key: cord-0033229-4bgmz5n7
authors: nan
title: 2014 ACMT Annual Scientific Meeting—March 28–30, 2014 Phoenix, AZ, USA
date: 2014-02-05
journal: J Med Toxicol
DOI: 10.1007/s13181-013-0376-x
sha: 24386f9c79437e7030e7b99220638acb6b5ff34b
doc_id: 33229
cord_uid: 4bgmz5n7

nan

prescribing of all opioids stratified by Drug Enforcement Agency (DEA) schedule and provider level of training were analyzed. Prescribing trends for five common opioids (codeine, hydrocodone, hydromorphone, morphine, and oxycodone) were individually explored. Visits were stratified into three categories by provider level of training: those that involved an attending only, a resident or midlevel provider (nurse practitioners, physician assistants). The proportion of visits for which each medication was prescribed was tabulated and trends were analyzed using surveyweighted logistic regression. Results: The weighted estimate of adult ED visits increased from 81,251,195 in 2001 to 100,027,879 in 2010 and the proportion of visits during which an opioid was prescribed by any provider increased from 10.0 to 19.0 %, p<0.001. Overall opioid prescribing increased for all visit types but was most pronounced in visits involving residents. Prescribing of schedule II agents increased more than schedule III-V agents for all groups (Table) . Hydromorphone use increased the most for all provider groups (433.4-529.9 %, p<0.001), followed by morphine (139.7-219.9 %, p<0.001) and oxycodone (94.7-142 .3 %, p<0.001). A variable effect was noted on codeine and hydrocodone prescribing among providers. Discussion: Opioid prescribing increased dramatically in the past decade in the ED, and visits involving residents had the greatest growth. Although attendings may influence resident prescribing, these trends could reflect increased emphasis on pain management in training programs. Other forces such as patient experience and accreditation requirements could be driving overall prescribing rates higher.

Conclusion: There were significant increases in opioid prescribing among visits involving all providers over time, with hydromorphone demonstrating the greatest increase among the opioids studied. Visits involving residents showed the largest change among providers. Research question: The purpose of this study is to determine whether differences in pediatric exposure rates to different buprenorphine products are stable over time.

Methods: Data from Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS®) System Poison Center Program, January 2011-March 2013, involving unintentional exposure to buprenorphine sublingual tablets or film by children aged <6 years were analyzed. To adjust for medication availability, event ratios (rates) were based on the number of patients filling prescriptions for each formulation ("Unique Recipients of a Dispensed Drug", URDD). Negative binomial regression was used to produce quarterly rates, average rates, and 95 % confidence intervals (CIs). Results: One thousand six hundred ninety-five reports were analyzed. Exposure rates for buprenorphine/naloxone combination tablets (7.0 exposures per 10,000 URDD (CI, 6.6-7.3)) exceeded those for buprenorphine monoingredient tablets (2.8 (CI, 2.4-3.2)) and combination film (0.9 (CI, 0.8-1.0)). The combination tablet and monoingredient tablet rates were significantly greater than film rates (rate ratios (RR): 7.6 (CI, 6.7-8.6; p<0.0001) for combination tablets and RR: 3.1 (CI, 2.6-3.7; p<0.0001) for monoingredient tablets compared with film). Relationships were consistent over time except for slight decreases in the monoingredient tablet rate.

Discussion: This study cannot determine whether the differences are caused by packaging or formulation. This analysis did not include generic buprenorphine/naloxone tablets, introduced in February 2013. Conclusion: The rate of unintentional exposures to buprenorphine/ naloxone sublingual film by young children is significantly less than the rate of exposure to buprenorphine/naloxone or buprenorphine monoingredient tablets. Background: Buprenorphine is sometimes diverted and abused. Previous reports showed differences in diversion and abuse rates between formulations, but observation periods were short. This study extends the comparison of diversion and abuse rates between buprenorphine sublingual formulations.

Research question: Are buprenorphine diversion and abuse rates stable over time?

Methods: Data from the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS®) System Drug Diversion (DD), Opioid Treatment (OTP), and Survey of Key Informants' Patients (SKIP) Programs were analyzed. The DD program captures new police investigations. The treatment programs (OTP and SKIP) collect patient reports of using a product "to get high" in the previous 30 days. Quarterly data from 2010Q4-2013Q1 (DD) and 2011Q2-2013Q1 (OTP/SKIP) were analyzed. To account for availability, event ratios (rates) were based on the number of patients filling prescriptions for each formulation ("Unique Recipients of a Dispensed Drug," URDD). Quarterly rates, average rates, and 95 % confidence intervals (CIs) were calculated using negative binomial regression. Results: One thousand five hundred five diversion reports and 5,293 abuse reports were analyzed. Average diversion rates for buprenorphine/ naloxone tablets (13.6 reports/10,000 URDD; CI, 12.8-14.5) and monoingredient tablets (8.7; CI, 7.6-9.8) exceeded the combination film rate (1.3; CI, 1.1-1.5) (rate ratio (RR) c/w film: 10.6 (CI, 9.0-12.4; p<0.0001) for combination tablets and 6.7 (CI, 5.5-8.2; p<0.0001) for monoingredient tablets). Average abuse rates for buprenorphine monoingredient tablets (61.8 reports/10,000 URDD; CI, 59.2-64.6) and buprenorphine/naloxone tablets (21.3; CI, 20.3-22.3) exceeded the combination film rate (9.1; CI, 8.7-9.6) (RR c/w film: 6.8 (CI, 6.3-7.3; p<0.0001) for monoingredient tablets and 2.3 (CI, 2.2-2.5; p<0.0001) for combination tablets).

Discussion: This analysis excludes generic buprenorphine/naloxone tablets, introduced in February 2013. Conclusion: Diversion and abuse rates for buprenorphine and buprenorphine/naloxone tablets consistently exceed those of buprenorphine/naloxone sublingual film.

Rasimas JJ Penn State College of Medicine, Hershey, PA, USA

Background: Ketamine has been associated with psychotomimesis, dissociation, and addiction. It is also used as a rapid-acting antidepressant at doses and infusion rates lower than those for anesthesia. Hypothesis: Ketamine for treatment of depression may cause adverse psychosomatic effects, mental illness may confer greater risk. Methods: Three concurrent prospective studies enrolled patients in openlabel (unipolar depressives (UPs)) and placebo-controlled (UPs and bipolar depressives (BPs)) trials to receive single-dose ketamine 0.5 mg/kg IV over 40 min. Serious medical conditions were exclusionary. No CNSactive agents were permitted for 18 days before infusion. Brief Psychiatric Rating Scale (BPRS) and Clinician-Administered Dissociative States Scale (CADSS) were employed to measure symptoms. Fisher's exact test compared groups regarding SAEs. ANOVAs analyzed symptom data with repeated measures from baseline to 24 h post-infusion. Results: Forty-one patients (29 UPs, 12 BPs) and 50 controls were treated from September 2011 to September 2013. One UP experienced profound sedation with a Riker score of 2, she recovered fully within 2 h. Another UP suffered cocaine relapse 22 days post-infusion. One BP had severe vomiting. Four subjects (two UP, one BP, and one control) experienced acute psychiatric reactions ("K-holes") with varying degrees of anxiety, fear, violent ideation, dissociation, and aphasia-one UP failed to return to pre-infusion symptom intensity at 190 min post-infusion. Patients reported more anxiety than controls at baseline, it decreased following infusion. Dissociation, substantial in all groups, was greater in BPs vs. UPs vs. controls. On measures of agitation, grandiosity, delusions, and disorientation, patients did not differ from controls. Most measures peaked at infusion end or within 40 min. Increases in thought disorder, odd behavior, excitement, hallucinosis, and dissociation were greater in open-label vs. blinded subjects. History of substance abuse, PTSD, or trauma did not correlate with study measures. Baseline data did not predict SAEs. Discussion: Due to thought disorder and aphasia, some patients were unratable and most were symptomatic.

Conclusion: Most subjects tolerate 0.5 mg/kg ketamine infusion over 40 min, although dissociation, thought disorder, and aphasia are common.

Major adverse reactions are more likely (p=0.043) in mood disorder patients, but not predicted by any demographic or clinical measure studied. Background: Calcium channel antagonist-induced shock remains a significant treatment challenge. Nifedipine, a dihydropyridine calcium channel antagonist, has a proposed mechanism of vasodilatation through increased nitric oxide (NO) production. Methylene blue (MB) inhibits NO production by inhibiting the activity of soluble guanylyl cyclase, thus may be useful to reverse hypotension associated with nifedipine toxicity. Methylene blue has not been studied as an antidote for nifedipine toxicity. Hypothesis: Methylene blue will improve survival following nifedipine intoxication in a swine model. Methods: This Institutional Animal Care and Use Committee-approved study used 24 swine that were sedated with alpha-chloralose, mechanically ventilated, and instrumented for drug delivery and hemodynamic measures. After stabilization and basal measures, nifedipine (0.01875 mg/kg/min) was infused until toxicity, defined as a reduction in product of cardiac output and mean arterial pressure of 20 %, was reached. Animals received a bolus of 20 mL/kg 0.9 % normal saline once toxicity occurred immediately followed by equal volume amounts of either normal saline as a sham treatment, MB (1 mg/kg as a bolus and subsequent infusion), epinephrine (0.1 μg/kg/min), or MB and epinephrine. All treatments were continued for 5 h after the initiation of toxicity or until death occurred. Hemodynamics was monitored throughout the study. Surviving animals were euthanized. Survival data was analyzed using the Student's t test.

Results: Nifedipine toxicity was characterized by vasodilatory hypotension, impaired contractility, and tachycardia with terminal bradycardia. The mean time to death after reaching toxicity was 232±67.5 min. There was no statistically significant change in survival in animals treated with MB, epinephrine, or MB plus epinephrine (Table) . Discussion: We observed no survival treatment effect with MB even in combination with epinephrine. Potential limitations of this experiment include: excessive severity of toxicity, insufficient dose of MB, untreated direct cardiac stress from prolonged compensatory tachycardia, and NO/ soluble guanylyl cyclase may play a minor role in nifedipine-induced hypotension.

Conclusion: Methylene blue demonstrated no improvement in survival of swine with nifedipine-induced toxicity. Further studies are needed to elucidate the value of MB in treating calcium channel antagonistinduced shock. The number of subjects with serious adverse events [SAEs] is listed in raw numbers in brackets under the total number of subjects in each group, while all other entries represent means (and 25/75 % interquartile ranges) for each subject group for the given measure, whose whole number Likert-based intensity ranges are listed in each column header. * p<0.05, significant differences based upon psychiatric illness category # p<0.05, significant differences across time points § p<0.05, significant differences on the basis of blinding status as compared to subjects in same illness category

The number of subjects with serious adverse events [SAEs] is listed in raw numbers in brackets under the total number of subjects in each group, while all other entries represent means (and 25/75 % interquartile ranges) for each subject group for the given measure, whose whole-number Likert-based intensity ranges are listed in each column header. * p<0.05, significant differences based upon psychiatric illness category # p<0.05, significant differences across time points § p<0.05, significant differences on the basis of blinding status as compared to subjects in same illness category Background: Therapeutic hypothermia improves neurologic recovery in cardiac arrest patients who regain spontaneous circulation. The incidence and outcome of patients who undergo therapeutic hypothermia after cardiac arrest associated with a toxic exposure is unknown.

Research question: This study describe the incidence, epidemiologic characteristics, and outcomes of patients who suffer cardiac arrest associated with toxic exposure that are treated with therapeutic hypothermia.

