A Sting, then Blisters and Pain
​A 25-year-old woman presented with a rash, and reported that she was in South Carolina when she felt a stinging sensation. That was followed by blisters on her foot.She noticed swelling of her foot, and had continued pain. She took pictures of the bite on days two and six. (Below.) She reported that she had a similar sting the previous summer. She said she had no fever, shortness of breath, or dizziness. Her vital signs were a temperature of 98.6°F, a heart rate of 80 bpm, a blood pressure of 100/60 mm Hg, a respiratory rate of 16 bpm, and an SPO2 of 100% on room air.She was alert and in no distress. Her oropharynx ...
Source: The Tox Cave - September 3, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Troublesome Cup of Tea
A 45-year-old woman presented to the emergency department with nausea and vomiting. Her symptoms had started seven days earlier and steadily worsened. She reported generalized abdominal pain and distention and that her eyes appeared yellow.The patient had no past medical history, took no medications, and said she did not drink or use drugs. Her history showed that she had been drinking an herbal preparation every day for the past five months to ameliorate her heavy menstrual periods.The patient had mild right upper quadrant tenderness but no distention, rebound, or guarding. Her lungs were clear, and her heart rate and rhy...
Source: The Tox Cave - July 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Magnum, P.I.
​An 11-year-old boy with cerebral palsy presented to the emergency department unresponsive. His mother said the child was in his normal state earlier that morning, but was blue and unresponsive when she tried to wake him from his morning nap. A home pulse oximeter reported an oxygen level of 55%.The mother placed the child on oxygen and called 911. He was still unresponsive on arrival, and his physical examination demonstrated flaccid paralysis and a GCS score of 3 with fixed dilated pupils. He was tachycardic with shallow respirations. His initial vital signs were a temperature of 36.9°C, a heart rate of 136 bpm, a ...
Source: The Tox Cave - June 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Pants on Fire
​A 37-year-old man presented to the ED with thigh pain. He said his e-cigarette battery exploded in his pants pocket after he placed his keys in the pocket. He said he took his pants off immediately and noted that the battery had melted.His initial vital signs were a temperature of 98.7°F, heart rate of 112 bpm, blood pressure of 159/95 mm Hg, and pulse oximetry of 98% on room air. He had a large area of burns of different degrees on his right thigh. Total body surface area of nine percent with first-, second-, and third-degree burns was noted.E-cigarette use, or vaping, has risen significantly in the past 10 years. ...
Source: The Tox Cave - May 2, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

I Can’t Hear You!
​A 50-year-old man presented to the emergency department complaining of ringing in his ears and difficulty understanding what people were saying. He was concerned that he was having a stroke. A full neurological exam was unremarkable aside from decreased hearing, but his hearing deficits appeared to be equal bilaterally. Otoscopic exam demonstrated a normal tympanic membrane, and the rest of his physical exam was unremarkable. The patient's past medical history was significant for hypertension and hypercholesterolemia, for which he took lisinopril and atorvastatin. He was recently treated with a 10-day course of doxycycl...
Source: The Tox Cave - April 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Now You See Me, Now You Don’t
​A 32-year-old man presented to the emergency department complaining of eye pain and decreased vision. He worked for the city and was removing rust and graffiti from a wall with a power washer when the spray ricocheted off the surface and into his eye. He presented with a bottle of the chemical he used, which contained hydrofluoric acid (HF) and other chemicals. He rinsed his eyes with tap water, but experienced persistent decreased vision and pain in both eyes. His exam was remarkable for bilateral injected conjunctiva and excessive tearing.More than 7,000 ocular exposures were reported to U.S. poison control centers pe...
Source: The Tox Cave - January 2, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

You Drank What?
​A 3-year-old boy presented to the ED after ingesting a liquid in an unmarked bottle. His parents said he vomited a few times before ED arrival. His initial vital signs were a blood pressure of 92/54 mm Hg, heart rate of 114 bpm, respiratory rate of 20 bpm, and pulse oximetry of 98% on room air. The parents reported that he may have ingested a cleaning solution known to contain aluminum hydroxide.The patient was breathing comfortably, and his airway was monitored closely in the ED. He had no oropharyngeal edema or erythema, and his lung sounds were clear. His mother said she did not think he drank too much of the fluid. ...
