Faculty Bibliography

BACKGROUND: While it is certain that some emergency department patients with acute drug overdose suffer adverse cardiovascular events (ACVE), predicting ACVE is difficult. The prognostic utility of the ECG for heterogeneous drug overdose patients remains to be proven. This study was undertaken to validate previously derived features of the initial ECG associated with ACVE in this population. METHODS AND RESULTS: We performed a prospective validation cohort study to evaluate adult emergency department patients with acute drug overdose at 2 urban university hospitals over 5 years in whom an emergency department admission ECG was performed. Exclusion criteria were alternate diagnoses, anaphylaxis, chronic drug toxicity, and missing outcome data. ACVE was defined as any of the following: circulatory shock, myocardial injury, ventricular dysrhythmia, or cardiac arrest. Blinded cardiologists interpreted ECGs for previously derived predictors of ACVE (ectopy, QT prolongation, nonsinus rhythm, ischemia/infarction), QT dispersion, and prominent R wave in lead AVR. Of 589 patients who met inclusion criteria (48% male, mean age 42), there were 95 ACVEs (39 shock, 64 myocardial injury, 26 dysrhythmia, 16 cardiac arrest). The most common drug exposures were as follows: benzodiazepines, opioids, and acetaminophen. Previously derived criteria were highly predictive of ACVE, with QT correction >500 ms as the highest risk feature (OR 11.2, CI 4.6-27). CONCLUSIONS: This study confirms that early ECG evaluation is essential to assess the cardiovascular prognosis and medical clearance of emergency department patients with acute drug overdose. Furthermore, this study validates previously derived high-risk features of the admission ECG to risk stratify for ACVE in this patient population.

CONTEXT: Salicylate poisoning remains a significant public health threat with more than 20,000 exposures reported annually in the United States. OBJECTIVE: We aimed to establish early predictors of severe in-hospital outcomes in Emergency Department patients presenting with acute salicylate poisoning. METHODS: This was a secondary data analysis of adult salicylate overdoses from a prospective cohort study of acute drug overdoses at two urban university teaching hospitals from 2009 to 2013. Patients were included based on confirmed salicylate ingestion and enrolled consecutively. Demographics, clinical parameters, treatment and disposition were collected from the medical record. Severe outcome was defined as a composite occurrence of acidemia (pH <7.3 or bicarbonate <16 mEq/L), hemodialysis, and/or death. RESULTS: Out of 1997 overdoses screened, 48 patients met inclusion/exclusion criteria. Patient characteristics were 43.8% male, median age 32 (range 18-87), mean initial salicylate concentration 28.1 mg/dL (SD 26.6), and 20.8% classified as severe outcome. Univariate analysis indicated that age, respiratory rate, lactate, coma, and the presence of co-ingestions were significantly associated with severe outcome, while initial salicylate concentration alone had no association. However, when adjusted for salicylate concentration, only age (OR 1.13; 95% CI 1.02-1.26) and respiratory rate (OR 1.29; 95% CI 1.02-1.63) were independent predictors. Additionally, lactate showed excellent test characteristics to predict severe outcome, with an optimal cutpoint of 2.25 mmol/L (78% sensitivity, 67% specificity). CONCLUSIONS: In adult Emergency Department patients with acute salicylate poisoning, independent predictors of severe outcome were older age and increased respiratory rate, as well as initial serum lactate, while initial salicylate concentration alone was not predictive.

BACKGROUND: Drug overdose is the leading cause of injury-related fatality in the United States, and respiratory failure remains a major source of morbidity and mortality. OBJECTIVES: We aimed to identify the incidence and risk factors for endotracheal intubation after acute drug overdose. METHODS: This secondary data analysis was performed on a 5-year prospective cohort at two urban tertiary-care hospitals. The present study analyzed adult patients with suspected acute drug overdose to derive independent clinical predictors of endotracheal intubation. RESULTS: We analyzed 2497 patients with acute drug overdose, of whom 87 (3.5%) underwent endotracheal intubation. Independent clinical risk factors for endotracheal intubation were: younger age (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.96-0.98), and history of obstructive lung disease (OR 6.6, 95% CI 3.5-12.3); however, heart failure had no association. Patients with obstructive lung disease had significantly more hypercapnia (mean difference 6.8 mm Hg, 95% CI 2.3-11.3) and a higher degree of acidemia (mean pH difference 0.04, 95% CI 0.01-0.07) than patients without obstructive lung disease. Lack of rapid sequence sedative/paralytic was associated with in-hospital fatality. Early complications of endotracheal intubation itself included desaturation (3.4%) and bradycardia (1%). CONCLUSIONS: Endotracheal intubation was infrequently performed on patients with acute drug overdose, and complications were rare when performed. Risk factors associated with endotracheal intubation included younger age and prior obstructive lung disease.

Background: Salicylate (ASA) poisoning remains a significant public health threat with upwards of 20,000 exposures annually in the USA and morbidity/mortality rates of up to 25 %. Identifying predictors of severe outcome allows for targeted treatment to lower these rates. Research Question:What factors are early predictors of severe in-hospital outcomes in ED patients presenting with ASA poisoning? Methods: This was a secondary data analysis of ASA overdoses from a prospective cohort study of suspected acute drug overdoses at two urban university teaching hospitals from 2009 to 2013. Patients were enrolled consecutively and were considered eligible for inclusion based on clinical suspicion of ASA ingestion. Children (<18) and alternate diagnoses were excluded. Demographics, clinical parameters, serum ASA concentrations, treatment modalities, and death/admission rate were collected from the medical record. Severe outcome was defined as a composite occurrence of any of the following: acidemia (pH <7.3 or bicarbonate <16 mEq/L), hemodialysis, or death.
Result(s): Forty-eight patients met inclusion criteria, with 43.8 % male, median age 32, mean initial ASA concentration 28.1, and 10 (21 %) classified as severe outcome. There were two deaths, neither of whom received hemodialysis. Patients were treated with sodium bicarbonate in one third of cases, while 54.2 % received activated charcoal and 64.6 % were admitted. Univariate analysis indicated that age (p = 0.04, t test), respiratory rate (RR) (p = 0.04, t test), creatinine (p = 0.05, t test), lactate (p = 0.002, t test), coma (p = 0.05, chi square), and presence of co-ingestions (p = 0.04, chi square) were significantly associated with severe outcome, while ASA alone had no association. However, when adjusted for serum ASA concentration, only age (OR 1.02 per additional year, CI 1.0-1.1), RR (1.09 per additional breath/min, CI 1.03-1.15), creatinine (2.8 per additional mg/dL CI 1.1-7.1), and co-ingestions (OR 6.4, CI 2.3-17.8) were independent predictors of severe outcome.
Discussion(s): We have derived independent predictors of severe outcome from acute ASA poisoning, which can aid in identifying patients who require more aggressive treatment, and does not include serum ASA concentration. Despite the severity of these cases, only one third received sodium bicarbonate, suggesting potential barriers to administration which require further study.
Conclusion(s): Age, RR, creatinine, and co-ingestions are predictive of severe outcome in ED patients with acute ASA poisonin