Faculty Bibliography

The use of extracorporeal treatments (ECTRs) for poisonings with four non-traditionally dialyzed toxins (NTDTs) is increasing in the United States. This study evaluated whether ECTRs are prescribed for toxin removal or the treatment of other medical illnesses or complications. We performed a Phase 2 retrospective analysis evaluating the main indication for ECTRs in patients with: poisoning with a NTDT (defined for this study as: acetaminophen, opioids, tricyclic antidepressants (TCAs) or digoxin) and ECTR. The first phase assessed all cases from a single site (New York City Poison Control Center) between the years 2000 and 2016 and the second phase surveyed all United States Poison Control Centers (PCCs). In Phase 1, demographics, toxin ingested, and main indication for ECTR were extracted. In Phase 2, a query to the National Poison Data System using the a pragmatic subset of inclusion criteria from Phase 1 that was restricted to single substance ingestions over a narrower time frame (2014-2016) provided the cases for study. A structured online questionnaire was sent to all United States PCCs to request their database review regarding the indication for ECTR for their cases. In Phase 1, 92 cases met inclusion criteria. In Phase 2, 519 cases were screened and 425 met inclusion criteria. In Phase 1 91/92 (98.9%) and Phase 2 411/425 (96.7%) extracorporeal treatments were used to treat underlying medical conditions or poisoning-related complications rather than accelerate toxin removal. The increasing number of ECTRs reported in patients who ingested one of the four NTDTs thus appears to be for medical indications rather than attempts at toxin removal, a distinction that is important to report.

CONTEXT/BACKGROUND:Short messaging service (SMS or text messaging) allows for the exchange of electronic text messages. Online chatting refers to Internet-based transmission of messages for real-time conversation. Poison Control Centers (PCCs) in the United States communicate with the public primarily via telephone. However, people increasingly prefer the convenience of SMS and chatting. Our objective is to describe the use of SMS and chatting by PCCs in the United States. METHODS:An electronic survey questionnaire was distributed to all 55 US poison control center members of the American Association of Poison Control Centers. The survey assessed protocols for SMS and chatting, inquiry volume, and staff satisfaction. Centers reporting use of SMS or chatting services were administered follow-up questions, which further documented SMS and chatting interfaces and startup and maintenance costs. Descriptive statistics were used to describe the data. No statistical analysis was performed. RESULTS:Of the 55 PCCs, 51 (93%) responded to the survey, 6 (12%) of which currently use or formerly used SMS and/or chatting. Inquiry volume ranged from 0 to 1 per day for SMS and 0 to 20 per day for chats. Startup costs ranged from $0 to $25,000. The most beneficial aspect, reported by 4 of the 6 PCCs (66.6%), was providing an alternative contact for inquiries. Most SMS and chatting interactions were completed within 10 and 30 min, respectively. All six centers completed telephone interactions within 10 min. The most disadvantageous aspects, reported by 2 of the 6 PCCs (33.3%), were staff apprehension and interaction length. Technology, such as syncing with existing call queuing software and databases, presented the greatest barrier to implementation. CONCLUSIONS:A minority of PCCs in the United States use SMS and chatting. Further research may investigate the economic feasibility of these systems, if SMS and chatting effectively expands public access, and patient comfort in contacting PCCs.

Objective: To highlight the variety of possible complications that may arise following ingestion of 35% hydrogen peroxide. Case report: A 40-year-old woman presented to the emergency department (ED) with blood-tinged emesis episodes following unintentional ingestion of 35% hydrogen peroxide. She complained of epigastric pain radiating to her right shoulder, headache, sore throat, and chest pain. Her triage vital signs were blood pressure 111/87 mmHg, heart rate 103/min, respiration rate 19/min, temperature 37.2 degreeC, oxygen saturation 96% (room air) with unremarkable initial physical exam aside from epigastric and diffuse abdominal tenderness. There was no obvious caustic injury to the oropharynx. Later, the patient complained of blurry vision. Initial testing was notable for elevated troponin (0.286 ng/ mL, reference <0.08 ng/mL), Non-specific T wave inversions were seen on the electrocardiogram (ECG). A computerised tomography (CT) scan of chest and abdomen showed diffuse gastric pneumatosis and pneumobilia without obvious evidence of coronary air emboli. A head CT showed no acute infarct or pneumocephalus. She was transferred for hyperbaric oxygen therapy; after one session her symptoms resolved, except for continued blurred vision. Additional evaluation including echocardiography and magnetic resonance imaging (MRI) was planned, but she left against medical advice before these were completed. At ophthalmology follow-up, she reported return to normal vision; however, she had left homonymous hemianopia, likely due to the ingestion.
Conclusion(s): Both gastrointestinal and neurologic complications following 35% hydrogen peroxide ingestion are reported as well as successful treatment with hyperbaric oxygen [1-2]. However, to our knowledge, this is the first case with cardiac involvement as evidenced by the elevated troponin concentration and an unusual case of homonymous hemianopia. We believe that these novel findings may be complications caused by paradoxical gas emboli that transited through a patent foramen ovale; a mechanism that has been described with iatrogenic air emboli [3], but not after hydrogen peroxide ingestion. This illustrates the variety of possible complications following ingestion of industrial strength hydrogen peroxide