Source: The Tox Cave - December 3, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Something Smells Fishy
​A 32-year-old woman and her 36-year-old husband with no past medical history presented to the ED with palpitations, headache, a feeling of warmth all over, and a rash extending from their upper chests to their faces.The blood pressures of the wife and husband were 91/56 mm Hg and 93/61 mm Hg, respectively. Both were mildly tachycardic with heart rates of 112 bpm and 108 bpm. The patients described intense pruritus, and they had patchy blanching and erythema over their chests and faces with mild eyelid edema. They reported that their symptoms started five to 10 minutes after sharing an ahi tuna poke bowl.What Is the...
Source: The Tox Cave - November 1, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Dia de los Muertos
​A 27-year-old man presented by EMS was agitated, confused, and combative. EMS said they had received a call for a patient who was minimally responsive lying on the sidewalk. They noted the patient with pinpoint pupils and decreased respirations. The concern was that he had been using heroin, so he was given 2 mg intranasal naloxone. This caused the patient to become acutely confused and combative. He was awake and alert but oriented x 0. His vital signs included a temperature of 99.1°F, a heart rate of 122 bpm, a respiratory rate of 26 bpm, and pulse oximetry of 97% on room air.At least 160 people were admitted to P...
Source: The Tox Cave - September 30, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Bayer of a Case
​A 30-year-old woman was brought in by EMS tearful and reluctant to answer questions initially. Her mother was with her and stated that the patient had been depressed and may have taken some pills in a suicide attempt. Her initial vitals on presentation were a temperature of 99.1°F, heart rate of 128 bpm, blood pressure of132/92 mm Hg, and a respiratory rate of 26 bpm. She had clear lungs and sinus tachycardia on cardiac monitoring. She admitted to having taken "a lot" of aspirin.Initial LabsCBC: WBC of 14, hemoglobin of 14 g/dL, hematocrit of 42%, platelet count of 250,000BMP: Sodium of 132 mEq/L, potassiu...
Source: The Tox Cave - August 31, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

‘Rats! I’m High’
​A 24-year-old man presented with uncontrollable epistaxis. He said he had been bleeding "a ton" from his nose continuously for four hours. He denied recent trauma, and explained that this epistaxis was sudden onset. He had no past medical history, and denied previous episodes of excessive bleeding. An examination demonstrated no signs of trauma and was unremarkable aside from the epistaxis. His nostrils revealed no obvious bleeding vessels for cauterization. His social history was remarkable for occasional drinking, marijuana use, and recent use of synthetic marijuana.His vital signs were a heart rate of 85 bp...
Source: The Tox Cave - July 2, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Internet Challenges Sending Kids to EDs
​Social media influences nearly every part of our lives—how we communicate, teach, and protest. It is powerful because it allows people around the world to connect instantaneously. One of those ways is the social media phenomenon popular since the early 2000s: internet challenges. These challenges range from funny, like the mannequin challenge, to charitable, such as the ice-water bucket challenge, to dangerous, like the blue whale challenge. Several of these can cause injury by ingestion or topical application.​The Tide Pod ChallengeConcerns of safety arose shortly after laundry pods were introduced in 2012 when...
Source: The Tox Cave - June 1, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Inadvertent Overdose in First Responders
​Part 4 in a Four-Part SeriesThe United States is in the midst of a significant opioid epidemic, and a large proportion of the illegal opioids being sold contain fentanyl or fentanyl analogs. The Drug Enforcement Administration reported that U.S. law enforcement agencies seized at least 239 kilograms of illicitly produced fentanyl from August 2013 to the end of 2015. (http://bit.ly/2obUOLs.) This drug is responsible for many opioid overdoses and deaths because of its extremely low lethal dose.First responders, a population not initially thought to be at risk, have been found to be exposed to synthetic fentanyl analogs. S...
