not surprised. Based on the current practice of many toxicologists, how can we fault the emergency physician for asking such a question? Medical toxicology has become a specialty in which the telephone has largely replaced the stethoscope as the primary tool of our trade. This is in no way meant to diminish the importance of poison control centers. Not only was the establishment of poison centers instrumental in the development of medical toxicology as a subspecialty [1], there is no doubt as to the public health benefit and system-wide cost savings engendered by poison centers [2–7]. My concern is the role played by toxicologists in our healthcare system. Presumably, fellowship training in medical toxicology allows us to make clinical recommendations and advise caregivers at a level beyond that of the emergency physician and poison information specialist. If this is true, how many patients does the medical toxicologist have to treat at the bedside to ensure the validity of our advice? What happens when the emergency physician on the other end of the telephone has laid hands on more poisoned patients in the preceding week than the toxicologist has in the preceding year? If we do not examine patients, treat them at bedside, and learn from our experience, what is it that distinguishes us from Poisindex™ or a poison information specialist?

Keywords Bodypacker .Deferasirox .Hyperemesis .N-acetylcysteine .CannabisAaron B. Skolnik and Anne-Michelle Ruhade Bakker JK, Nanayakkara PW, Geeraedts LM Jr, deLange ES, Mackintosh MO, Bonjer HJ. Body Packers: aPlea for Conservative Treatment. Langenbecks ArchSurg. 2012 Jan; 397(1):125-30. Epub 2011 Oct 8.Background: Smuggling of drugs via internal concealment,known as “body packing,” is on the rise. Early methods ofinternal concealment relied on swallowed drug packets con-structed from available materials such as balloons and con-doms. Packet rupture was associated with high mortality.Modern drug packets are machine produced and carry alower risk of rupture. Body packers may present with non-life-threatening symptoms such as nausea or bowel obstruc-tion. The optimal approach to management of these patientsis not known.Research Question: This study aims to evaluate the effica-cyof aprotocol for diagnosis andtreatmentof body packers,including determining the need for surgical intervention.Methods: A retrospective chart review was performed overa 6-year period. Patients were identified by a recordeddiagnosis of “body packer.” All patients included in thestudy were treated according to a protocol including vitalsign monitoring, laboratory testing, and radiographs. If plainabdominal X-rays were inconclusive, a CT scan of theabdomen was performed. The study center's protocol man-dated surgical removal of drug packets for signs of drugintoxication, ileus, or persistence of drug packets in thestomach for >48 h. Surgically treated patients were com-pared to conservatively managed patients.Results: Cocaine was the most commonly found drug inboth surgically (n064) and conservatively managed (n079) patients. There was no significant difference in thenumber of packets ingested between groups. Surgicallymanaged patients had higher prevalence of abdominalpain (53 vs. 31 %) and vomiting (20 vs. 13 %) atpresentation. Sixteen percent of surgical patients devel-oped a wound infection, 16 % had a fascial dehiscence,and 8 % had both. Wound infection was associated witha longer length of hospitalization. Mean hospital lengthof stay was significantly prolonged in surgically man-aged patients (7 vs. 2 days). Comparing asymptomaticpatients who underwent surgery for packets remaining inthe stomach >48 h to those with drug packets in the stomachfor 48 vs. 48 h. Surgical treatment should be reserved for thosepatients with ileus or signs of drug intoxication.Critique: This study is limited by its retrospective nature.As a single-center study, the results may not be general-izable to different patient populations. The cutoff time of48 h to determine surgery was chosen arbitrarily. Optimaltiming of surgical intervention in asymptomatic patients isstill not certain. The ideal surgical approach to packetretrieval is unknown and the surgical method in this studywas not standardized. The authors note that wound compli-cations occurred at higher frequency than expected for lap-arotomy when compared to several references. Alternative

There are no published studies that have compared quality outcomes of hospitalized poisoned patients primarily under the care of physician medical toxicologists to patients treated by non-toxicologists. We hypothesized that inpatients primarily cared for by medical toxicologists would exhibit shorter lengths of stay (LOS), lower costs, and decreased mortality. Patients discharged in 2010 and 2011 from seven hospitals within the same health care system and greater metropolitan area with Medicare severity diagnosis-related groups for “poisoning and toxic effects of drugs” with and without major comorbidities or complications (917 & 918, respectively) were identified from a Premier® database. The database contained severity-weighted comparisons between expected and observed outcomes for each patient. Outcome parameters were differences between expected and observed LOS, cost, and percent mortality. These were then compared among groups of patients primarily admitted and cared for by (1) medical toxicologists at one hospital (Banner Good Samaritan Medical Center, BGS), (2) non-toxicologists at BGS, and (3) non-toxicologists at six other hospitals. Records of 3,581 patients contained complete data for assessment of at least one outcome measure. Patients cared for by medical toxicologists experienced favorable differences in LOS, costs, and mortality compared with other patient groups (p

In the Southwestern United States, the venom of the scorpion Centruroides sculpturatus (common name bark scorpion) can cause serious and potentially fatal neurotoxicity, with young children most vulnerable to its effects. Historically, advances in the quality of supportive care have made significant improvements in morbidity and mortality. In recent years, the development of effective antivenom therapies has changed the landscape of caring for these patients. This article reviews the background, pathophysiology, diagnosis, and treatment options for C. sculpturatus envenomation. Recent advances in immunotherapy and subsequent implications for pediatric emergency care providers are discussed. Language: en