Methods: This is a retrospective review of a postcardiac arrest database and medical records of all patients registered to receive therapeutic hypothermia via our institution's clinical pathway between November 2007 and February 2013. The database includes prospectively collected clinical data utilizing Utstein criteria and the Cerebral Performance Categories (CPC) Scale. All patients were treated in an evidence-based clinical pathway that included therapeutic cooling. The database and each patient's medical record was systematically reviewed independently by two physician investigators to determine a toxic versus nontoxic cardiac arrest with toxic defined as a xenobiotic that directly and immediately caused the patient's cardiac arrest. Causality was determined by consensus of two of three investigators. Groups were compared using Fisher's exact test.

Results: Three hundred eighty-nine patients underwent treatment during the study period and 48 of 389 (12 %) were deemed toxic arrests. Patients who suffered toxic arrests were slightly younger, less likely to have an initial shockable rhythm, and less likely to receive bystander CPR as compared to nontoxic cases (see table) . The most common xenobiotics included cocaine (n=16), benzodiazepines (n=13), and opioids (n=9). Within the toxic subset, an initial shockable rhythm was associated with greater survival rate (11/16) than a nonshockable rhythm (9/31; p=0.01). Discussion: Toxic patients treated with therapeutic hypothermia had similar survival and neurologic function compared to nontoxic causes. Limitations to our study include accuracy of assigning causality, incomplete confirmation of exposures, relatively small patient population, CPC scores extrapolated from medical records, and inability to control for potentially confounding co-morbid conditions. Conclusion: Toxin-associated cardiac arrests accounted for a significant proportion of patients in this study. Additional, larger studies may help to elucidate the optimal role for therapeutic hypothermia in toxin-induced cardiac arrest. Discussion: These data suggest that patients with anticholinergic toxicity are more likely to receive benzodiazepines than physostigmine (32.1 vs 13.1 %) as monotherapy, and a significant number of these patients did not receive treatment for their toxidrome. The use of physostigmine was not correlated with intubation rates or rhabdomyolysis though numbers were small. Conclusion: We find it interesting that physostigmine was infrequently used as treatment by toxicologists, given its recommendation for use in anticholinergic toxicity.

St-Onge M 1 , Dube PA 2 , Gosselin S 3 , Guimont C 4 , Godwin J 1 , Blais R 3 , et al. Background: Several drugs known to mimic brain death in overdose have led to confused prognoses and unintended harm. We present three cases of fatal opioid poisoning that would have delayed pronouncement of death via standard means undermining organ donation but for the addition of a cerebral perfusion study (CPS). Hypothesis: Relying on prerequisite findings in brain death (coma, absent brainstem reflexes, and apnea) have limited predictive value and the potential for catastrophic harm (premature organ donation) in drug overdose while pending drug concentrations cause harm by delay, in these cases CPS can ultimately hasten diagnosis.

Methods: A review of consult service records was performed and all patients on whom a CPS was performed in order to facilitate determination of brain death were included. Results: Three patients with accidental opioid exposure, an 8-month-old boy, a 16-year-old girl and a 28-year-old male heroin addict, were found comatose and with respiratory failure. Two had arrested prior to hospitalization. All had severe anoxic injury and deteriorated over 24-48 h becoming increasingly difficult to support. Formal brain-death exams in each demonstrated absent electrical activity on electroencephalogram, lack of response to ventilatory drive (PCO 2 , hypoxia) and absent brain stem reflexes; however, families were hesitant to allow organ procurement until they were reassured drug intoxication was not blunting response during the death exam. In each patient, a CPS demonstrated a lack of perfusion ultimately facilitating brain death diagnosis and organ donation. Discussion: The medical literature includes reports where various types of drug overdose mimicked brain death. State criteria for determining brain death typically include a formal neurologic exam, lack of patient response to ventilatory drive off sedation (i.e., 15 mmHg increases in PCO 2 ) and optional EEG. Additionally, in overdoses, it is suggested brain death not be diagnosed until toxic drug concentrations are absent. Determining drug concentrations however often take significant time potentially undermining continued stability compromising procurement of viable organs for transplantation in applicable cases.

Conclusion: Cerebral perfusion study may provide us with a more efficient way to ascertain patient death in overdose victims when drug toxicity mimics brain death. Altered mental status, vomiting, hyperpnea, tachypnea, and bradypnea should prompt a search for cyanide toxicity (using serum lactate >8 mmol/L as a marker) and carbon monoxide exposure. The presence of other, mild symptoms (e.g., headache, nausea, dizziness, and weakness) without vital sign abnormalities is unlikely to indicate clinically significant cyanide toxicity, and should not result in antidotal therapy, or specific laboratory evaluation; however, carbon monoxide toxicity should be considered in these patients.

We propose a diagnostic algorithm that delineates evaluation and treatment indications for patients who range from minimally symptomatic to critically ill after potential cyanide exposure via smoke inhalation.

Bosak AB, Ruha AM Banner Good Samaritan Medical Center, Phoenix, AZ, USA Background: North American rattlesnake envenomations typically result in local tissue injury and hematotoxicity. Neurotoxicity is uncommon and most often associated with bites by the Mojave rattlesnake, Crotalus scutulatus. Neurotoxicity following bites by the Sidewinder rattlesnake, Crotalus cerastes, has not been reported.

Hypothesis: This is the first reported case of a Sidewinder envenomation resulting in neurotoxicity.

Methods: This is a case report of a 56-year-old man who was bitten on the right foot through a leather boot by a snake he described as having horns and exhibiting sideways movement. Two independent herpetologists confirmed the species to be C. cerastes by photo. The patient developed painful right-sided paresthesias and weakness progressing from the toes to the distal thigh. Physical exam 3 h after the bite revealed ecchymosis at the bite site, decreased sensation in the right foot, mild weakness of the leg, and pronounced fasciculations of the anterior thigh musculature. Fasciculations progressed to involuntary contractions of the large muscles of the thigh. Laboratory studies revealed normal platelets, protime, fibrinogen, CPK, and electrolytes throughout hospitalization. Antivenom was withheld based on unclear benefit for treatment of neurotoxicity. Over the next 48-72 h, symptoms progressed to include right arm, bilateral ptosis, and respiratory muscle weakness with three consecutive worsening negative inspiratory force measurements. Respiratory failure did not occur. He was anorexic and unable to walk independently. On day 5, he had improved enough to ambulate with a walker and was discharged. On 10-day follow-up, he reported continued but improved paresthesias, right-sided weakness, atypical chest pain, poor appetite, and new abdominal cramping. The patient was lost to follow up. Results: The patient developed prolonged neurotoxicity without hematotoxicity or significant local tissue injury. Discussion: C. cerastes has not previously been implicated in the development of neurotoxic venom effects. Conclusion: Neurotoxicity may develop following bites by the Sidewinder rattlesnake. It is unknown whether such effects would be prevented or reversed with antivenom. Methods: This is a single-patient chart review. A 57-year-old woman presented to a level 1 trauma center with a self-inflicted stab wound to her left chest. Imaging revealed a pneumothorax, which was treated with tube thoracostomy. Ten hours later, the patient became unresponsive. Arterial blood gas showed a pH of 7.4, PaCO 2 of 35, and PaO2 of 88 mmHg. The patient was intubated, and 10 min later became systolic. She was treated with chest compressions, epinephrine, and sodium bicarbonate, leading to ventricular tachycardia. Return of spontaneous circulation was achieved with defibrillation. Post arrest, venous blood gas revealed a pH of 7.18 and PaCO 2 of 73 mmHg. Labs sent at the time of the arrest were significant for a serum aspirin level of 100 mg/dL. Hemodialysis was indicated for treatment of the salicylate overdose; however, concerns arose regarding dialysis catheter placement and temperature maintenance during active cooling. After discussions with toxicology, hemodialysis was initiated. The patient improved and was discharged to inpatient psychiatry on hospital day 46. Results: The patient was actively cooled to goal temperature within 3 h of initiating the hypothermic protocol despite placement of the dialysis catheter and preparing to start hemodialysis. Background: Ondansetron, a centrally acting 5-HT3 receptor antagonist when used for preventing emesis, has a well-established safety profile. Large, pediatric symptomatic ingestions have not been well described. Hypothesis: Ondansetron-mediated 5-HT3 antagonism may cause severe toxicity in massive overdose.

Methods: This is a case report. The hospital consulted the regional poison center. Clinical course and laboratory data were obtained as a result of this consultation.

Results: A previously healthy 2-year-old female presented after suspected consumption of 58 (36 mg/kg) ondansetron 8 mg oral dissolving tablets (ODT) out a bottle of 60. Only two tablets were found. Within 1 h of ingestion, the child demonstrated difficulty ambulating, nystagmus, tremors, and sleepiness. At the initial healthcare facility, the patient had emesis and worsening CNS depression, requiring intubation and mechanical ventilation. Heart rate was 152 and blood pressure was 138/87 (lowest at 80/38). EKG showed sinus tachycardia with QTC prolongation of 507 ms. Exam was significant for myoclonic jerks with unequal but reactive pupils. Laboratory evaluation and head CT scan were normal. On the following day, the patient became more responsive, and the QTC prolongation resolved with her recovering without sequelae. Discussion: By history, this patient ingested a massive overdose. Ondansetron has a well-described safety profile with a large therapeutic margin. In the USA, ondansetron ODT is typically dispensed in blister packs. Because of hyperemesis gravidarum, the child's mother obtained a bottle of 60 ondansetron ODT without blister pack packaging from a foreign pharmacy. The ODT formulation has a flavoring agent in the tablet making them palatable to children. The mechanism of toxicity is uncertain but has been attributed to increase of synaptic serotonin concentrations as a result of 5-HT3 receptor antagonism and decreased receptor selectivity. Ondansetron may also be a weak antagonist of 5-HT1A, 5-HT1B, and α1-adrenergic receptors.

Conclusion: Because of flavoring and rapid oral dissolution, ondansetron ODT can be attractive to children and result in severe consequences. Appropriate packaging such as blister packs may deter children from significant ingestion. In our patient, toxicity manifested as CNS depression requiring intubation, QTc prolongation, hypotension, and symptoms of serotonin excess. Methods: This is an institutional review board-approved observational study of four emergency department patients receiving parenteral opioids. Exclusion criteria were as follows: age <18 or >90, pregnancy, traumarelated chief complaint, upper extremity amputation, and inability to consent. After enrollment, patients were asked about prior opioid exposure, home medications, and dominant handedness. The patient's electronic medical record was also evaluated for history of opioid prescriptions or use. A portable biosensor (Q sensor, Affectiva) was placed on the inner wrist of each subject, which continuously measured electrodermal activity (EDA), skin temperature, and locomotion. Data were continuously recorded for 5 min prior to opioid administration, during administration, and for 30 min after administration. Data were analyzed for overall trends in biometric parameters following administration.

Results: Individual results are presented in the table.

Discussion: In this pilot study, opioid injection was associated with a rise in EDA. Previous opioid use seemed to be associated with a blunted response. In one patient, apparent drug-seeking behavior correlated with lack of change in EDA. Laterality seemed to be an important factor, as magnitude of response varied between dominant and nondominant wrists. Biometric changes should be further explored as a marker of opioid use in various clinical scenarios. Limitations: Larger application across varying ages, demographics, and range of opioid tolerance will be required to further delineate the expected biometric parameter changes. Conclusion: Changes in EDA occur with administration of opioids, may vary depending on opioid use history, and can be easily measured by portable biosensors. Introduction: Pregabalin, gabapentin and baclofen produce central nervous system effects by interaction with gamma-aminobutyric acid (GABA) and/or GABA receptors. There has been interest in internet discussion fora and in recent anecdotal reports to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) of pregabalin misuse. Baclofen is used in the treatment of GHB withdrawal and there are reports of users buying baclofen off the internet to self-treat withdrawal. There is no data on the prevalence of misuse of these drugs. The aim of this survey was to investigate misuse of these drugs in a clubbing cohort that have previously been shown to have a high prevalence of use of recreational drugs. Methods: We surveyed adults attending nightclubs catering for men who have sex with men (MSM) in South London in June 2013. Basic demographic data (age, sex, whether they had sex with men, women or both), together with data on whether individuals had heard of pregabalin, gabapentin and baclofen and if so, whether they had ever misused them were collected. Participants were classified MSM if they were male and had sex with men or both men and women. The results suggest that there is misuse of pregabalin, gabapentin and baclofen in a small, but significant proportion of this high drug-using MSM population. Further work is required to determine whether this is more widespread and to further understand the routes of supply and motivations for use so that appropriate preventive strategies can be implemented. Results: The patient was treated with brominodine, metoprolol, mannitol, solumedrol, and homatropine. Her IOP improved to 21 mmHg OS and 22 mmHg OD prior to discharge 24 h later. Discussion: Our patient experienced BAACG secondary to her use of oncedaily Qsymia, which contains 3.75 mg of phentermine and 23 mg of topiramate. While BAACG has been described in relation to topiramate in the ophthalmology literature, to our knowledge, it has not been described for Qysmia or in the toxicology literature. The mechanism of the development of BAACG from topiramate is hypothesized to be a uveal effusion leading to anterior displacement of the lens-iris diaphragm, resulting in miopization and reduction of anterior chamber depth. Phentermine has not been reported to cause BAACG. Our patient was instructed to discontinue the Qsymia.