Source: The Tox Cave - April 2, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Agony of Withdrawal
​Part 3 in a Four-Part Series​A 26-year-old man presented with fatigue. He complained of body aches, diarrhea, and nausea. His history was significant for chronic back pain, for which he had been prescribed oxycodone that he has taken daily for three years. He reported that he had stopped taking it two days before his visit.He denied other medication or drug use. He was alert but restless and diaphoretic. His ECG showed sinus tachycardia. His labs included a WBC of 12, Hgb of 12, glucose of 89 mg/dL, creatinine of 1.0 mg/dL, sodium of 140 mEq/L, potassium of 3.8 mEq/L, and CK of 140 U/L. He was experiencing opioid with...
Source: The Tox Cave - February 28, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Narcan or Narcan’t?
​Part 2 in a Four-part Series​A 57-year-old man presented with acute onset altered mental status. His family said he had been behaving normally. Prior to dinner, however, he became difficult to arouse, and was speaking gibberish. He was somnolent but arousable to physical stimuli on arrival in the ED.He answered questions inappropriately and would then go back to sleep. His past medical history was consistent with hypertension, hypercholesterolemia, and spinal fusion a month ago. His medications included lisinopril, atorvastatin, and hydrocodone. His vital signs were a blood pressure of 110/65 mm Hg, heart rate of 90 b...
Source: The Tox Cave - January 2, 2018 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Modern-Day Plague
​Part 1 in a Four-part SeriesA 32-year-old man was taken to the ED by EMS after being found unresponsive in a subway station. His pupils were pinpoint, and he was breathing at fourth breaths per minute. He had a blood pressure of 94/63 mm Hg, pulse oximetry of 91% on room air, and a heart rate of 51 beats per minute. He was given 2 mg of intranasal Narcan by EMS and became more responsive, breathing at 14 breaths per minute with a blood pressure of 125/82 mm Hg, heart rate of 74 bpm, and 98% on room air. He admitted in the ED to using three bags of heroin.​The opioid epidemic is a national public health crisis in the U...
Source: The Tox Cave - November 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Proof is the Bottle
​An 18-year-old woman presented for altered mental status. EMS reported that she was at a beach party when she became unresponsive. Friends said she may have been drinking alcohol, but denied other illicit drug use. Initial vital signs included a blood pressure of 117/69 mm Hg, heart rate of 110 bpm, respiratory rate of 11 bpm, SPO2 99% on room air, and a temperature of 98.9°F. ​The patient was somnolent and reacted intermittently to physical stimuli on exam. She intermittently moved all four extremities. Her gag reflex was intact. Pupils were 4 mm bilaterally reactive without nystagmus. She had tachycardia, her lu...
Source: The Tox Cave - October 2, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

How to Be Cool
​A 27-year-old man with an unknown past medical history presented with altered mental status. Bystanders found him on the sidewalk acting strangely, according to EMS. The patient was drowsy with incomprehensible speech on arrival. He was diaphoretic, tachycardic, and combative. No signs of trauma were noted. His heart rate was 130 bpm, blood pressure 169/90 mm Hg, respiratory rate 30 bpm, SPO2 98% on room air, and temperature 105.3°F. His blood glucose was 150. The patient continued to be minimally responsive.​Etiologies of HyperthermiaNeuroleptic malignant syndromeSerotonin syndromeAnticholinergic syndromeSympatho...
Source: The Tox Cave - September 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Pain in the Bite
​A 14-year-old boy with no past medical history was brought to the ED in some distress by his parents. One hour earlier while looking for his baseball glove in the garage he had felt a small pinprick just above his right ankle. The patient, however, became increasingly uncomfortable and began complaining of diffuse abdominal pain.​His initial vital signs were a temperature of 97°F, heart rate of 112 bpm, blood pressure of 151/91 mm Hg, and 98% pulse oximetry on room air. He appeared uncomfortable, was diaphoretic, and had a rigid abdomen. A small puncture wound with some mild erythema to the lateral right ankle was...
