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Time to Antivenom Administration in Snakebite
Research Forum Abstracts
Drug Amphetamines Opiates Barbs Cocaine Benzos THC
D/D (Inhouse/Comp)
D/L (Inhouse/Comp)
L/D (Inhouse/Comp)
L/L (Inhouse/Comp)
Total in Agreement
Total
Agreement
95% C.I.
27 26 2 19 34 44
3 1 0 2 10 1
6 15 2 5 58 10
222 216 254 232 156 203
249 242 256 251 190 247
258 258 258 258 258 258
97% 94% 99% 97% 74% 96%
95-99% 91-97% 98-100% 95-99% 67-79% 94-98%
metabolites, which resulted in 181 (70%) samples positive for at least one agent with potential abuse. Agreement between the two tests was: The in-house and comprehensive screens had good agreement except for benzodiazepines. The comprehensive screen picked up a total of 58 (57%) benzodiazepines not detected on the in-house screen; of those, 37 (36%) detected the presence of lorazepam and another 17 (16%) detected clonazepam. Furthermore, the comprehensive screen picked up additional drugs not tested for in the in-house screen, the most prevalent of which were gabapentin 19 (7%), tramadol 13 (5%) and meprobamate 7 (3%). Conclusions: Comprehensive drug of abuse screens with IA and MS agree with inhouse screens for most drugs of abuse. However, lorazepam and clonazepam are commonly missed. In addition, the comprehensive screen detected a small proportion of other drugs with psychiatric effects. The impact of such additional data, especially if timely, on ED treatment and disposition of patients remains to be determined.
113
The Effects of Neutralization Therapy for Acute Alkali Ingestion in Rabbit
Sun KM, Lee JH, Rhee JE, Jo YH, Kim KS, Lee J-H, Kim TY, Lee SB/Seoul National University Bundang Hospital, Gyeonggi-do, Korea
Study Objectives: To evaluate the change in temperature of the gastric lumen contents and the efficacy of neutralization with weak acid against commercially sold strong alkali ingestion. Methods: Twenty-three male New Zealand White rabbits were anesthetized with intramuscular injection of ketamine and xylazine. After gastric lavage was done, an oro-gastric catheter and an electric thermometer probe were inserted into stomach. Then 3 mL/kg of room-temperature (24-26 C) 1M sodium hydroxide (NaOH) disinfectant was instilled in the gastric lumen. The rabbits were divided into three groups. Group 1 (n ¼ 8) was treated with NaOH only. After 5 minutes, Group 2 (n ¼ 7) and group 3 (n ¼ 8) were treated with 39 mL/kg of room-temperature orange juice or water. We monitored intra-gastric temperature continuously, compared arterial pHs before alkali insult and 30 minutes later. We measured gastric pH and examined pathologic findings of esophagus, stomach, and duodenum after sacrificing. Results: Gastric lumen temperatures were gradually increased from 32.6 C to 38.7 C after alkali instillation. Significant temperature decreases of 7.5 C or 12.0 C were observed for lumen temperature following treated with water or orange juice, respectively (p < 0.01). Post-treatment temperature did not exceed pre-treatment temperature for the entire observation period. Gastric pH of neutralization group was much lower than alkali alone or dilution group (7.0 0.7 vs. 11.6 0.2 or 10.6 0.4, respectively, mean SD, p < 0.01). In microscopic findings of stomach, only mucosal injuries were observed in neutralization groups, while there were no significant differences among groups in esophageal or duodenal injury. Conclusions: Neutralization therapy with room-temperature orange juice for acute gastrointestinal injuries by liquid alkali did not make additional thermal injury, and might have protective effects against local tissue destruction of stomach.