Conclusion: This case report highlights the potential of a new FDAapproved weight loss medication Qsymia to cause bilateral acute angle closure glaucoma.

Chenoweth JA 1,2 , Radke JB 1,2 , Ford JB 1 , Sutter ME 1 , Albertson TE Methods: This is a single-patient chart review. An 8-month-old female was sleeping on her grandmother's chest when she suddenly lost postural tone. She was noted to be apneic with perioral cyanosis. Following a blind finger sweep, mouth to mouth resuscitation was performed. On arrival at a local hospital, she was noted to have agonal respirations and decreased muscle tone so she was intubated. On exam, she was noted to have pinpoint pupils and when her grandmother looked for the 75 μg/h fentanyl patch she had been wearing on her chest, she was unable to find it. The patient was given a trial of naloxone (0.05 mg) with return or muscle tone and pupillary response. After 2 h, she once again was noted to have decreased muscle tone and pinpoint pupils which again responded to naloxone (0.086 mg). A pediatric gastroenterologist was consulted and endoscopy was performed to attempt fentanyl patch retrieval.

Results: A single 75 μg fentanyl patch was retrieved from the esophagus resulting in gradual resolution of opioid toxicity. Discussion: The amount of fentanyl contained in a single trans-dermal patch can cause significant morbidity and mortality. In our case, we calculated a total of 12.375 mg of fentanyl was contained in a single 75 μg patch. Ingestion of the patch can result in prolonged opioid toxicity. Treatment with naloxone can dramatically reduce the respiratory, neurologic, and gastrointestinal effects of fentanyl, but enhanced elimination techniques could also be considered. Endoscopic removal can be attempted, particularly in younger patients where the patch may become entrapped in the esophagus or stomach. In patients older than 9 months, whole bowel irrigation could also be considered. Conclusion: Endoscopic retrieval is an effect means of removing ingested sustained release patches in infants.

Connors NC, Nelson LS New York University School of Medicine, New York, NY, USA Background: Opioid intoxication is an increasingly common reason for an emergency department visit. Naloxone, a competitive mu-opioid receptor antagonist, can be used judiciously to reverse hypoventilation, but in excess, can precipitate opioid withdrawal syndrome (OWS) in opioiddependent patients. The optimal dose of naloxone remains controversial, particularly in this latter group.

Research question: What naloxone dose do authoritative sources recommend to treat opioid-induced hypoventilation?

Methods: A convenience sample of textbooks, study guides, and internet resources published within the last 10 years in the fields of emergency medicine (EM; four), anesthesiology (four), medical toxicology (MT; four), pediatrics (two), internal medicine (IM; two), and general medicine (ACLS, pharmacology reference, and internet resources; six) were reviewed for their recommended naloxone initial dosing, dose range, and titration protocol for opioid toxicity.

Results: Twenty-two resources were identified that provided a naloxone dose recommendation. Of these, 12/22 (55 %) recommended an initial dose of 0.04 or 0.05 mg IV and 9/22 (41 %) suggested 0.4 or 0.5 mg IV. The maximum dose by titration recommended by source was 2 mg in six, 10 mg in eight, and 20 mg in two. No trend towards lower recommended dosage was noted based on year of publication (R 2 =0.012). An initial dosage less than 0.1 mg recommended by source was 3/4 MT, 3/4 anesthesia, 4/6 general medicine, and 2/4 EM. No IM or pediatric sources recommended an initial dose less than 0.4 mg. Discussion: Low-dose naloxone is highly effective in reversing ventilatory depression, and though it is slower in onset than higher doses, OWS is less concerning. The increase in chronic opioid therapy for pain and an increase prevalence of opioid abuse raises the likelihood of OWS following naloxone. Recent data suggests an initial naloxone dose of 0.04 mg IV is preferred. Lumex measurements in the patient's room were 2.6 μg/mm 3 . The patient used facial cream daily for 6 weeks and stopped 1 month prior to the first Hg level. Treatment included a full course of succimer. Hypertension was managed with diltiazem. Sleep and pain were managed with amitriptyline. Fasciculations, back pain, insomnia were present at 3 months. At 6 months follow-up, he had rejoined his soccer team but continued on diltiazem for persistent hypertension and tachycardia. Discussion: It is important to obtain a full medication history in adolescents using various acne treatments. Hg poisoning in pediatric patients is most commonly confused with pheochromocytoma and Kawasaki's disease. Patients presenting with similar symptoms yet an incomplete picture should prompt an evaluation for Hg poisoning. Conclusion: Determination of Hg toxicity may be challenging. Awareness of acne treatment facial products may prompt an early diagnosis of Hg poisoning. This case demonstrates collaboration between local and state health departments and a toxicology service.

Diaz JH LSU Schools of Medicine and Public Health, New Orleans, LA, USA Background: Popular survivor television programs feature outdoorsmen recommending that novices survive wilderness experiences by consuming edible raw animals and plants.

Research Question: Do survivor copycat behaviors result in potentially fatal food-borne infections and poisonings? Methods: In case series analyses, internet searches identified poisonings and infections following consumption of raw plants and animals with poisonings confirmed by positive chromatography and infections defined by positive microscopic, serologic, or molecular diagnostics. Statistical significance was defined by p values ≤0.05 with continuous variables analyzed by t tests and categorical variables by chi-squares (Χ 2 ). Results: Thirty-eight cases of neuroangiostrongyliasis (NAS) with eosinophilic meningoencephalitis and 16 cases of paragonimiasis (PG) with hemorrhagic pneumonitis followed consumption of raw animals infected with causative parasites, rat lungworms (Angiostrongylus cantonensis), and American lung flukes (Paragonimus kellicotti), respectively. The mean age of NAS cases was 21.5 years, mostly males (P=0.039, Χ 2 ) from Hawaii (P=0.039, Χ 2 ) who consumed raw snails or frogs (P=0.003, Χ 2 ). The mean age of the PG patients was 27.3 years with one death, mostly males from Missouri (P<0.0001, Χ 2 ) who consumed raw crayfish (P<0.0001, Χ 2 ) while intoxicated (P=0.028, Χ 2 ). Six cases of plant poisonings were reported in five males with mean age of 26.4 years and one female (age 14). Four plant poisonings with three fatalities followed consumption of water hemlock (Cicuta maculata). Two fatalities followed consumption of poison hemlock (Conium maculatum). In fatal plant poisonings, hemlocks were misidentified as either wild carrot or ginseng. There were more infections then poisonings, but plant poisonings caused more fatalities than parasitic infections (P<0.0001, Χ 2 ). Discussion: Risk factors for infectious diseases from survivor copycat behaviors included male gender and consumption of raw animals while intoxicated outdoors. Risk factors for plant poisonings from survivor copycat behaviors included male gender and misidentification of poisonous plants as nonpoisonous. Recommended preventive interventions included proper preparation of self-harvested natural foods, wilderness survival training, and alcohol avoidance. Conclusion: Survivor copycat behaviors resulted in significant risks for parasitic infections and fatal plant poisonings in young males consuming raw animals and plants during outdoor experiences when intoxicated.

Dissanayake Table for individual metals). Exclusion criteria were less than 18 years of age or age range not recorded. Additionally, acute iron exposures were excluded. The following data were collected: demographics, source of referral, reported signs or symptoms, and therapy provided.

Results: Fifty-four adult patients were identified. Of these, 55.5 % of patients were male, with an average age of 52 (SD, 16.2). Reasons for referral were predominantly interpretation of prior lab data (31, 57.4 %), unintentional nonpharmaceutical exposures (17, 31.5 %), and organ dysfunction (7, 13 %). The most common exposures were cobalt (21, 38.9 %), chromium, and mercury (13, 24.1 % each). Fifteen patients reported exposures to more than one metal. Thirtyseven (68.5 %) patients had symptoms reported. The most frequent were numbness/paresthesias (eight, 21.6 %), rash (four, 10.8 %), nausea/vomiting (two, 5.4 %), peripheral neuropathy (two, 5.4 %), and hemolysis (two, 5.4 %). Only six patients (11.1 %) were judged to have symptoms most likely related to a toxicological exposure. Eight patients (14.8 %) received toxicological treatment, including four of the six patients with symptoms likely related to a toxicological exposure. Three patients received chelation with succimer, while one also received vitamin C, and another received dimercaprol, gastric lavage, whole bowel irrigation, and intravenous fluids.

The fourth was treated with intravenous fluids.

Conclusion: This review of database information on adult patients presenting to a medical toxicologist for evaluation of heavy metal exposure finds that these patients are more often men referred by a primary care doctor or other outpatient physician. The most common exposures were cobalt, chromium, and mercury. Limitations include reliance on providers to enter information, resultant incomplete data entry, or potential reporting bias towards more unusual cases. Background: Acetaminophen overdose is a commonly reported overdose in the USA. There are multiple opioid-acetaminophen combination medications on the market. The percentage of people with acute liver failure associated with unintentional acetaminophen overdose is increasing. Patients may be unaware that acetaminophen is contained in certain prescription medications. Study objectives: Our study will assess if patients in the emergency department are aware that acetaminophen is contained in Percocet®. It will also evaluate if educating patients about their prescribed medication will increase their knowledge that Percocet contains acetaminophen. Materials and measure: We performed a prospective randomized study on patients ages 19 years and older, who presented to the Emergency Department Fast Track, and were being discharged with an outpatient prescription for Percocet (or its generic equivalent). Upon discharge, patients in both the control and intervention groups were given a questionnaire to complete. Prior to answering the questionnaire, the intervention group was read a script with information about Percocet and acetaminophen. A percentage of patients were contacted after their encounter for a repeat phone questionnaire.

Results: A total of 55 patients were enrolled. The intervention group answered significantly more correct questions than the control group. A majority of patients in the control group were unaware that Percocet contains acetaminophen. At a 4-month follow-up, patient scores in the intervention group decreased while those in the control group increased. Results: Five hundred fifty-seven patients were recorded as given naloxone during the study period. Sixty-eight (12.2 %) of the patients were 18 years and younger; of these, 14 (2.5 %) were <2 years, 17 (3.1 %) were 2-6 years, 4 (0.7 %) were 7-12 years, and 33 (5.7 %) were 13-18 years. The number of males were greater than females in all groups except the 7to 12-year group (males=females). For ages <2, 2-6, and 7-12 years, unintentional pharmacologic exposure was associated with receiving naloxone in 85.7, 88.2, and 50 % of cases, respectively. Patients of 13-18 years had 0.0 % unintentional pharmacologic exposures. Patients received naloxone for coma and/or respiratory depression in 78.6 % for the <2-year group, 76.5 % in the 2-to 6-year group, 100 % in the 7-to 12year group, and 60.6 % in the 13-to 18-year group. The proportion of xenobiotics associated with naloxone administration in each age group was calculated. The most common xenobiotics associated with naloxone administration were buprenorphine (17.7 %), oxycodone (13.2 %), and clonidine (11.8 %). Discussion: The prescription opioid abuse epidemic results in increased availability of opioids in the home. The ToxIC database shows that naloxone use in children is mostly due to unintentional pharmacologic exposures which support this. The most common xenobiotic implicated was buprenorphine.

