‘To Alcohol! The Cause of, and Solution to, All of Life's Problems’
A 37-year-old woman is brought into the emergency department by EMS after being found down next to a bottle of an unknown substance. (See photo.) Her family said she was initially tearful and repeatedly mumbling, “I’m sorry,” and became progressively less responsive.
She was obtunded and intubated for airway protection upon arrival to the ED. Her initial vital signs were a temperature of 98.8°F, heart rate 110 bpm, blood pressure 187/118 mm Hg, respiratory rate 22 bpm, and pulse oximetry 98% on ventilator. Initial ABG reveals a pH 6.89, pCO2 16, pO2 174, and bicarbonate 3.1. Pertinent lab results include a metabo...
Source: The Tox Cave - August 3, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Don’t Smoke ’Em if You Got ’Em
A 22-year-old man with no past medical history presented to the emergency department with altered mental status. He was brought in by police who reported using a TASER on him three times after he became violent with them. His friends report he smoked K2. His initial vital signs included a temperature of 99.9°F, a heart rate of 137 bpm, blood pressure of 151/76 mm Hg, a respiratory rate of 22 bpm, and pulse oximetry of 98% on room air. The patient was agitated and combative, and was placed in four-point restraints.
K2 is a synthetic cannabinoid. Other commonly used synthetic cannabinoids include spice, moon rocks, com...
Source: The Tox Cave - July 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Don’t Smoke ’Em if You Got ’Em
A 22-year-old man with no past medical history presented to the emergency department with altered mental status. He was brought in by police who reported using a TASER on him three times after he became violent with them. His friends report he smoked K2. His initial vital signs included a temperature of 99.9°F, a heart rate of 137 bpm, blood pressure of 151/76 mm Hg, a respiratory rate of 22 bpm, and pulse oximetry of 98% on room air. The patient was agitated and combative, and was placed in four-point restraints.
K2 is a synthetic cannabinoid. Other commonly used synthetic cannabinoids include spice, moon rocks, comat...
Source: The Tox Cave - July 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Good, the Bad, and the Ugly
The urine drug screen commonly utilized in the emergency department is an immunoassay that uses antibodies to detect specific drugs or their metabolites. This allows for rapid screening for drugs of abuse, but it has many limitations.
Gas chromatography-mass spectrometry (GC-MS) is the confirmatory test, but it is more costly, time-consuming, and generally can only be performed by outside laboratories. This confirmatory test is generally not useful in the emergency department, but has a role in cases of pediatric exposures, research, or occupational drug testing.
One of the limitations of a urine drug s...
Source: The Tox Cave - June 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Good, the Bad, and the Ugly
The urine drug screen commonly utilized in the emergency department is an immunoassay that uses antibodies to detect specific drugs or their metabolites. This allows for rapid screening for drugs of abuse, but it has many limitations.
Gas chromatography-mass spectrometry (GC-MS) is the confirmatory test, but it is more costly, time-consuming, and generally can only be performed by outside laboratories. This confirmatory test is generally not useful in the emergency department, but has a role in cases of pediatric exposures, research, or occupational drug testing.
One of the limitations of a urine drug screen a...
Source: The Tox Cave - June 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The No-Sugar Daddy
A 40-year-old man presented with hypoglycemia following an intentional overdose with Humalog Mix 75/25 (75% insulin lispro protamine suspension and 25% insulin lispro injection). He reported injecting 900 units into his abdomen one hour prior to ED presentation. He complained of lightheadedness and nausea. His initial vital signs were heart rate 110 bpm, blood pressure 112/70 mm Hg, respiratory rate 14 breaths per minute, and oxygen saturation 99% on room air. His physical exam is remarkable for a visible injection site on the abdomen. Blood glucose is 50, potassium is 3.1, and creatinine is 0.8. The patient reports a pres...
Source: The Tox Cave - May 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The No-Sugar Daddy
A 40-year-old man presented with hypoglycemia following an intentional overdose with Humalog Mix 75/25 (75% insulin lispro protamine suspension and 25% insulin lispro injection). He reported injecting 900 units into his abdomen one hour prior to ED presentation. He complained of lightheadedness and nausea. His initial vital signs were heart rate 110 bpm, blood pressure 112/70 mm Hg, respiratory rate 14 breaths per minute, and oxygen saturation 99% on room air. His physical exam is remarkable for a visible injection site on the abdomen. Blood glucose is 50, potassium is 3.1, and creatinine is 0.8. The patient reports a pres...
Source: The Tox Cave - May 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Patch Down the Hatch
A 42-year-old man presented with somnolence. His initial vital signs were heart rate 54 bpm, blood pressure 92/68 mm Hg, temperature 37°C, respiratory rate 6, and pulse oximetry 90% on room air. His physical examination was remarkable for depressed level of consciousness, miosis, and bradypnea. His mental status and respiratory rate temporarily improved with the administration of 0.04 mg naloxone. He reports swallowing several “patches” in a suicide attempt.