114
Time to Antivenom Administration in Snakebite
Gerardo CJ, Evans CS, Kuchibhatla M, Drake WG, Mando-Vandrick JD, Yen M, Kopec KT, Lavonas EJ/Duke University Medical Center, Durham, NC; Duke University School of Medicine, Durham, NC; Boston Children’s Hospital and Beth Israel Deaconess Medical Center, Boston, MA; Einstein Medical Center, Philadelphia, PA; Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO
Study Objectives: In crotaline snakebite, current recommendations are to administer antivenom to patients with progressive venom effect. In order to prevent
S44 Annals of Emergency Medicine
unnecessary antivenom administration, “watchful waiting” is recommended for patients whose condition is stable and not progressing. It is unknown if this approach decreases overall antivenom. Our objective was to determine the association between the time from bite to initial antivenom administration, and the total amount of antivenom administered; and to determine what proportion of patients did not receive antivenom using this recommended approach. Methods: We performed a retrospective chart review from April 2009 to October 2012 of patients presenting with crotaline snake envenomation. All patients presenting to a single tertiary care emergency department within 24 hours of reported snakebite and documented envenomation syndrome were included. Two blinded abstractors recorded each data point. Any disagreement in data was resolved by abstractor agreement and adjudicated by study personnel if necessary. Our primary outcome was total amount of antivenom given and secondary outcomes included proximal extension of local symptoms. Pearson correlation was used to examine the association between the total number of antivenom vials received and the time from bite to antivenom administration. General linear model was used to examine this association with categorized time to antivenom administration (0-3, 3-6, > 6þ hours), with and without covariates. The covariates used in the adjusted model are age, number of joints crossed by swelling at initial presentation and year of envenomation. Results: Preliminary analysis of 75 patients demonstrates that 71 (95%) received antivenom. Of the 71 patients, 43 (60.6%) were male. Age ranged from 15 months to 72 years, mean age was 36.5(SD ¼ 20.5) years. The total number of vials administered is correlated with the maximum progression of local limb symptoms (r ¼ 0.44, p ¼ 0.0002). The total number of vials administered is negatively correlated with the time to antivenom administration (r¼-0.18, p ¼ 0.14). Unadjusted analysis of general linear model of total vials of antivenom received by the time to antivenom divided into three groups (0-3, 3-6, >6 hours) showed significant association (p¼ 0.03) and there was significant difference between the 0-3 and >6 hours (12.7(SE¼0.8) vs. 8.7(SE¼1.3), p ¼ 0.01). Covariate adjusted analysis for age, initial joints crossed and year of envenomation did not show significant relation between total number of vials administered and time to antivenom administration (p ¼ 0.23). Conclusions: The strong correlation between progression of local limb symptoms and the total amount of antivenom suggests good adherence to current recommendations. This approach resulted in a small proportion of patients not receiving antivenom. The total amount of antivenom received was negatively correlated to time from bite to initial antivenom administration. Unadjusted analysis showed significant difference in the amount of antivenom received by those who received it in 0-3 vs. > 6 hours. A “watchful waiting” approach was not associated with increased antivenom use, rather the time to initial antivenom administration was a marker of a less severe clinical course.
115
Ongoing Opioid Misuse Identification in the Emergency Department Using the COMM Instrument Compared to Clinician Judgment
Varney SM, Bebarta VS, Ganem VJ, Carey KR, Ramos RG, Zarzabal LA/San Antonio Military Medical Center, San Antonio, TX; Wilford Hall Ambulatory Surgical Center, San Antonio, TX
Study Objective: Pain is a common complaint in the emergency department (ED). Emergency medicine providers (EMPs) have little time to assess patients for aberrant opioid behavior. The Current Opioid Misuse Measure (COMMTM) is a validated tool used to monitor pain patients on opioid therapy. We sought to compare EMP clinical judgment to a validated instrument, the COMM, to identify patients who may be at risk for ongoing prescription opioid misuse. Methods: We conducted an observational study of patients over age 18 years who sought treatment in the ED of a military tertiary care hospital and received at least one
Volume 62, no. 4s : October 2013
Drug Amphetamines Opiates Barbs Cocaine Benzos THC
D/D (Inhouse/Comp)
D/L (Inhouse/Comp)
L/D (Inhouse/Comp)
L/L (Inhouse/Comp)
Total in Agreement
Total
Agreement
95% C.I.
27 26 2 19 34 44
3 1 0 2 10 1
6 15 2 5 58 10
222 216 254 232 156 203
249 242 256 251 190 247
258 258 258 258 258 258
97% 94% 99% 97% 74% 96%
95-99% 91-97% 98-100% 95-99% 67-79% 94-98%
metabolites, which resulted in 181 (70%) samples positive for at least one agent with potential abuse. Agreement between the two tests was: The in-house and comprehensive screens had good agreement except for benzodiazepines. The comprehensive screen picked up a total of 58 (57%) benzodiazepines not detected on the in-house screen; of those, 37 (36%) detected the presence of lorazepam and another 17 (16%) detected clonazepam. Furthermore, the comprehensive screen picked up additional drugs not tested for in the in-house screen, the most prevalent of which were gabapentin 19 (7%), tramadol 13 (5%) and meprobamate 7 (3%). Conclusions: Comprehensive drug of abuse screens with IA and MS agree with inhouse screens for most drugs of abuse. However, lorazepam and clonazepam are commonly missed. In addition, the comprehensive screen detected a small proportion of other drugs with psychiatric effects. The impact of such additional data, especially if timely, on ED treatment and disposition of patients remains to be determined.