Conclusion: According to the ToxIC database, the most common cause for naloxone administration in the pediatric population was unintentional pharmacologic exposure. , followed by unintentional pharmaceutical exposure (10 %), and withdrawal (9 %). The most common classes of agents consumed were non-opioid analgesics (31 %), sedativehypnotics/muscle relaxants (18 %), opioids (17 %), anticonvulsants (10 %), and antidepressants (10 %). Acetaminophen was ingested in 25 % of all cases. Thirty-seven percent of cases involved exposure to multiple drugs and 32 % involved exposure to more than one drug class. Seventy-nine patients (77 %) were symptomatic. Twenty-nine percent manifested a specific toxidrome, with sedative hypnotic being the most common (13 %), followed by toxidrome withdrawal (5 %), mostly from opioids. Central nervous system depression was present in 17 % of cases (71 % of whom involved sedative hypnotic/muscle relaxants). Tachycardia was present in 15 % of the cases; 6 % developed acetaminopheninduced hepatotoxicity. The most common antidotes administered were N-acetylcysteine (20 %), sodium bicarbonate (9 %), flumazenil (4 %), and physostigmine (4 %). All six patients with carbon monoxide therapy underwent hyperbaric oxygen therapy. Twenty-three percent of women did not receive any treatment, despite the fact that 42 % of them were symptomatic. Discussion: Most pregnant women presenting to hospital with acute poisoning were engaged in self-harm or suicidal behavior, and the majority were symptomatic. As roughly half of untreated pregnant women were symptomatic, prospective studies should explore whether pregnant patients are treated less aggressively than their nonpregnant counterparts and pregnancy outcomes. Conclusion: Most acute poisoning cases in pregnant women are intentional (self-harm) and symptomatic. Methods: This is a single-patient chart review of a 13-month-old female with no past medical history who presented to a hospital after ingesting Tylenol extra strength. The 4 h acetaminophen level was 343 μg/mL and she was started on IV NAC. Twelve hours later, she developed a tonicclonic seizure with sodium at that time measuring 124 mEq/l, a decrease from 142 mEq/l at the time of admission. She was treated with hypertonic saline, lorazepam, levetiracetam, and had no further seizures. A brain MRI and EEG were normal. Results: The EMR ordering system did not allow for volume adjustment of NAC for a young child. The NAC dose was correct; however, the diluent volume was a standard amount for an adult but not an 8 kg child, the first bag contained 150 mg/kg of NAC in 200 mL of D5W, the second contained 50 mg/kg in 500 mL of D5W, and the third contained 100 mg/kg in 1,000 mL of D5W (with total of 900 mL given at the time of seizure). Discussion: Because the 21-h IV NAC administration involves preparation of three different bags, an order set was developed to reduce ordering errors. With the exception of patient's weight, no other aspect of this order set was adjustable (including diluent choice or volume of preparation).

These preset values caused the pharmacist to prepare a solution that contained too much free water, decreasing patient's intravascular sodium and resulting in a seizure. Conclusions: Phenobarbital appears to be a safe and effective alternative to benzodiazepines for the treatment of alcohol withdrawal in noncritically ill patients and may be benzodiazepine sparing. She was started on CVVHD. An Impella® LD device and intravenous pacemaker were placed. MAP increased from 60 to 75 mmHg. EGD was done 16 h post-ingestion and revealed a large load of pill fragments (picture), which were suctioned and removed. Twenty hours after ingestion, her cardiac output decreased to only that provided by the Impella® device. Five days after admission, the Impella® device was weaned, but the patient was unable to be oxygenated and was placed on extracorporeal membrane oxygenation (ECMO) for ARDS. ECMO was used for 2 days to support her oxygenation. Beta blockade effects appeared to resolve 5 days into her hospitalization. Vasopressors and mechanical ventilation were weaned by days 7 and 11, respectively. Full renal function and good recovery were complete in 30 days. Discussion: Atenolol is almost entirely renally excreted. We present levels demonstrating removal with CVVHD. This is the first case reported of using the Impella® device for this overdose. This is the first report of EGD decontamination of atenolol overdose. The large pill fragments burden found and removed from this patient at 16 h after ingestion is somewhat surprising. Methods: This is a consecutive-patient case series of five girls aged 7-11 transferred from an outside facility for specialty burn center evaluation. Symptoms developed 24 h after playing with limes and lemons near a backyard swimming pool. Results: The girls had skin findings of large flaccid bullae on an erythematous base over sun-exposed areas, not following any dermatomal distribution. Initially, parents were questioned regarding possible pool chemical exposure and abuse. Two girls required admission to the intensive care burn unit, one was admitted to the floor and two were discharged from the emergency department. Initial treatment for patients 1-3 included pain control with intravenous opioids, use of bacitracin ointment, and non-adherent Xeroform® and Adaptic® dressings. Clobetasol ointment was started on hospital day 2 on patients 1-3 and applied during dressing changes. Procedural sedation was required for dressing changes and debridement for patients 1, 2, and 3. Patients 4 and 5 were discharged home with bacitracin ointment and Xeroform® dressings. Following discharge, return visits were required for dressing changes in all five patients. Over the next 3 weeks, erythematous areas gradually became hyperpigmented. Plant specimens were identified by local botanists as Key Lime (Citrus aurantifolia) and Lisbon Lemon (Citrus limon). Discussion: Few phytophotodermatitis outbreaks demonstrate such severity in multiple pediatric patients, requiring transfer to a burn center for management. Optimal management of severe psoralen toxicity is not well established. In these cases, supportive care and topical steroids were used with good result. Oral steroids and silver impregnated dressings may also be considered. Conclusion: Psoralen phytophotodermatitis diagnosis requires a high index of suspicion and may be initially misdiagnosed as herpes zoster, lymphangitis, chemical burns, poison oak, or jellyfish envenomation. Although potential abuse or pool chemical burns were considered in these cases, it became clear that the lesions were actually due to citrus exposure. Discussion: Over the past several years, URMC has evolved its TCS to a point where significant income is being generated through inpatient and outpatient consultation, as well as clinic visits. However, it should be noted that at our institution this work has been conducted by a single toxicologist who has committed significant time and effort towards success. Conclusion: A TCS can be supported financially with the appropriate support and structure. This service, when optimally operated can be of great benefit to patients, the community, as well as its associated medical center. Methods: This is a case series of incidents wherein laboratory workers were inappropriately exposed to a chemical hazard. The consultation logs of our academic toxicology service from April 8, 2008 to October 3, 2013 were reviewed to compile a list of these cases, which were then crossreferenced with our electronic medical record. We collected variables regarding the characteristics of each incident (e.g. the name of the chemical, the safety equipment used, and medical outcome on followup). These variables were then used to construct a Haddon matrix (Table 1) . Results: Six different cases were identified, routes of exposure ranged from inhalation to ocular. Time of exposure ranged from seconds to 60 min, symptoms ranged from irritation to chest discomfort. The majority took place without the use of PPE, although two incidents happened despite use of safety equipment. There were no known long-term sequelae of these exposures. Discussion: The utility of Haddon matrices is to analyze hazardous circumstances to determine prevention and mitigation strategies for future implementation. Examination of the Haddon matrices constructed from each of these cases yields common areas amenable to intervention: lack of personal protective equipment, improper storage conditions, lack of worker vigilance, improper spill containment/area clean-up, incongruous risk perception, incomplete adherence to existing safety practices, inadequate initial decontamination prior to ED arrival, and lack of witnesses during the exposure. Conclusion: This data will be used to improve education materials and instruction for students in laboratory research and to support a culture of safety and prevention in our university laboratories. • Improper spill containment resulting in potential future exposure • No oversight within office to monitor injury Mexico entered a total of 235 cases involving 43 agents. One hundred ninety-six (83 %) patients presented with clinical signs of toxicity, while 39 were asymptomatic. The most common clinical presentations were confusion, CNS and respiratory depression, agitation/delirium, or anticholinergic toxidrome. GI decontamination was performed on 44 patients: 37 received gastric lavage and 10 received activated charcoal. Medical treatments, given to 55 patients, were benzodiazepines (44 patients), antipsychotics (11 patients), atropine (7 patients), as well as NAC, calcium, glucose, vasopressors, high-dose insulin euglycemic therapy, and intralipid (1 to 4 patients for each). The most common intoxicants (and number of cases) were synthetic cathinones (42), ethanol (30), antipsychotics (20), sedatives (19), carbon monoxide (12), cannabinoids (12), acid/corrosives (11), and opioids/heroin (6). Conclusion: These initial data indicate that emerging drugs of abuse, prescription agents, and alcohol are well-represented intoxicants in urban toxicology practice settings worldwide. The increased use of gastric lavage over charcoal represents a trend which markedly differs from the USA and warrants further research. Our experience suggests that an international, web-based registry of bedside medical toxicology consultations is feasible. This project can create opportunities for global collaborative research and education among toxicologists with the ultimate goal of improving the care of poisoned patients worldwide.

Lapoint J Southern California Permanente Medical Group, San Diego, CA, USA Background: Cannabinoid hyperemesis syndrome (CHS) is described as cyclical episodes of nausea, vomiting, and abdominal pain associated with chronic and heavy cannabinoid use. The pathophysiology of CHS is poorly understood and published theories fail to explain the involvement of the endogenous cannabinoid system in the development of reported symptoms. Hypothesis: Topical capsaicin will improve symptoms associated with CHS. Methods: Prospective, nonblinded, nonplacebo-controlled trial of topical capsaicin preparation (0.075 %) in two patients with CHS. Case 1: A 19year-old female presents to the emergency department for the third time in 1 week complaining of nausea, vomiting, and severe generalized abdominal pain. She previously underwent negative CT of the abdomen and pelvis, negative transvaginal ultrasonography, negative pelvic exam, and with the exception of mild hypokalemia, negative laboratory values. Further history revealed the patient has frequent and heavy use of marijuana. Her pain completely resolved when placed in a hot shower in the emergency department. She was treated for hypokalemia and when her pain and nausea returned, a trial of topical capsaicin cream was initiated. Her pain decreased from 8/10 to 4/10 and she was subsequently discharged home. Case 2: A 28-year-old man with history of cyclical nausea, vomiting, and abdominal pain for 3 years presents to the emergency department with return of his symptoms. His previous work up includes negative CT of abdomen and pelvis, negative EGD, and cholecystectomy. History revealed frequent and heavy marijuana smoking with improvement of symptoms upon exposure to hot water. A trial of topical capsaicin cream was initiated and the patient reported improvement in symptoms from 8/10 to 3/10. He was then discharged home. Discussion: Capsaicin's only known receptor, TRPV1, is known to interact with endocannabinoids and plays a role in pain transmission. The results here suggest TRPV1 may play a role in the pathophysiology of CHS as well as indicate a safe and convenient therapeutic option for these often challenging cases. Conclusion: Topical capsaicin therapy for CHS has potential as both a therapeutic modality and mechanistic probe that merits further investigation. The 34 cases were derived from 17 different institutions. Males accounted for 13/34 (38.2 %) of subjects. The median (IQR) age was 48 (34.5-56)years, with the youngest patient being 13 months. ILE was administered most often for nondyhydropyrine calcium channel blockers (n=9), followed by dihydropyridine-class calcium channel blockers (n=5), or the combination of a beta blocker and a calcium channel blocker (n=4). ILE was administered for beta blockers alone in five subjects. Local anesthetics accounted for only three cases of ILE administration. Various other medications accounted for the remaining cases. Bradycardia (HR<50 bpm) was observed in 11/34 (32.3 %), while hypotension (systolic blood pressure <90 mmHg) occurred in 29/34 (85.3 %). Three patients experienced a high-grade AV block prior to ILE administration. Six (17.6 %) patients experienced cardiac arrest prior to implementation of ILE. In total, 10/34 (29.4 %) patients died. Acute kidney injury (creatinine >2.0 mg/dL) was present in 7/34 (20.6 %), while metabolic acidosis (pH <7.2) was present in 14/34 (41.7 %) Conclusion: In this series of patients who received ILE, the majority of cases involved nonlocal anesthetics. Most patients were in shock and had evidence of abnormal tissue perfusion.

