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 Phil...
Source: The Tox Cave - September 29, 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, pot...
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 analog...
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 SeriesA 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 SeriesA 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 lungs...
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 syndromeSympathomim...
Source: The Tox Cave - September 1, 2017 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