113
The Effects of Neutralization Therapy for Acute Alkali Ingestion in Rabbit
Sun KM, Lee JH, Rhee JE, Jo YH, Kim KS, Lee J-H, Kim TY, Lee SB/Seoul National University Bundang Hospital, Gyeonggi-do, Korea
Study Objectives: To evaluate the change in temperature of the gastric lumen contents and the efficacy of neutralization with weak acid against commercially sold strong alkali ingestion. Methods: Twenty-three male New Zealand White rabbits were anesthetized with intramuscular injection of ketamine and xylazine. After gastric lavage was done, an oro-gastric catheter and an electric thermometer probe were inserted into stomach. Then 3 mL/kg of room-temperature (24-26 C) 1M sodium hydroxide (NaOH) disinfectant was instilled in the gastric lumen. The rabbits were divided into three groups. Group 1 (n ¼ 8) was treated with NaOH only. After 5 minutes, Group 2 (n ¼ 7) and group 3 (n ¼ 8) were treated with 39 mL/kg of room-temperature orange juice or water. We monitored intra-gastric temperature continuously, compared arterial pHs before alkali insult and 30 minutes later. We measured gastric pH and examined pathologic findings of esophagus, stomach, and duodenum after sacrificing. Results: Gastric lumen temperatures were gradually increased from 32.6 C to 38.7 C after alkali instillation. Significant temperature decreases of 7.5 C or 12.0 C were observed for lumen temperature following treated with water or orange juice, respectively (p < 0.01). Post-treatment temperature did not exceed pre-treatment temperature for the entire observation period. Gastric pH of neutralization group was much lower than alkali alone or dilution group (7.0 0.7 vs. 11.6 0.2 or 10.6 0.4, respectively, mean SD, p < 0.01). In microscopic findings of stomach, only mucosal injuries were observed in neutralization groups, while there were no significant differences among groups in esophageal or duodenal injury. Conclusions: Neutralization therapy with room-temperature orange juice for acute gastrointestinal injuries by liquid alkali did not make additional thermal injury, and might have protective effects against local tissue destruction of stomach.
114
Time to Antivenom Administration in Snakebite
Gerardo CJ, Evans CS, Kuchibhatla M, Drake WG, Mando-Vandrick JD, Yen M, Kopec KT, Lavonas EJ/Duke University Medical Center, Durham, NC; Duke University School of Medicine, Durham, NC; Boston Children’s Hospital and Beth Israel Deaconess Medical Center, Boston, MA; Einstein Medical Center, Philadelphia, PA; Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, CO
Study Objectives: In crotaline snakebite, current recommendations are to administer antivenom to patients with progressive venom effect. In order to prevent
S44 Annals of Emergency Medicine
unnecessary antivenom administration, “watchful waiting” is recommended for patients whose condition is stable and not progressing. It is unknown if this approach decreases overall antivenom. Our objective was to determine the association between the time from bite to initial antivenom administration, and the total amount of antivenom administered; and to determine what proportion of patients did not receive antivenom using this recommended approach. Methods: We performed a retrospective chart review from April 2009 to October 2012 of patients presenting with crotaline snake envenomation. All patients presenting to a single tertiary care emergency department within 24 hours of reported snakebite and documented envenomation syndrome were included. Two blinded abstractors recorded each data point. Any disagreement in data was resolved by abstractor agreement and adjudicated by study personnel if necessary. Our primary outcome was total amount of antivenom given and secondary outcomes included proximal extension of local symptoms. Pearson correlation was used to examine the association between the total number of antivenom vials received and the time from bite to antivenom administration. General linear model was used to examine this association with categorized time to antivenom administration (0-3, 3-6, > 6þ hours), with and without covariates. The covariates used in the adjusted model are age, number of joints crossed by swelling at initial presentation and year of envenomation. Results: Preliminary analysis of 75 patients demonstrates that 71 (95%) received antivenom. Of the 71 patients, 43 (60.6%) were male. Age ranged from 15 months to 72 years, mean age was 36.5(SD ¼ 20.5) years. The total number of vials administered is correlated with the maximum progression of local limb symptoms (r ¼ 0.44, p ¼ 0.0002). The total number of vials administered is negatively correlated with the time to antivenom administration (r¼-0.18, p ¼ 0.14). Unadjusted analysis of general linear model of total vials of antivenom received by the time to antivenom divided into three groups (0-3, 3-6, >6 hours) showed significant association (p¼ 0.03) and there was significant difference between the 0-3 and >6 hours (12.7(SE¼0.8) vs. 8.7(SE¼1.3), p ¼ 0.01). Covariate adjusted analysis for age, initial joints crossed and year of envenomation did not show significant relation between total number of vials administered and time to antivenom administration (p ¼ 0.23). Conclusions: The strong correlation between progression of local limb symptoms and the total amount of antivenom suggests good adherence to current recommendations. This approach resulted in a small proportion of patients not receiving antivenom. The total amount of antivenom received was negatively correlated to time from bite to initial antivenom administration. Unadjusted analysis showed significant difference in the amount of antivenom received by those who received it in 0-3 vs. > 6 hours. A “watchful waiting” approach was not associated with increased antivenom use, rather the time to initial antivenom administration was a marker of a less severe clinical course.
115
Ongoing Opioid Misuse Identification in the Emergency Department Using the COMM Instrument Compared to Clinician Judgment
Varney SM, Bebarta VS, Ganem VJ, Carey KR, Ramos RG, Zarzabal LA/San Antonio Military Medical Center, San Antonio, TX; Wilford Hall Ambulatory Surgical Center, San Antonio, TX
Study Objective: Pain is a common complaint in the emergency department (ED). Emergency medicine providers (EMPs) have little time to assess patients for aberrant opioid behavior. The Current Opioid Misuse Measure (COMMTM) is a validated tool used to monitor pain patients on opioid therapy. We sought to compare EMP clinical judgment to a validated instrument, the COMM, to identify patients who may be at risk for ongoing prescription opioid misuse. Methods: We conducted an observational study of patients over age 18 years who sought treatment in the ED of a military tertiary care hospital and received at least one
Volume 62, no. 4s : October 2013