Lin HH, Barton N, Wiegand TJ University of Rochester Medical Center, Rochester, NY, USA Background: Baclofen is a gamma-aminobutyric acid (GABA) agonist used as a muscle relaxant in the treatment of spasticity. Baclofen is occasionally necessary to continue during pregnancy due to preexisting neurological conditions. Neonatal abstinence syndrome (NAS) including seizures in a benzodiazepine-refractory case has been reported with baclofen and additional information regarding optimal treatment is needed. Hypothesis: The administration of a baclofen taper shortly after birth will help prevent NAS from intrauterine baclofen exposure. Methods: A single-patient chart review and review of the literature regarding baclofen exposure during pregnancy and NAS was performed. A 43year-old female with history of spasticity secondary to a spinal cord injury gave birth to a healthy full-term infant male via spontaneous vaginal delivery. Throughout pregnancy, the mother had received oral baclofen 80 mg daily. In order to mitigate NAS, a baclofen taper was planned after a multidisciplinary meeting. The initial dose was 0.1 mg/kg/day for 4 days, followed by a daily decrease of 0.01 mg/kg/day until discontinuation of the baclofen on the 13th day of life. Daily assessment for NAS was performed using the modified Finnegan NAS scoring system.

Results: Eighty-two modified Finnegan NAS scores were obtained in the first 16 days of life with a mean score of 2.0±2.4. A max NAS score of 9 was observed on the 13th day of life. At no point were there three consecutive NAS scores ≥8, indicating no need for further pharmacological intervention. The infant was discharged 3 days after the taper ended. Discussion: This study demonstrates the absence of NAS in an infant who received a baclofen taper after intrauterine baclofen exposure from a mother taking 80 mg/day. In addition to the taper, the baby received baclofen through breast milk as well. In fact, baclofen concentrations in milk ranged from 0.28 to 0.38 μg/mL which provided an additional approximate dose of 0.02 mg/kg/day (1/3 diet breast milk). Conclusion: The administration of a baclofen taper can prevent NAS in the setting of intrauterine baclofen exposure.

Lin HH, Barton N, Wiegand TJ University of Rochester Medical Center, Rochester, NY, USA Background: Baclofen is a gamma-aminobutyric acid (GABA) agonist used as a muscle relaxant in the treatment of spasticity. Baclofen may be used by pregnant and lactating patients but may cause serious toxicity in infants. Other than one case report, there is little data regarding distribution of baclofen into breast milk. Hypothesis: Nursing infants may be exposed to clinically significant amounts of baclofen when the mother is on oral baclofen. Methods: A single-patient chart review was conducted. A 43-year-old female with spasticity secondary to a spinal cord injury began supplying breast milk for her baby shortly after giving birth to a healthy full-term infant male. During and after pregnancy, the mother received oral baclofen, 20 mg QID at evenly spaced intervals, between 0600 and 2200 daily. For three consecutive days, breast milk samples were collected at estimated trough (0530) and peak (2400) times. Using high-performance liquid chromatography and tandem mass spectrometry, baclofen concentrations were determined for each sample. Results: Baclofen mean trough levels were 0.297±0.021 μg/mL and mean peak levels were 0.343±0.033 μg/mL (Table 1) . Discussion: Our patient was taking 80 mg of oral baclofen (20 mg QID) daily and had breast milk concentrations ranging from 0.28 to 0.38 μg/mL. A 3 kg infant consuming 750 mL of breast milk per day would be ingesting approximately 0.075 mg/kg/day, approximately 1/4th the weight-based dose of baclofen (0.29 mg/kg/day) in an average 70 kg adult consuming 20 mg baclofen daily. Infants, however, may have longer elimination halflives and accumulate baclofen at greater concentrations. Infants may also be more sensitive to the effects of baclofen and exposure to lower amounts of baclofen over time could cause significant toxicity. In our infant-mother pair, the breast milk was initially limited to 1/3 amount of total daily diet (2/3 formula), only after observing for clinical effects and obtaining levels in milk did we increase the ratio to 50 %. Conclusion: This report adds to the data on baclofen distribution in breast milk. Nursing mothers may have to limit amount of breast milk intake as distribution may be significant. Background: Learning toxicology is an asynchronous process. Clinically severe or novel toxicities are infrequent. The expected breadth of knowledge in toxicology for emergency medicine (EM) residents is much larger than what is typically experienced during a residency. When medical toxicologists are available faculty, they are not ubiquitously available to reinforce salient learning points. In order to more uniformly teach toxicology, we used the social media platform Twitter to broaden our reach and accessibility. We attempt to measure the effectiveness of social media as a teaching tool among a select group of EM residents.

Methods: This is an observational study of three EM toxicologists and seven EM residents from two EM residency programs. We used qualitative descriptions of teaching content and a pre-and post-intervention survey during a 5-month period. Results: EM toxicologists posted an average of 25 separate topics per month. Residents posted about two questions or replies per month. At the onset, all residents were using social media for personal purposes. The few (3/7) that were using any social media for education were viewing context less than once per day. By the conclusion, the majority (5/6) residents were using social media for educational purposes; half daily. Content felt to be most "useful" were "teaching pearls" (5/6), followed by "clinical cases" (4/6) and "news" (4/6). Barriers to use included content ("my questions are so base… it's way easier to just google it"), unfamiliarity or distrust ("I'm resistant… to social media"), and lack of routine use ("I'm not used to opening up Twitter like I am with opening my gmail").

Conclusions: Our small study suggests that social media can be used as an educational platform for residency education, but for a selected group of learners. Once using Twitter for education, our residents generally continued to use it. We also observe that our group of residents preferred to be passive consumers of educational content. Self-described barriers to use included content level and ease of use of the platform.

Mazer (Table) . Discussion: Trends in overall opioid prescribing did not significantly change for pain-related visits in ACs from 2006 to 2010. These findings suggest that more acute visits, such as in emergency departments, or following inpatient hospitalizations may be major contributors to the increased rates of opioid prescribing in the USA. Our study was limited in that there was not adequate data to evaluate all specialties and small sample size for some specialties in certain years may have contributed to increased variability in the data. The threat of scorpion envenomation to pediatric patients is well known. However, little information is available regarding adults with severe scorpion envenomation.

Research Question: Are adults with severe envenomation from Centruroides sculpturatus at risk for significant morbidity? Methods: This is a retrospective study of adults (age, >18 years) presenting to a tertiary referral center with severe scorpion envenomation from January 1, 2007 thru March 3, 2013. Patients were identified by a search of the hospital's electronic medical records for encounters containing ICD-9 code family "venomous animals and plants as the cause of poisoning and toxic reactions". Patients with grades III or IV envenomation for which medical records were available were included in the study. Descriptive statistical analysis was performed.

Results: Thirty patients met inclusion criteria, 60 % were female (18/30), average age was 38.6 (20-81) years, and average time to healthcare facility was 134.3 (14-720) min. Signs and symptoms are summarized (Table) . Average length of stay was 27.7 (1.5-307) h with 53 % (16/30) requiring hospital admission. Two patients developed rhabdomyolysis (CK >500 IU/L). Two patients were pregnant with one requiring admission and fetal monitoring; both had good outcomes. Two patients required cardiac evaluation due to elevated troponin, chest pain, and pre-existing CAD. Two patients required intubation due to iatrogenic sedation. One had respiratory failure due to a medication error that occurred after signs of envenomation had largely resolved; this patient had evidence of aspiration on CXR. Another patient developed CNS and respiratory depression from titration of opioids and benzodiazepines necessitating two doses of naloxone and ICU transfer. The most frequently used symptom control agents were benzodiazepines 87 % (26/30) and opioids 83 % (25/30).

Discussion: Adults with severe scorpion envenomation often require overnight admission to control symptoms or to manage side effects of treatment. These patients may be at risk for medical errors. Conclusion: Little information is available in the medical literature regarding adults with severe scorpion envenomation. This study suggests that this population may be at risk for significant morbidity. Over half would like to expand their toxicology practice but the majority perceives significant barriers to expansion. Conclusion: Full-time practice is unusual in MT. PCC work is common, but full-time compensation is not. Many MTs do not feel that they are fairly compensated. Research question: What is the prevalence of non-APAP containing xenobiotics associated with AST >1,000 seen by medical toxicologists? Methods: Using the search criteria "AST >1,000", all cases entered into the Toxicology Investigators Consortium (ToxIC) database from May 1, 2012 to October 30, 2013 were reviewed. Four hundred sixty-two cases met these criteria. Two hundred sixty-three cases with an APAPcontaining xenobiotic as primary or secondary agent of exposure were excluded. Sixty-four cases where a xenobiotic was not specified, and another five cases that were deemed "unlikely tox related" were also excluded. Of the remaining 130 cases, there were 95 single-agent exposures and 35 multi-agent exposures. We limited our analysis to singleagent exposures for the prevalence of different xenobiotics and the clinical outcomes. Results: Ethanol was the primary xenobiotic in 52/95 (55 %) cases. Of these, 14 (27 %) developed metabolic acidosis (pH<7.2), 8 (15.3 %) developed hyperreflexia, myoclonus or clonus, 5 (9.6 %) developed acute kidney injury (AKI) (creatinine >2), and 3 (5.7 %) died. Opioids accounted for 9/95 (9 %) cases. AKI occurred in seven (78 %) opioid cases, rhabdomyolysis (CPK >1,000) in five (55 %), and death in two (22 %). Methamphetamine exposures comprised 7/95 (7 %) cases. Four (57 %) developed AKI and five (71 %) developed rhabdomyolysis. Mortality among this group was 14 %. Overall mortality among all single-agent non-APAP cases analyzed was 9 %. Other agents associated with death included rivaroxaban and valproic acid. Synthetic cathinones, carbamazepine, carisoprodol, acetazolamide, methimazole, risperidol, and black cohash were also associated with AST >1,000. Discussion: Ethanol was commonly associated with AST >1,000 in this series although this is not typical of ethanol-induced liver injury. The high prevalence AKI in the opioid and methamphetamine patients suggested development of multisystem failure. Prospective studies on patients with AST >1,000 would better characterize the mechanisms of these liver injuries.

Conclusion: Frequently abused xenobiotics including ethanol, opioids, and methamphetamine accounted for the most non-APAP associated AST >1,000 cases seen by medical toxicologists. Introduction: In July 2013, the FDA issued a black box warning for mefloquine relating to acute neuropsychiatric events (NSEs). Numerous case reports exist pertaining to neuropsychiatric events in the literature; however, our literature review did not find any larger case series.

