August 2021: Adulterant in Fentanyl Complicates OD
A 38-year-old woman with opioid use disorder presented to the emergency department after an unintentional overdose. EMS said the patient was found with decreased respirations, and she was given 2 mg intranasal naloxone. She was awake, alert, and oriented x 3 in the emergency department.She reported that she used one bundle of fentanyl/heroin a day intravenously and that she had recently been hospitalized for four weeks for a wound infection. She stated that she used her usual dosage of fentanyl/heroin on discharge, not realizing how much her tolerance had decreased.She also said the fentanyl contained “tranq" (xy...
Source: The Tox Cave - August 2, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
June 2021: Mounting Evidence Supports Ivermectin for COVID-19
Ivermectin has been proposed as a treatment for COVID-19 based on in vitro studies. It is currently FDA-approved for treating parasites (intestinal strongyloidiasis and onchocerciasis) but not approved for COVID-19, though a large body of evidence supports its use in inpatients and outpatients. (Antiviral Res. 2020;178:104787; https://bit.ly/3bpeTrm.)Mechanism of ActionIvermectin is an antiparasitic agent that binds directly and has high affinity to the glutamate-gated chloride ion channels in invertebrate muscle and nerve cells of microfilaria. This causes the cell membrane to have increased permeability to chl...
Source: The Tox Cave - June 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
May 2021: The Asphyxiants that Cause Pulmonary Toxicity
The American Association of Poison Control Centers reported more than 37,000 exposures to gas, fumes, and vapors in 2019, and those were the most common exposures in pediatric deaths. Toxicity from gas, fume, and vapor exposures can be categorized by their mechanism: simple asphyxiants, pulmonary irritants, and systemic asphyxiants.Simple AsphyxiationSimple asphyxiants work by displacing oxygen from ambient air. Patients may be exposed to these chemicals by huffing. A 2010 survey reported that more than two million adolescents in the United States ages 12-17 reported using inhalants at least once, including noble ga...
Source: The Tox Cave - April 30, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
April 2021: An Eye on the Problem
A 3-year-old boy presented to the emergency department with lethargy. He was bradycardic and somnolent, responding only to physical stimuli. His vital signs were a temperature of 37°C, a heart rate of 50 bpm, a respiratory rate of 26 breaths per minute, a blood pressure of 92/41 mm Hg, and a pulse oximetry of 100% on room air.When awoken, the child answered questions appropriately but then fell back asleep quickly. His pupils were pinpoint. There were no signs of trauma. A cardiac examination demonstrated bradycardia, and the remainder of the examination was unremarkable.The child was given an IV fluid bolus and placed...
Source: The Tox Cave - April 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
March 2021: The Toxicity of Fire Smoke
A 54-year-old man was brought to the ED unresponsive by paramedics after his neighbors called 911 because they smelled smoke in his apartment. The patient was found unconscious in his living room, and a fire was burning in an adjoining room.His initial vital signs were a blood pressure of 115/80 mm Hg, a heart rate of 120 bpm, a respiratory rate of 30 bpm, an SPO2 of 94% on a nonrebreather, and a temperature of 98.9° F. The patient was unresponsive to verbal and physical stimuli but had spontaneous respirations. His nose and mouth were filled with soot, his lungs had trace wheezes, and his skin appeared flushed.What toxin...
Source: The Tox Cave - March 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
February 2021: Clinical Presentation Provides Clue to Toxicity
A 43-year-old man with a history of bipolar disorder, hypertension, and asthma presented with altered mental status and a tremor. He reported increasing fatigue and hand tremors for one day. He said he and his family recently had food poisoning with vomiting and diarrhea for several days. Those symptoms had resolved. He continued to take all of his prescribed medications, which included lithium carbonate (Lithobid) 800 mg BID and amlodipine 10 mg daily.His initial vital signs were a heart rate of 104 bpm, a blood pressure of 136/82 mm Hg, a respiratory rate of 16 bpm, an oxygen saturation of 99% on room air, and a temperat...
Source: The Tox Cave - January 29, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Delayed GI Symptoms and a Liver Transplant
A 16-year-old boy presented to an emergency department in rural Pennsylvania for nausea, vomiting, and diarrhea. He reported diffuse abdominal cramping that had started two hours earlier. Shortly prior to arrival, he had multiple episodes of nonbloody diarrhea and emesis. He had no significant past medical history, and was not currently taking any medications or supplements. Initially, the history he gave was limited due to a language barrier. His sister was also being evaluated for similar symptoms.The boy's vital signs were a heart rate of 130 bpm, a blood pressure of 100/50 mm Hg, a respiratory rate of 26 bpm, an oxy...
Source: The Tox Cave - November 30, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
An Overdose that Happens Hours Later
A 15-year-old girl was brought to the emergency department by EMS after a seizure witnessed by her mother. She admitted that she had ingested "a handful of pills" in a suicide attempt five hours earlier. The mother said her daughter had a history of cutting but no prior suicide attempts.Her past medical history was significant for depression, for which she took bupropion XL, and she reported past alcohol and marijuana use. Her initial vital signs were a temperature of 97.9°F, a pulse of 162 bpm, a blood pressure of 127/65 mm Hg, a respiratory rate of 14 bpm, and a pulse ox of 100% on room air. Her exam was si...
Source: The Tox Cave - November 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
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 was...
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 res...
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. The...
Source: The Tox Cave - May 1, 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