Objective: Clozapine is a second-generation antipsychotic medication used to treat refractory schizophrenia. There are limited reports of confirmed clozapine ingestions in young children. We report a case of two siblings who ingested clozapine due to a pharmacy dispensing error; both recovered with supportive care. Case report: A 5-year-old girl and her 19-month-old sister, both previously healthy, presented to the emergency department (ED) around 10 pm with lethargy and confusion soon after they both took their first evening dose of what was believed to be 200mg cimetidine, newly prescribed to treat molluscum contagiosum. In the ED, they were both tachycardic, but otherwise had ageappropriate vital signs. On physical examination, both children were noted to be lethargic and drooling with roving eye movements. The older sibling was also confused and agitated at times with abnormal arm movements. Both children were observed for four hours and discharged home. The 19-month-old remained somnolent, but returned to baseline the following afternoon. The 5-year-old was persistently lethargic and confused the following day, with some improvement 36 hours post-ingestion. Their mother was in close contact with their pediatrician during this time. Given the persistence of symptoms inconsistent with cimetidine, the mother examined the tablets in the prescribed bottle and through a pill identifier, identified the tablets as 200 mg clozapine. Both children were seen in the pediatrician's office on day two and day three post-ingestion with normal electrocardiograms and normal complete blood counts on day three. About 85 hours post-ingestion the older sibling's serum clozapine concentration was reported as 17 mug/L and norclozapine concentration as 55 mug/L (25-400 mug/L). The older sibling returned to her baseline 4 days post-ingestion. When the dispensing error was reported to the pharmacy, it was discovered that the bottles of cimetidine and clozapine had been placed next to one another on the shelf in the pharmacy. Further investigation into the error was undertaken and as a preliminary safety measure, clozapine was moved to a more secure location in the pharmacy. Three months post-exposure, both children were healthy with no sequelae noted on follow-up.
Conclusion(s): We describe two children who ingested clozapine and developed drooling and altered mental status. It took several days for the children to return to their baseline mental status, but complete recovery occurred with supportive care. Efforts should be taken to reduce pharmacy dispensing errors that can lead to serious toxicity in children

Objective: In-flight pain emergencies are responsible for 17% of medical diversions on commercial airlines [1]. While the Federal Aviation Authority mandates that airlines carry aspirin in the emergency medical kit (EMK), some airlines carry opioids. This case highlights the risks associated with in-flight administration of opioid analgesics from an ill-equipped EMK. Case report: The poison center was consulted about a 38-yearold, opioid-naive woman who was brought to an emergency department directly from the airport following a transatlantic flight on a large European airliner. She had normal vital signs but was somnolent and nauseous with bilateral miosis. In her possession was a physician note attesting that she had complained of leg pain during the flight and was given buprenorphine (400 mug sublingual) and aspirin (300mg oral) from the emergency medical kit on board the flight. In the absence of hypoventilation, we recommended against naloxone administration. The patient was admitted to the intensive care unit for monitoring and discharged home 24 hours later without sequelae. We investigated the EMK contents of the patient's airline and were extremely concerned by our findings. The quantity of buprenorphine (30 x 200 mug tablets), its convenient location within the lid compartment (next to the stethoscope and face mask), and the relative scarcity of naloxone (2 x 0.4 mg ampules) were all striking. While buprenorphine has a ceiling effect on respiratory depression in healthy volunteers, its high mu-opioid receptor affinity makes it difficult to treat with standard doses of naloxone [2]. Many physicians are also unfamiliar with analgesic buprenorphine doses which are 10-fold lower than doses used for opioid medication assisted therapy. Lastly, sublingual buprenorphine has a peak therapeutic effect 1-4 hours following administration: too late and too long for pain on a plane for shorter flights.
Conclusion(s): The large quantity of easily-accessible buprenorphine in an airline's EMK directly contributed to this patient's overdose. While the patient did not suffer permanent injury, she was subjected to many medical tests and hospitalized for 24 hours in a costly ICU bed. We seriously question the role of buprenorphine in the management of in-flight pain crises. (Table Presented)