Hypothesis: The prevalence of NSEs among patients reporting adverse events (AEs) related to mefloquine is low and that the most common AE would be the very nonspecific "headache." Methods: Using the search term "mefloquine", all cases entered into the Texas Poison Center Network (TPCN) database from January 1, 2000 to June 1, 2013 were reviewed. The codes for all AEs were assessed. The individual charts for all cases that included a code for NSEs were reviewed in detail. Patients with coingestions were included. Results: Fifty-six mefloquine cases were identified. Fifty-two percent were male. The ages: 55 % were ≥20, 12.5 % were 6-9, and 30.4 % were 0-5. The most common symptoms were all gastrointestinal, nausea (10.7 %), diarrhea (8.9 %), and abdominal pain (7.1 %). Neuropsychiatric symptoms were identified in nine (16 %) cases, all were single agent exposures. Among the nine cases, dizziness occurred in five, confusion in three, headache in two, agitation in two, and visual hallucinations in one. The number of tablets ingested ranged from 1 to 7. The duration of exposures ranged from a single one to the pills taken over 1 week. Medication dosing errors occurred in four of these nine cases because the patients took the medication daily instead of weekly. Discussion: While the most common AEs associated with mefloquine were gastrointestinal, the neuropsychiatric symptoms were more commonly reported than what we expected. Also, the symptoms included confusion and hallucinations. Headache, while present, was not very common. Interestingly, 4/9 patients with NSEs had mistakenly taken the medicine daily vs. the prescribed weekly regimen, reflecting the ease in which this medicine can be taken inappropriately.

Conclusion: Mefloquine-related neuropsychiatric symptoms occurred in 16 % of the reported cases and the most common NSE was dizziness.

Ordonez J 1 , Forrester MB 2 , Wax PM 3 , Kleinschmidt KC 3 , On behalf of the ACMT Toxicology Investigators Consortium (ToxIC) While not all of the data from the TPCN database are downloaded into NPDS, much is, and it thus reflects the total NPDS to a reasonable degree. The clinical information analyzed included all cases with hepatotoxicity, coagulopathy, acute kidney injury, liver function test abnormalities, hepatic necrosis, and hepatitis. Results: In the ToxIC registry, we identified 2,787 (11 %) acetaminophen cases from 24,609 total exposures vs 44,241 acetaminophen cases (7 %) from 640,946 total exposures in TPCN database. Twenty-two percent of the acetaminophen cases in the ToxIC registry had hepatotoxicity vs 2 % in the TPCN database. NAC was administered in 69 % of ToxIC patients vs 17 % in TPCN. The table has other comparisons. Discussion: Hepatotoxicity, coagulopathy, and acute renal injury were more commonly seen in ToxIC registry than TPCN cases and NAC was more frequently given in the ToxIC registry than TPCN database. A limitation is differences in coding between these two databases.

Conclusion: APAP-exposed patients in the ToxIC registry are more severely poisoned than those in the TPCN database. Background: Carbon dioxide is a colorless, odorless gas with poor warning properties. Deaths from exposure are probably uncommon, but there are numerous reports in the literature and media. There has been no attempt to identify these cases systematically to assess the burden of mortality from carbon dioxide poisoning in the USA. This is likely difficult to do because of diverse reporting mechanisms.

Research question: What is the incidence of carbon dioxide associated fatalities in the USA between January 1, 2000 and December 31, 2011?

Methods: This is a retrospective review of multiple databases to identify fatalities associated with carbon dioxide from 2000 to 2011. We will manually review the annual reports from the National Poison Data System (NPDS) using defined search criteria. We will search PubMed and Web of Science for cases published in the literature, search the LexisNexis database for print news articles, and search the National Electronic Injury Surveillance System (NEISS). All results will be reviewed by a medical toxicologist for duplicate or improperly classified cases. Results: We identified 5 deaths in NPDS, 6 deaths in the literature, 124 in news articles, and 0 deaths in NEISS. Three deaths from the literature search were excluded because of improper classification. There were 124 news articles; however, many described the same case or actually referred to carbon monoxide instead; excluding these left 16 fatalities. Of these 16, 2 described cases reported in NPDS and 1 was from the literature search.

Reported ages of the 21 total unique cases ranged from 19 to 80 years, and included an extremely wide range of circumstances ranging from a fastfood restaurant bathroom carbon dioxide leak to being locked in a room when the carbon dioxide-based fire suppression system was triggered. Sixteen deaths (69.5 %) were unintentional and 12 (52 %) were occupational. Five incidents involved multiple deaths. Discussion: The news media database yielded the most cases, many of which were not reported in other databases. Many deaths were unintentional and occurred at work. Conclusion: We identified 21 unique cases of carbon dioxide-associated fatalities in the USA in an 11-year time period with a very diverse situation for nearly every fatality.

Radke JB 1,2 , Chenoweth JA 1,2 , Ford JB 1 , Sutter ME 1 1 University of California, Davis, Sacramento, CA, USA; 2 Veterans Administration Northern California Health Care System, Mather, CA, USA Background: Tricyclic antidepressants cause predominantly cardiovascular and neurologic toxicity. Onset of symptoms is rapid in overdose and is often seen within the first 1-2 h.

Hypothesis: Pill bezoars can significantly alter onset and peak symptoms in overdose.

Methods: A 53-year-old male with a history of hypertension and diabetes presented to the emergency department (ED) with altered mental status. The patient's sister at bedside said that his regular medications included metformin, glyburide, aspirin, prasurgrel, and metoprolol. The patient had several episodes of emesis the night prior, but was otherwise normal. His wife tried to wake him in the morning and noted that he was confused, with slurred speech, so she called emergency medical services and he was brought to the ED around 1000 hours. The initial electrocardiogram (ECG) showed sinus tachycardia with a rate of 118 bpm, QRS of 116 ms with no tall R wave in aVr. There were no prior ECGs for comparison. A sodium bicarbonate bolus was given without change in the QRS duration. The patient became more obtunded and was intubated at 1600 hours. He had a generalized tonic-clonic seizure at 1630 hours despite optimal ventilation. The patient received a CT scan of his abdomen which revealed a large amount of hyperdense material resembling pills in his stomach. The patient continued to have a prolonged QRS (peak of 138 ms) and was therefore started on sodium bicarbonate therapy. Gastroenterology was consulted for an EGD to extract the pills. He was treated with activated charcoal and whole bowel irrigation after the EGD to limit toxicity of the remaining pills.

Results: Urine GC/MS and whole pill identification was positive for clomipramine. His tachycardia gradually improved, as did his QRS, which was <100 ms on hospital day #9. Methods: This is a single-patient chart review. A 63-year-old man with a prior history of deep vein thrombosis, peptic ulcer disease, hypertension, and dyslipidemia underwent a total hip athroplasty, receiving MoM prosthesis. Three years later, he was admitted to the hospital with decompensated heart failure with an ejection fraction of 10-15 %. During the previous year, the patient had progressive shortness of breath and exercise intolerance and was diagnosed with non-ischemic cardiomyopathy after an extensive work-up, including cardiac catheterization and biopsy. Cobalt concentrations were obtained given the history of MoM prosthesis. Results: The peak measured urine cobalt concentration was 202 μg/L (reference range, 0.1-2 μg/L) and was felt to be contributory to the development of the patient's cardiomyopathy. The patient also had a urine chromium concentration of 57.6 μg/L (reference range, 0-10 μg/L).

Orthopedics was consulted for potential removal of the prosthesis, but the patient had developed renal failure and Staphylococcus aureus sepsis and was not stable for surgery. The patient underwent chelation therapy with succimer, which decreased his measured urine cobalt concentration to 11 μg/L. Subsequently he developed an arterial thrombus in the lower extremity, which required operative removal and fasciotomy. He was placed on extracorporeal membrane oxygenation due to hemodynamic instability. The patient had a biventricular assist device placed, but ultimately expired. Six patients received prophylaxis against antivenom reaction. Seven (9 %) adverse reactions to antivenom were reported. Six procedures were performed, including four wound debridements and two fasciotomies. Thirty-nine percent of the patients had at least one set of follow-up labs. One patient was readmitted 2 days post-bite for worsening thrombocytopenia and bleeding. Three additional patients were admitted 4-7 days post-bite, all with late thrombocytopenia and two with complete defibrination. One was admitted a third time 15 days post-bite for a second thrombocytopenia recurrence. Discussion: These data provide a nationally representative sample of snakebite victims seen at the bedside by medical toxicologists. The registry provides a unique opportunity to study numerous aspects of snake envenomation, including at-risk populations, rare effects, unusual treatments, and relationship between patient factors, severity, and outcomes. Methodology: A Toxicall database at a regional poison center serving a population of 2.8 million people was queried for all records indicating a snakebite from January 2003 through June 2013. Results were then searched using the free-text section in the notes field for the following terms: "fang", "tooth", "teeth", "x-ray", "xray", and "x ray". As a snake tooth or fang were anticipated to be the key foreign bodies identified on X-ray imaging, variations of these terms were used in the search criteria. Each chart that had at least one of these terms was independently reviewed for the presence or absence of a foreign body.

Results: The query returned 1,679 charts indicating a snakebite, of which 11 % (n=183) contained one of the aforementioned search terms. Review of these charts did not result in any cases with a retained foreign body. Conclusion: Snakebites are a common-presenting problem in US emergency departments. Our review found no instances of retained foreign body in snakebites occurring between 2003 and June 2013. Based on the data from this poison center, we propose that snakebites do not require routine imaging to evaluate for retained foreign bodies as this is an exceedingly rare occurrence.

