Faculty Bibliography

OBJECTIVES/OBJECTIVE:The primary objective was to compare adenosine administration time with the single syringe (SS) versus double syringe (DS) method in a simulated pediatric emergency department (ED) patient. Secondary objectives were to compare preparation time, preparation errors, administration errors, and participant preference/perception. METHODS:This was a prospective, randomized, crossover simulation study. Adenosine doses were prepared by a pharmacist and administered by a physician. The primary outcome was administration time. Secondary outcomes were preparation times, participant preference, pharmacist-rated ease of preparation, and physician-rated ease of administration. RESULTS:Sixteen pharmacist-physician pairs were included. The SS method had a shorter administration time versus the DS method [SS, median (IQR): 13 (10 to 15.8) s versus DS, median (IQR): 26 (20.8 to 31.3) s, P<0.001; median difference (95% CI): -13 (-22.5 to -9) s]. There were no significant differences in preparation times or pharmacist-rated ease of administration between the SS and DS methods. The SS method had a higher physician-rated ease of administration and was preferred by 68.8% of study participants. CONCLUSIONS:The SS method had a faster adenosine administration time versus the DS method in a simulation setting, while also having similar preparation time, preparation errors, and administration errors. The SS method was rated easier to administer and preferred by most participants. Further study is required, as this study is limited by its simulation design and lack of clinical outcomes.

INTRODUCTION/UNASSIGNED:Alkyl nitrites ("poppers") are used recreationally for sexual enhancement, muscle relaxation, and euphoria. However, they can be toxic and cause adverse reactions such as methemoglobinemia. While inhalation is the typical route of usage, the New York City Poison Center has noted an increase in calls related to ingestion. Given the uncertainty of usage instructions at the point of sale, our study aimed to assess instructions provided to consumers about alkyl nitrite use and to evaluate the proximity and co-sale of alkyl nitrites with similarly appearing energy drink shots. METHODS/UNASSIGNED:We conducted a cross-sectional convenience sample survey of smoke shops, cannabis dispensaries, and exotic shops within the catchment area of an urban poison center. Plain clothes "investigators" (i.e., the researchers) visited these retailers and followed a predetermined protocol and script to request information regarding the availability and usage of alkyl nitrites. Additionally, the researchers attempted to visually assess the proximity of alkyl nitrites to similarly appearing energy drink shots during their visit. RESULTS/UNASSIGNED:drinks and alkyl nitrites were located near these energy drink shots in twenty (39%) of these fifty-one stores. DISCUSSION/UNASSIGNED:Many commercial alkyl nitrite retailers in our survey area lack knowledge or provide potentially inaccurate information regarding the use of alkyl nitrites. Additionally, alkyl nitrites are often sold alongside commercial energy drinks, potentially increasing the risk of incidental ingestion. CONCLUSIONS/UNASSIGNED:Further research is necessary to determine the impact of these patterns of sale and potential misinformation. Discussing preliminary results of our survey with the New York City Department of Health led to the rapid creation of an informational poster and local outreach. Clinicians should report cases of alkyl nitrite use to their regional poison center to allow for more targeted and timely public health intervention.

INTRODUCTION/UNASSIGNED:Consensus guidelines for out-of-hospital assessment and triage of paracetamol (acetaminophen) exposure were published in 2006. Changes in the healthcare system, paracetamol ingestion trends, and availability of paracetamol-containing products necessitate an update to these guidelines. Updated guidelines were created for out-of-hospital management of paracetamol exposure in the United States and Canada. METHODS/UNASSIGNED:A modified Delphi consensus methodology was used to create a decision framework to evaluate clinical aspects of care related to paracetamol overdose in the out-of-hospital setting. Twenty-one panelists were selected by four clinical toxicology societies (America's Poison Centers®, American Academy of Clinical Toxicology, American College of Medical Toxicology, and Canadian Association for Poison Centres and Clinical Toxicology) to participate as panelists. Guidelines were collected from most poison centers in the United States and Canada, and systematic collection and review of medical literature was conducted. RESULTS/UNASSIGNED:The panel developed a guideline for out-of-hospital management of paracetamol exposure that encompasses acute and repeated supratherapeutic ingestion patterns. Acute ingestion is defined as any ingestion presenting within 24 h of initial ingestion, regardless of ingestion pattern. Repeated supratherapeutic ingestion is defined as an exposure that occurs over a period of 24 h or more. This guideline emphasizes the importance of obtaining accurate history. When ingestion history is determined as accurate, dosage and ingestion pattern are used to decide treatment referral. It is recommended that patients be referred to the emergency department if their ingestion amount is: (1) ≥200 mg/kg or 10 g (whichever is less) within 24 h; (2) ≥150 mg/kg/24 h or 6 g/day (whichever is less) within 48 h; (3) ≥100 mg/kg/24 h or 4 g/day (whichever is less) for more than 48 h. DISCUSSION/UNASSIGNED:The need for standardizing the out-of-hospital assessment and triage of paracetamol exposure is pressing. Despite the availability of acetylcysteine, some patients develop fatal liver failure due to missed diagnoses and delays in treatment. Failure to recognize cases requiring acetylcysteine is associated with significant morbidity and mortality. CONCLUSION/UNASSIGNED:This consensus statement provides evidence-based guidance for out-of-hospital management of paracetamol ingestion to standardize healthcare facility referral criteria for paracetamol exposed patients.