Popular transdermal patches are listed in the table. Others include diclofenac, buprenorphine, hormone patches (estrogen, contraceptive, testosterone), methy...
Source: The Tox Cave - March 31, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Patch Down the Hatch
A 42-year-old man presented with somnolence. Initial vital signs include: heart rate 54 bpm, blood pressure 92/68 mm/Hg, temperature 37°C, respiratory rate 6, pulse oximetry 90% on room air. Physical examination is remarkable for depressed level of consciousness, miosis, and bradypnea. His mental status and respiratory rate temporarily improved with the administration of 0.04 mg naloxone. He reports swallowing several “patches” in a suicide attempt.
What are examples of medications available as a transdermal patch? Compare the dose of drug delivered and the patch content.
Popular transdermal patches are listed bel...
Source: The Tox Cave - March 31, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Just in the Nic o’ tine
A 21-year-old man presented with palpitations, tremulousness, nausea, and vomiting. He reported ingesting one 14 mg nicotine patch in a suicide attempt. Initial vital signs include heart rate 132 bpm, blood pressure 140/80 mm Hg, temperature 37°C, respiratory rate 26 bpm, and pulse oximetry 100% on room air. Physical examination is remarkable for agitation, fine resting tremor, tachycardia, and pressured speech.
The lethal dose of nicotine is estimated to range from 1 mg/kg to 10 mg/kg. Reports of nicotine toxicity have occurred with the ingestion of as little as one whole cigarette or three cigarette butts in childr...
Source: The Tox Cave - March 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Just in the Nic o’ tine
A 21-year-old man presented with palpitations, tremulousness, nausea, and vomiting. He reported ingesting one 14 mg nicotine patch in a suicide attempt. Initial vital signs include heart rate 132 bpm, blood pressure 140/80 mm Hg, temperature 37°C, respiratory rate 26 bpm, and pulse oximetry 100% on room air. Physical examination is remarkable for agitation, fine resting tremor, tachycardia, and pressured speech.
The lethal dose of nicotine is estimated to range from 1 mg/kg to 10 mg/kg. Reports of nicotine toxicity have occurred with the ingestion of as little as one whole cigarette or three cigarette butts in children...
Source: The Tox Cave - March 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
In the Nalox“ZONE”
A 27-year-old woman with no past medical history presented to the ED by EMS after being found unresponsive at home by her partner. EMS reported that she was unresponsive with a GCS of 3, pinpoint pupils, and sonorous breath sounds. Naloxone 0.4 mg IV was administered, and the patient became responsive. The patient was delirious, agitated, and tachycardic upon arrival to the ED. She was administered lorazepam 2 mg IV without improvement. Her agitation and delirium were so severe that she was intubated, paralyzed with rocuronium, and started on a midazolam infusion.
What is the appropriate dose of IV naloxone?
No conse...
Source: The Tox Cave - February 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
In the Nalox“ZONE”
A 27-year-old woman with no past medical history presented to the ED by EMS after being found unresponsive at home by her partner. EMS reported that she was unresponsive with a GCS of 3, pinpoint pupils, and sonorous breath sounds. Naloxone 0.4 mg IV was administered, and the patient became responsive. The patient was delirious, agitated, and tachycardic upon arrival to the ED. She was administered lorazepam 2 mg IV without improvement. Her agitation and delirium were so severe that she was intubated, paralyzed with rocuronium, and started on a midazolam infusion.
What is the appropriate dose of IV naloxone?
No consensu...
Source: The Tox Cave - January 30, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Go For the Gold
A 44-year-old-man with a past medical history of alcohol abuse was brought to the emergency department by EMS. He was found sleeping on a bench and appeared intoxicated. His initial vital signs were temperature 90.9°F, heart rate 62 bpm, blood pressure 130/84 mm Hg, respiratory rate 16 bpm, and pulse oximetry 98% on room air. He is disheveled patient, and has a depressed level of consciousness, slurred speech, and the distinct odor of mint and urine. Pertinent lab findings include an ethanol level of 340 mg/dL.
The minty odor is tipoff in this case that he is inebriated from mouthwash. The ethanol concentration in mo...
Source: The Tox Cave - January 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Go For the Gold
A 44-year-old-man with a past medical history of alcohol abuse was brought to the emergency department by EMS. He was found sleeping on a bench and appeared intoxicated. His initial vital signs were temperature 90.9°F, heart rate 62 bpm, blood pressure 130/84 mm Hg, respiratory rate 16 bpm, and pulse oximetry 98% on room air. He is disheveled patient, and has a depressed level of consciousness, slurred speech, and the distinct odor of mint and urine. Pertinent lab findings include an ethanol level of 340 mg/dL.
The minty odor is tipoff in this case that he is inebriated from mouthwash. The ethanol concentration in mout...
Source: The Tox Cave - January 2, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