Simmons JC, Rushton WF, King JD, Charlton NP University of Virginia, Charlottesville, VA, USA Background: Serotonergic agents have become ubiquitous throughout medical care and include drugs such as selective serotonin reuptake inhibitors (SSRI), monoamine oxidase inhibitors, select opioids (tramadol, fentanyl, and meperidine), antimicrobials (linezolid), over-the-counter preparations (dextromethorphan), lithium, and drugs of abuse (MDMA, LSD, cocaine, mushrooms). Despite the frequent prescribing pattern of serotonergic medications, medical students have often been unable to identify serotonergic medications during their medical toxicology rotation. The object of this study is to determine if senior medical students are cognizant of drugs that have high serotonergic activity and could potentiate serotonin syndrome. Methods: A clinical vignette regarding an adolescent male who daily takes an SSRI and who presented with fulminant serotonin syndrome after abusing dextromethorphan was distributed to a fourth year medical school class at one institution. Students were given a list of drugs commonly used in the ICU setting and asked to identify which were known to increase serotonergic activity and thus be avoided in the management of this patient. Response to the survey was entirely voluntary and two reminder emails were sent to increase responses. Results: One hundred twenty participants replied out of a class of 155 for a 77.4 % response rate. The following agents were correctly identified for their potential to increase serotonergic activity: 87.5 % sertraline, 50.8 % meperidine, 35.8 % linezolid, 18.3 % fentanyl, and 16.7 % lithium. The following agents were incorrectly identified as worsening serotonin syndrome: 45 % quetiapine, 12.5 % dexmedetomidine, 5 % propofol, 3.3 % midazolam, and 0 % cefepime. Discussion: Our results demonstrate significant gaps in understanding of serotonergic agents among fourth year medical students. While 87.5 % were able to identify that sertraline would worsen the syndrome, only 50 % identified meperidine as serotonergic despite the historical implications of this interaction. Also concerning was the belief that quetiapine had serotonin agonist activity reflecting failure to understand the mechanism of this commonly prescribed xenobiotic. Conclusion: Senior medical students require increased education on the pharmacology of commonly used serotonergic drugs in the ICU setting to avoid worsening serotonin syndrome or causing an iatrogenic adverse drug reaction. Objective: Recently, an effective antivenom for clinically significant scorpion envenomation has been approved by the Food and Drug Administration (FDA) and is being increasingly used in emergency departments across the country, but no formal economic analysis on its impact on cost of management of these patients has been performed. Methods: Three different strategies of clinical management of scorpion envenomation with systemic neurotoxic symptoms in pediatric patients were compared for cost minimization from a third-party-payer perspective. In strategy I, patients with clinically significant scorpion envenomation with cranial nerve dysfunction and/or somatic skeletal neuromuscular dysfunction were managed with supportive care only and without use of scorpion antivenom. In strategy II, an aggressive strategy of fulldose Anascorp® antivenom (initial dose of three vials with the use of additional vials administered one vial at a time) was considered. In strategy III, a single-vial serial dosing strategy of Anascorp® titrated to clinical response was considered. Clinical probabilities for the different strategies were obtained from retrospective review of medical records of patients with scorpion envenomation over a 10-year period at our institution and from published information. Baselines cost values were obtained from patient reimbursement data from our institution. Indirect costs were not considered in this analysis. Results: In the baseline analysis, strategy I of supportive care only with no antivenom was the least costly at $3,466.50 per patient. Strategy III of singlevial serial dosing was intermediate but less expensive than strategy II of fulldose antivenom, with an incremental cost of $3,171.08 per patient. In a oneway sensitivity analysis, at a threshold antivenom cost of $1,577.87, strategy III of single-vial serial dosing became the least costly strategy. Conclusion: For children with scorpion envenomation with neurotoxic symptoms, use of a management strategy based on serial dosing of Anascorp® titrated to clinical response is less costly than a strategy of initial use of full-dose antivenom. Also, lowering the cost of antivenom would make use of titrated antivenom dosing in all children with significant neurotoxic symptoms the most favored strategy even compared to the strategy of conservative management without use of antivenom. Review of records and history is negative for other known causes of TTP. The mechanism by which this occurred is unknown. Proposed mechanisms include the effects of abuse-preventing inactive ingredients which are found in the newest reformulation. A comparison of inactive ingredients is made (Table) . Cases of TTP have not been linked to older formulations of Opana ER® suggesting a mechanism unique to the newest formulation. Conclusion: Hemolytic anemia and thrombotic thrombocytopenic purpura may occur following the intravenous injection of reformulated Opana ER®. Background: Although uncommon, severe ergotism continues to occur in Thailand. We sought to determine the precipitating factors and clinical manifestations of these cases. Method: This is a retrospective cohort study of all patients with ergotism consulted to Ramathibodi Poison Center Bangkok, Thailand from January 2006 to August 2013. Cases were identified by substance codes, and data were abstracted by poison center senior scientist. Result: Twelve cases of ergotism were identified. Patient ages ranged from 15 months to 50 years. Nine patients were female. All cases were associated with ergotamine 1 mg/caffeine 100 mg combination tablets. Nine cases (75 %) were precipitated by drug-drug interactions with CYP 3A4 inhibitors: lopinavir/ ritonavir (eight cases) and erythromycin (one case). In none of these cases was overdose suspected. The other cases involved suicidal intent (two cases) and accidental ingestion (one case). Ten patients had vascular insufficiency symptoms including cooling, numbness, pain, and pulse deficit in distal limbs, treated with vasodilators and anticoagulants. Five of these patients initially had low or unmeasurable blood pressure by noninvasive technique which resolved after intravenous vasodilator administration. One patient died from rhabdomyolysis and acute renal failure, two underwent partial foot amputations due to lower extremity gangrene, and seven patients recovered fully. Two patients did not develop vascular insufficiency symptoms. One was a 15-month-old boy with unsupervised ingestion of an unknown dose presented with alteration of consciousness and seizure. He was intubated, treated with diazepam and phenobarbital. He died on the next day. Another case was 14-year-old female who ingested 100 tablets with suicidal intent. She presented with vomiting and recovered with supportive care. Discussion: Severe ergotism cases continue to occur in Thailand. Most cases are caused by interaction with CYP3A4 inhibitors, which increase ergotamine bioavailability at least fourfold. Factitious low blood pressure in these cases was caused by severe vasospasm. The severe symptom in 15-month-old case may be from poor metabolism of ergotamine and caffeine due to immature of CYP3A4 and 1A2, respectively. Conclusion: Severe ergotism can be precipitated by drug interaction and present with factitious hypotension caused by profound vasospasm. random serum vancomycin level of 160 mg/L. No other etiology of his renal injury was identified, although he had received a single dose of ibuprofen on the preceding day. Per the recommendations of the poison center, the patient was transferred to a pediatric tertiary care hospital, where continuous venovenous hemofiltration (CVVH) was performed with an HF 1,200 filter (Medivators, Inc.) at a flow rate of 100 mL/min for 16.5 h. During CVVH, the renal function improved and the vancomycin level declined to 38.9 mg/L. Using a first-order elimination model, the vancomycin half lives were estimated to be 53 h before CVVH and 9 h during CVVH. After hemofiltration, the patient's renal function continued to improve, and he was discharged with outpatient nephrology follow-up. Conclusion: Supratherapeutic vancomycin levels can lead to acute renal toxicity or can be exacerbated by primary renal injury. The primary mechanism underlying this patient's toxicity is not known. CVVH performed with a large-pore membrane appears to enhance the clearance of vancomycin and decrease its serum elimination half-life.

Stephani JA, Hendrickson RG Oregon Health & Science University, Portland, OR, USA Background: National and statewide laws to control methamphetamine precursors including pseudoephedrine have been enacted to decrease clandestine lab manufacture and subsequent availability/use of methamphetamine. In 2006, Oregon enacted a law requiring a prescription to obtain pseudoephedrine. No such law exists in Washington, which is thought to share similar sources of methamphetamine. The short-and long-term effect of Oregon's statewide pseudoephedrine law on methamphetamine-related deaths is unknown. Hypothesis: The 2006 Oregon law requiring a prescription for pseudoephedrine was associated with short-and long-term decreases in methamphetamine-related deaths. Discussion: A 2006 Oregon law that required a prescription for pseudoephedrine was associated with no change in short-or long-term methamphetamine-related deaths compared to a similar county in a neighboring state that did not enact a law. The years immediately following the law were associated with a short-term decrease in methamphetamine-related deaths, but a similar trend was also seen in King County, Washington, suggesting alternative variables may have been contributing, including national legislation or changes in the methamphetamine source, purity, and price secondary to the decrease in methamphetamine labs.

The Oregon law restricting pseudoephedrine as prescriptiononly was not associated with a decrease in methamphetamine-related deaths. Discussion: The initial decrease in methamphetamine-related poison center calls was seen in both Oregon and Washington, indicating that a possible confounding variable may have contributed to decreased methamphetamine-related calls. The initial decrease may represent a decline in methamphetamine use in the community or a change in potency/price resulting in decreased hospital admissions or emergency department visits. However, over a longer period, the call volume of both centers increased to levels similar to those in the pre-law periods, though Oregon call volumes remained decreased in the long term compared to Washington calls. Conclusion: A law restricting pseudoephedrine in Oregon was associated with a small long-term decrease in methamphetamine-related poison center call volume in Oregon compared to Washington. In the short term, the law was associated with a decrease in methamphetamine-related calls in both states. Conclusion: Restricting pseudoephedrine to prescription-only in the state of Oregon had no effect on methamphetamine treatment admissions. Background: Dabigatran and rivaroxaban are newer anticoagulants being used more commonly in clinical practice. Cases of bleeding have been reported with use of these agents since approval. We performed an observational case series to characterize the presentation and outcome of exposures to these medications. Methods: Combined retrospective and prospective case series of exposures to dabigatran and rivaroxaban reported to our poison control system. Retrospective cases were identified between 1/11 and 5/12. Prospectively collected cases were collected from May 2012 to July 2013. Miscoded cases and those with possible warfarin co-ingestion were excluded. Other cases of co-ingestion were included. Main data variables collected included demographics, outcome, disposition, nature of exposure, treatments received, and laboratory parameters.

Results: Fifty-seven total cases were identified, with 7 excluded, leaving 37 dabigatran and 12 rivaroxaban cases for analysis. Children age 12 or less accounted for five dabigatran and two rivaroxaban cases. Bleeding was reported in 15 dabigatran cases. There were four cases of acute selfharm overdose with dabigatran ranging from 1,800 to 3,900 mg. Mild bleeding was reported in only one of these overdose cases and there were no deaths in this group. There were two fatal hemorrhages in dabigatran cases, both in patients chronically on this medication. Coagulation parameters were abnormal in many cases and did not correlate well with bleeding or outcome. Bleeding was reported in five rivaroxaban cases, all in patients with chronic exposure to the drug without known overdose. No cases of intentional self-harm overdose of rivaroxaban were reported, and there were no deaths. None of the pediatric cases from either group had adverse outcomes or bleeding. Discussion: Adverse bleeding will continue to rise with exposures to the newer oral anticoagulants. Our data demonstrated that chronic dosing of these agents resulted in more episodes of bleeding than intentional overdose or excess dosing. Accidental pediatric exposures also resulted in few effects and no episodes of bleeding.

Conclusion: This case series of dabigatran and rivaroxaban exposures demonstrated the greatest degree of risk of adverse events in patients chronically taking these medications irrespective of excess dosing. Acute self-harm ingestions and accidental pediatric ingestions in our series had few adverse effects.

Swartzentruber GS, Yanta JH, Pizon AF, Menke NB University of Pittsburgh Medical Center, Pittsburgh, PA, USA

Background: Methemoglobinemia may result from a wide variety of oxidant stressors. Dapsone and its acetylated metabolite, dapsone hydroxylamine, are known oxidants and have been frequently reported as a cause of methemoglobinemia. Topical dapsone has not been previously reported as a cause of methemoglobinemia. We present a case of methemoglobinemia after using topical dapsone 5 % gel for facial acne. Hypothesis: Topical dapsone has the potential to cause methemoglobinemia.

Methods: This is a single-patient chart review. A 19-year-old female without significant past medical history presented to the emergency department with blue lips and nail beds. Her home medications included citalopram, topical dapsone (Aczone®), and oral contraceptives. She awoke on the day of presentation and noted that her lips and fingers were blue. She complained of a mild headache and mild shortness of breath. Initial vital signs were normal except for an oxygen saturation of 82 % on room air. Her dyspnea persisted despite treatment with 2 l per minute of oxygen by nasal cannula. Oxygen saturation increased to 90 % following treatment with oxygen. Chest radiograph and electrocardiogram were normal. Laboratory studies were within normal limits (Hgb, 12.4 mg/dL) except for a methemoglobin (MetHgb) level of 20.3 %. She was treated with a single intravenous bolus of 2 mg/kg methylene blue which resulted in complete resolution of her cyanosis and symptoms. A repeat MetHgb level 120 min after treatment was 1.9 %. A urine gas chromatography/mass spectrometry qualitative drug screen demonstrated dapsone. Nine hours after treatment, her MetHgb level was 7.2 %, she was asymptomatic, and was therefore discharged home. Case discussion: We hypothesize this patient's methemoglobinemia was the result of systemic absorption of topical dapsone gel.

Conclusions: Topical dapsone gel may be absorbed systemically thereby causing oxidant stress and resulting in methemoglobinemia.

Swartzentruber GS 1 , Cibik LA 2 , Richardson WH 3 , Lloyd VJ 3 1 University of Pittsburgh Medical Center, Pittsburgh, PA, USA; 2 Baptist Medical Center, Jacksonville, FL, USA; 3 Palmetto Health Richland, Columbia, SC, USA Background: Myocardial infarction (MI) has been reported previously as a complication of snake envenomation. To our knowledge, ST-elevation MI (STEMI) has not been previously reported as a complication of North American crotaline envenomation. Hypothesis: Rattlesnake envenomation can cause MI by a mechanism not yet clearly elucidated.

Methods: This is a single-patient chart review. A 72-year-old male presented to the emergency department (ED) with chest pain shortly after being bitten by a juvenile canebrake rattlesnake (Crotalus horridus). EMS was called and en route to the ED the patient developed chest pain and hypotension. His vital signs on arrival were T 97.4, HR 89, RR 28, BP 96/72, O2 saturation 100 % on non-rebreather mask. Swelling was present over the left dorsal hand and a single puncture wound was noted on the second digit.