Source: The Tox Cave - August 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Buggy Case
​A 35-year-old man with a history of asthma presented with an exposure after spraying his garage with an insecticide he bought at the hardware store. Shortly after spraying the insecticide, he noticed eye itchiness, tingling, pruritus over his arms and legs, and shortness of breath. His blood pressure was 130/85 mm Hg, heart rate 70 bpm, respiratory rate 14 bpm, temperature 98.7°F, and SpO2 96% on room air.​He was alert and anxious, his skin was warm with mild erythema, and he had urticaria over his forearms and ankles. His lung exam revealed diffuse wheezing bilaterally. His eyes were watery, and his pupils were 4...
Source: The Tox Cave - July 3, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Lethal Poison Used in Syria
​The Syrian government recently used what is believed to be sarin on civilians, killing 80 people and injuring many more. (CNN. April 20, 2017; http://cnn.it/2oXX47G.) The use of a nerve agent was confirmed by the Turkish government after examining several bodies during autopsy.Sarin was first developed by the Germans as a pesticide in 1938, and is one of the G-series nerve agents that includes tabun, soman, and cyclosarin. Sarin was also used in a terrorist attack in the Tokyo subway in 1995, killing 12 people. (TIME. March 20, 2015; http://ti.me/2oY3F1Y.) Sarin is an organophosphorus compound similar to what is found i...
Source: The Tox Cave - June 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Death by Poison
​Poison has been used for many purposes since humans have existed, often for assassination or assassination attempts. Some of those make the news, the most recent being the assassination of Kim Jong-nam, the half-brother of North Korean leader Kim Jong-un.Authorities identified the nerve agent VX on his face, and video corroborated two women wiping a substance on his face before his collapse and death. VX is the most potent nerve agent, and was developed in the United States in the 1950s during the Cold War. It is an acetylcholinesterase inhibitor, and exerts its effects like organophosphate insecticides. Victims develop...
Source: The Tox Cave - May 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Jittery Patient
​A 22-year-old woman with no past medical history presented to the emergency department with palpitations. She reported that she had ingested a handful of caffeine tablets with a large glass of wine two hours earlier. She reported feeling "stressed out" and wanting to hurt herself. The patient was alert but appeared anxious on arrival at the ED.Her blood pressure was 90/49 mm Hg, heart rate was 115 beats/min, respiratory rate was 20 breaths/min, and SPO2 was 100% on room air. An ECG showed sinus tachycardia at 120 beats/min with normal intervals. Shortly after arrival, her blood pressure dropped to 83/42 mm Hg,...
Source: The Tox Cave - March 31, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

How to Sedate the Violent Patient
​The emergency department can be an exciting yet sometimes violent place to work, often because of a patient presenting with excited delirium syndrome (ExDS), the most severe form of agitation. It is associated with the use of sympathomimetics such as methamphetamine, cocaine, and PCP.​Patients with ExDS present with sudden onset of aggressive and bizarre behavior. These patients generally demonstrate unexpected physical strength and hyperthermia. This disease process is extremely important for prehospital responders and emergency physicians to recognize because almost two-thirds of the patients with ExDS die at the sc...
Source: The Tox Cave - March 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Another Case of Vomiting
​A 26-year-old man presented to the emergency department with nausea, vomiting, and abdominal pain. He said he had had the pain, which he said encompassed his entire abdomen, for three days.​He had been unable to tolerate anything by mouth. His vitals on presentation included a heart rate of 115 bpm, blood pressure of 126/70 mm Hg, respiratory rate of 22 bpm, and pulse oximetry of 100% on room air.Physical examination revealed dry mucus membranes, dry skin, tachycardia without murmurs, and clear lungs. Abdominal examination demonstrates hyperactive bowel sounds without pain on palpation or hepatosplenomegaly. The patie...
Source: The Tox Cave - December 1, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A Weak Admission
​A 64-year old woman presented to the emergency department with nausea, vomiting, dry mouth, dry eyes, and difficulty keeping her eyes open. She admitted to eating mandarin oranges out of a can the night before, and at that time she thought they "tasted funny" but did not think much of it.​The next morning she noticed she was having trouble opening her eyes and that her mouth was dry. She looked inside the can of oranges and saw it was discolored.Her presenting vital signs were unremarkable. The patient was alert and awake. She had ptosis bilaterally, with mydriatic pupils unresponsive to light. The patient h...
