Faculty Bibliography

Experience with toxicity relating to intravenous (IV) paracetamol is discussed in the context of international experience. Issues in management and recent international strategies to minimise hazard are highlighted

STUDY OBJECTIVE: The ECG is an essential tool in the care of poisoned patients. This study is designed to investigate the accuracy of ECG interpretation reported to a poison center. METHODS: In this prospective study, all cases in which both an electronically faxed copy of the ECG and the caller's interpretation of the ECG were available were eligible for inclusion. ECG interpretation of callers was compared with that of a blinded electrophysiologist. In cases of disagreement, a Delphi panel of toxicologists decided whether the differences were clinically significant or would have changed recommendations. RESULTS: Two hundred cases were included, with complete agreement in 78. In 23 cases, the sole difference was nonspecific ST-T-wave changes, which were believed insignificant and classified as agreement for a total of 101. The Delphi panel reviewed the remaining 99. In 42 cases, the differences in ECG interpretations were thought to be clinically significant; 37 of these would have resulted in a change in management recommendations. Forty-five cases were thought not likely to be clinically significant and would not have resulted in a recommendation change. Twelve cases were thought not clinically significant but would still have resulted in a change in recommendations. CONCLUSION: Initial interpretation of the ECG reported by callers to the poison center is frequently inaccurate. In this study, the misinterpretation was clinically significant or would have resulted in a change in management recommendations in approximately one quarter of all calls

BACKGROUND: The differential diagnosis of non-traumatic lower extremity pain and swelling runs the gamut from simple musculoskeletal injury to a possibly life-threatening deep venous thrombosis (DVT). Although evaluation and management are often guided by physical examination and history, a diagnostic study is often required. Institutional factors surrounding diagnostic imaging often lead physicians to empirically treat these patients for DVT with a plan for definitive diagnosis at a later time. OBJECTIVES: We discuss plantaris tendon rupture, the ability of the clinician to differentiate DVT from musculoskeletal injury, and the risks of anticoagulation in the setting of an undifferentiated, painful, swollen lower extremity. CASE REPORT: We report the case of a 57-year-old transgendered woman who presented with left lower extremity pain and swelling and was found to have a rare cause of tennis leg: plantaris tendon rupture. CONCLUSIONS: Frequently, clinical examination and history are insufficient to distinguish DVT from musculoskeletal injury. In these instances, anticoagulation carries a risk of compartment syndrome and hemorrhage with uncertain benefit to the patient. A definitive diagnosis should be sought before initiation of anticoagulation of the swollen, painful lower extremity

Background: In a previous study we derived high-risk ECG features associated with adverse cardiovascular events (ACVEs) in emergency department (ED) patients with acute drug overdose. Objectives: We aimed to externally validate that ischemia, non- sinus rhythm, and ectopy are associated with ACVE in this population. Methods: This prospective cohort study evaluated consecutive ED patients with acute drug overdose over 5 months at two urban teaching hospitals uninvolved in the original derivation cohort. Data included demographics, history, vital signs, and elements of the initial ECG (rhythm, intervals, ischemia, infarction), interpreted by a masked cardiologist. ECG evidence of ischemia and infarction were defined according to AHA criteria. In-hospital ACVE was defined by composite outcome: shock (vasopressors), myocardial injury (troponin I > 0.09ng/mL), severe dysrhythmia (VT/VF), or cardiac arrest (loss of pulse). Results: of 238 initially screened, 81 were excluded (30 age <18, 41 no ECG, 2 alternate diagnosis, 8 insufficient data), leaving 157 for analysis (48% female, mean age 40.8, 14% prior coronary disease). Most common drug classes ingested were acetamino- phen-containing (24%), sympathomimetics (20%), and opioids (19%). Included patients had mean pulse=84/minute (range 32-156), mean QRS=90 msec (range 68-174), mean QTc=433 msec (range 296-704), while 17% had ischemia, 9% infarction, and 4% ectopy. In-hospital ACVE occurred in 11 patients (7%), of whom 18% had prior coronary disease (p=NS). There were 9 myocardial injury, 3 shock, 2 dysrhythmia, and 3 cardiac arrests. Ischemia (OR 15.2, p<0.001), non-sinus rhythm (OR 8.6, p<0.01), and ectopy (OR 7.4, p<0.05) were highly associated with ACVE, while QRS, QTc, and infarction were not significantly predictive. Conclusion: This study validates the predictive utility of high- risk ECG features for ED patients with acute drug overdose. A screening ECG may be an important tool to evaluate in-hospital prognosis for acute drug overdose