Results: The initial EKG demonstrated ST elevation in leads II, III, and aVF. Laboratory results included 9.7 WBC, 13.2 Hgb, 524 Plt, 12.3/0.9 PT/INR, 28.9 PTT, 712 fibrinogen, and troponin was elevated at 0.24. Hypotension resolved following a 1,000 cm 3 bolus of 0.9 % saline. Rectal aspirin (300 mg), heparin, and six vials of crotaline Fab antivenom were administered in the emergency department. The patient was admitted for emergent cardiac catheterization and intubated for ongoing hypoxia. The circumflex artery revealed a 70-80 % midvessel stenosis with thrombus formation. There was additional thrombus formation just proximal to the branching point of the second obtuse marginal branch. After thrombectomy and stent implantation, there was no residual obstruction. The patient was extubated on hospital day #2. Fourteen vials of crotaline Fab antivenom were administered. He was discharged to home in good condition after 6 days in the hospital. Discussion: Complex hematologic abnormalities such as platelet aggregation are well described following crotaline envenomation including recognized species-dependent effects. In this patient with moderate coronary atherosclerosis, thrombus formation could be a complication of the hemotoxic venom effect of C. horridus. With the common use of anticoagulation and platelet-inhibiting medications in the setting of STEMI, management of STEMI in conjunction with crotaline envenomation presents unique challenges. Conclusions: STEMI is a rare but potential life-threatening complication of North American crotaline envenomation.

Tran A 1 , Grimaldi L 2,3 , Shah A 4 , Menon S 2 , Levine M Research question: How do international ACMT members self-evaluate their interested, goals, and priorities, and how can their responses guide strategic planning for this globally distributed network of toxicologists with diverse skills and needs? Methods: A nine-question online survey was created in summer 2013 with input from International Committee members and ACMT leadership. We requested all international ACMT members provide feedback about their current responsibilities, projects, short-and long-term goals, and how ACMT and the International Committee could serve their professional and educational needs.

Results: There were 32 responses from 12 countries. The primary employment areas of respondents were bedside or inpatient consultation services (81 %), poison control centers, medical education, research, and public health agencies. The most common areas of interest within toxicology included pharmaceutical drug toxicity (65 %), pesticides, agrochemicals, emerging illicit drugs, and snakebites. Topics desired for continuing education included heavy metals, medico-legal issues, emerging drugs, addiction medicine, industrial and occupational toxicology, radiation safety, and grant-writing/research funding opportunities. Funding remains a common barrier to international members' goals (31 %). Accreditation of international members as fellows of ACMT is highly valued in countries which lack other official medical toxicology recognition. When asked how ACMT could better serve their needs, members requested more online continuing education aimed at skill transfer to local specialists in emergency medicine and toxicology, and facilitating research collaborations within the worldwide toxicology community. Finally, over 20 international conferences and scientific meetings were suggested for possible ACMT-sponsored symposia, where members could work with regional medical communities to explore ways that medical toxicologists can help address the global epidemic of poisonings worldwide.

Conclusions: Online education, collaborative research, international conference participation, and grant provision were the most commonly expressed themes from the survey responses. Although limited by the small sample size, this survey experience provides valuable insight for restructuring the International Committee and formulating its strategic plan.

Vohra R, Mittendorf G UCSF Fresno Medical Center, Fresno, CA, USA Introduction: Poison control centers pioneered the use of telephones for remote medical direction over 50 years ago, but newer telemedicine technologies have recently emerged. We present three clinical cases where video-telephone calls using Apple Inc's "FaceTime" application facilitated toxicology consultation in an emergency department.

Research Question: Is FaceTime a useful adjunct for medical toxicology consultations? Case reports: (A) Aspirin toxicity was suspected in a 55-year-old man with a prior medical history of tuberculosis who presented with respiratory distress. FaceTime was used to confirm the patient's salicylism toxidrome (diaphoresis, tinnitus, confusion, and respiratory distress) as well as radiographs demonstrating TB scars and pulmonary edema. These visual details prompted a recommendation for emergency hemodialysis, even though lab results were pending. A salicylate level of 96 mg/dL was resulted just as hemodialysis was begun. (B) A 42-year-old man with anxiety, chest pain, and headaches admitted to taking amyl nitrate "poppers" just prior to arrival. FaceTime confirmed the presence of perioral and nailbed cyanosis, and oxygen saturation of 88 % despite oxygen supplementation. Empiric therapy with methylene blue supplementation was recommended, the patient's labs revealed methemoglobin level of 24 % and an elevated troponin (0.56 ng/dL). (C) A 6-year-old developmentally delayed girl swallowed dilute bleach from a mislabeled bottle. After choking and gagging initially, she returned to her baseline state, which included mutism and a predilection to drooling. FaceTime consultation with a toxicologist assured the emergency clinician and the patient's parents that the child was safe for discharge following an oral fluids trial. Discussion: Nonrecorded video-phone technology represents an innovation for potentially enhancing valuable interactions between toxicologists, health professionals, and patients and relatives. Select physical examination findings, ECGs, and radiographs are types of data which can be transmitted effectively over FaceTime.

Conclusion: By facilitating real-time diagnosis, bedside education, and visual feedback among practitioners and consultants, videophone calls can enhance toxicology consultation and clinical outreach in an era of declining telephone call volumes to poison centers nationwide. A larger set of clinical experiences is needed to explore the place of these types of technologies in the changing landscape of medical toxicology. Background: Methylene blue is a phenothiazine derivative used clinically as an antidote for methemoglobinemia, as a surgical dye, and as a vasopressor in refractory vasodilatory shock. Both methylene blue and its primary metabolite, azure B, are inhibitors of monoamine oxidase A. Hypothesis: Methylene blue has sufficient inhibition of monoamine oxidase A to precipitate serotonin syndrome (SS), even at low doses.

Methods: This is a single-patient chart review. A 38-year-old female with a past medical history of depression, carcinoid syndrome, and dermatographia presented to the emergency department with palpitations and fatigue. She reported a recent history of lethargy, anxiety, and lightheadedness. She was taking dapsone for 12 months and had started paroxetine a few weeks prior. Initial vital signs were T 98.6, HR 146, BP 169/104, RR 22, and SatO2 90 %. Her SatO2 did not improve with 100 %. Her workup was unremarkable (Hgb, 13 mg/dL) except for a methemoglobin (MetHgb) level of 20.8 %. She was given a dose of methylene blue 1 mg/kg which was repeated after she failed to improve. During transfer, she became diaphoretic, myoclonic, agitated, and intermittently confused. Her MetHgb level had decreased to 2.6 % after treatment but rebounded to 9.0 % on hospital day 2. Vital signs on arrival were T 98.6, HR 133, RR 16, BP 153/83, and SatO2 95 %. She was awake, alert, anxious, and profusely diaphoretic. She was slow to respond to questions and had mild trismus. She had repetitive flexion and extension of her left lower extremity which was difficult for her to control. She had concurrent rigid lower extremities and sustained clonus at the knees and ankles. She was diagnosed with SS by a medical toxicologist. She was treated with intravenous lorazepam for these symptoms. Her symptoms resolved within 24 h and her vital signs normalized. A urine gas chromatography/mass spectrometry demonstrated paroxetine, dapsone, and methylene blue.

Discussion: We report a case of serotonin syndrome in the setting of lowdose administration of methylene blue for the treatment of symptomatic methemoglobinemia.

Conclusions: Concurrent use of methylene blue with serotonergic xenobiotics at doses as low as 2 mg/kg can precipitate serotonin syndrome.

Wieferich KJ, Raja AJ, Yanta JH, Menke NB University of Pittsburgh Medical Center, Pittsburgh, PA, USA Background: Stress-induced cardiomyopathy is a transient non-ischemic cardiomyopathy, usually caused by an acute physical or emotional stressor that presents with findings concerning for acute coronary syndrome despite lack of angiographic coronary artery disease. Rare case reports have described this phenomenon in the setting of iatrogenic opioid withdrawal. In our case, stress-induced cardiomyopathy occurred after discontinuation of opioid medications. Hypothesis: Abstinent opioid withdrawal can induce stress-induced cardiomyopathy.

Methods and Results: This is a single-patient chart review. The patient is a 37-year-old male with a history of oxycodone, heroin, and fentanyl abuse who presented to the Emergency Department with a chief complaint of opioid withdrawal symptoms 5 days after last using oxycodone. He denied recent opioid or other drug use. On presentation, he was agitated, nauseated, tachypneic, diaphoretic, and complained of diffuse abdominal pain. Initial vital signs were temperature (36.8°C), blood pressure (147/98), pulse (88), respiratory rate (32), and saturating (98 %) on room air. Urine drug screen was positive for opiates only. Four milligrams of lorazepam and 4 mg of midazolam were administered in attempt to control his agitation. Due to uncontrolled agitation, the patient was intubated. Further evaluation revealed diffuse ST segment depression on EKG with elevated serum troponin (initial 14 ng/mL, peak 44 ng/mL). A previous EKG from 1-year prior was normal. Cardiology was consulted and the patient started on aspirin, clopidogrel, and heparin. The patient underwent coronary angiography that revealed normal coronaries and left ventriculography demonstrated diffuse left ventricular hypokinesis with apical sparing and an ejection fraction of 15 %. He was diagnosed with non-ischemic cardiomyopathy and started on aspirin, lisinopril, hydrochlorothiazide, and carvedilol. The patient left against medical advice on hospital day 3, therefore no follow up was obtained. Discussion: We believe that the patient developed stress-induced cardiomyopathy from opioid withdrawal secondary to abstinence. He was found to have new ST changes on EKG, troponin elevation with no evidence of coronary artery disease, and diffuse LV hypokinesis, this presentation is consistent with the Mayo diagnostic criteria for stress cardiomyopathy.

Conclusion: Severe non-ischemic cardiomyopathy may occur as a complication of opioid withdrawal due to abstinence.

Wiegand TJ, Ahari S, O'Geen R University of Rochester Medical Center, Rochester, NY, USA Background: Physostigmine is used for the treatment of antimuscarinic toxicity. Our consult service regularly uses this antidote to treat coma and delirium from certain atypical antipsychotics (e.g., quetiapine, olanzapine). Clozapine is an atypical antipsychotic with mixed muscarinic agonist/antagonist effects. Hypothesis: Physostigmine treatment may help resolve antimuscarinic effects and CNS depression in clozapine overdose.

Methods: This is a single-patient chart review. A 37-year-old male with polysubstance abuse was found unconscious beside a bag of pink powder.

Vancomycin has a molecular weight of 1,485 Da, a volume of distribution of 0.39 L/kg, is 30 % protein-bound, and is cleared primarily via glomerular filtration. Case Report: A 10-year-old, 46 kg male with severe eczema was admitted for treatment of cellulitis caused by multidrug

On presentation, the patient was comatose and required emergent intubation due to respiratory failure and need for airway stabilization. Vitals included HR of 120 beats/ min, BP of 122/78 mmHg, RR of 10 breaths/min, and O 2 saturation of 93 % via non-rebreather. Foley catheter placement yielded 2 l of urine. The patient did not require sedation for intubation. Initially, copious secretions required oropharyngeal suctioning. Miosis was also present along with hypoactive bowels and relaxed neuromuscular tone. EKG showed sinus tachycardia and QTc of 490 ms. Urine drug screen was positive for benzodiazepines and comprehensive screen confirmed methadone and clozapine (which the patient was not prescribed)

Orbeez": The magic absorbing bead-risk of pediatric bowel obstruction?

FUNGUS AMONGUS: Testing the public's ability to identify mushrooms

Electronic cigarette exposures reported to poison centers

Comparison of diphenhydramine and Datura abuse

Long-term outcomes following deliberate self poisoning: a 10-year longitudinal population-based study

Prevalence and characteristics of hypofibrinogenemia after North American rattlesnake envenomation reported to a statewide poison control system

Made to deliver: a comparison of lead contamination in imported and non-imported spices