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 no...
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 mm...
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...
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