Source: The Tox Cave - November 1, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Whip It Good
A 29-year-old man presented to the emergency department with numbness and tingling of his entire body for three weeks. He said the symptoms started when he entered a drug rehab facility for benzodiazepine and opiate abuse, and that the last time he used either drug was more than a month ago. His initial vitals demonstrated a heart rate of 106 bpm, blood pressure of 115/70 mm Hg, temperature of 98.6°F, respiratory rate of 14 bpm, and SPO2 of 99% on room air.He is well nourished, alert, and oriented but anxious-appearing. His neurologic exam demonstrates no ataxia on ambulation with cranial nerves II-XII intact. His moto...
Source: The Tox Cave - October 3, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Lactate Intolerant
A 76-year-old woman presented to the ED with altered mental status. Her family said she had increasing fatigue for two days. That morning, the patient had nausea, vomiting, and shoulder pain. EMS found she had a blood glucose of 34. She was given an ampule of D50 and brought to the ED.The patient reported dizziness and fatigue in the ED, and stated that she had not eaten for a few days. Her initial vital signs included temperature 94.1℉, pulse 76 bpm, blood pressure 120/67 mm Hg, respiratory rate 18 bpm, and pulse oximetry 99% on room air. Her physical examination is unremarkable.Initial laboratory values are remarkable ...
Source: The Tox Cave - September 1, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Leucovorin to the Rescue​
A 78-year-old man was advised to go to the emergency department by his rheumatologist after reporting symptoms of nausea, severe fatigue, and feeling "off" for two days. The patient had recently been prescribed methotrexate for his polymyalgia rheumatica, and was instructed to take 5 mg once a week, but he misunderstood and took 5 mg daily for six days.The patient's heart rate was 80 beats per minute, his blood pressure was 155/75 mm Hg, his pulse ox was 98% on room air, and his temperature was 98°F. His initial labs included a CBC with no abnormalities, but his creatinine was 2.5 mg/dL with a GFR of 25. Base...
Source: The Tox Cave - August 1, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

No Pea'ce in the Pods​
Discussion of Recent Literature. Pediatr Emerg Care 2013;29(6):743.Davis MG, Casavant MJ, et al. Pediatric Exposures to Laundry and Dishwasher Detergents in the United States: 2013-2014. Pediatrics 2016;137(5):e20154529.Russell JL, Wiles DA, et al. Significant Chemical Burns Associated with Dermal Exposure to Laundry Pod Detergent. J Med Toxicol 2014;10(3):292.Tags: detergent pod, laundry detergent, vomiting, poisoning, erythema, decontaminationPublished: 7/2/2016 10:06:00 AM (Source: The Tox Cave)
Source: The Tox Cave - July 2, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Rigid Patient
​A 24-year-old man with a history of schizophrenia presented with altered mental status. His mother said he had become more catatonic and rigid over the previous two days. She reported that he was prescribed Abilify 5 mg by mouth daily for three years, but a long-acting depot of Abilify 400 mg had been administered two days before by court order. His vital signs include a heart rate of 120 bpm, blood pressure 140/90 mm Hg, temperature 38.5°C, respiratory rate is 14 bpm, and SPO2 is 98% on room air. The patient is alert and diaphoretic. Pupils are 3 mm. Cogwheeling, rigidity, and two beats of ankle clonus are als...
Source: The Tox Cave - June 2, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Baby Got NAC
A 21-year-old woman with no past medical history presented to the emergency department for evaluation of an overdose. She was brought in by ambulance after her boyfriend called the police because she admitted to him that she had ingested a large amount of acetaminophen (APAP). The patient was 21 weeks pregnant and admitted to having ingested half of a bottle of extra-strength Tylenol six hours before arrival. The ED contacted the poison control center, and asked if N-acetylcysteine (NAC) is safe in pregnancy and if the dosing regimen changes for the pregnant patient.NAC's Mechanism of ActionAPAP is primarily metabolized by...
Source: The Tox Cave - May 2, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs