- Email: [email protected]
364: Acid Base Status as a Predictor of Severity in Salicylate Toxicity
Research Forum Abstracts Results: A total of 120 subjects were enrolled in the study, resulting in 57 subjects enrolled into each group, and six subjects who were treatment failures. Baseline characteristics did not differ (p ⬎ 0.05) between children in the study and placebo groups. However, one interesting difference that approached significance was that children in the study group had experienced more venipuncture needlesticks in the past two years (M ⫽ 6.8, SD ⫽ 15.0) than the placebo group (M ⫽ 2.8, SD ⫽ 3.7, t(63) ⫽ ⫺1.97, p ⫽ 0.054). The relative risk of a painful venipuncture stick was 1.2, or 20% greater (95% confidence interval 0.77 to 1.90) in the placebo group than the study group. There were no significant differences in mean levels of patient, parent or observer ratings of procedural anxiety, or patient pulse rate or the patient’s mean rating of venipuncture pain between the study and placebo groups (p ⬎ 0.05). There were no significant differences in mean pain ratings (p ⬎ 0.05) when data were grouped by patient age ranges (⬍ 7 years, 7–11 years, 12–18 years). Conclusion: Application of liposomal lidocaine prior to venipuncture did show a small reduction in relative risk of patient perceived venipuncture pain, but did not reduce the mean level of patient perceived pain during venipuncture. No differences in mean levels of procedural anxiety rating, patient pulse rate, or mean venipuncture pain rating was observed between study groups.
361
Medication Errors Occurring in Fomepizole Administration
Wong S, King R, Molai S, Fleishman J, Commons B, Labat M, Kleinschmidt K/ University of Texas Southwestern Medical Center, Dallas, TX; Medical Center of Lewisville, Lewisville, TX
Study Objective: Fomepizole (4MP) is an antidote for methanol and ethylene glycol toxicities. The first dose of 4MP is 15 mg/kg; the maintenance dose is decreased 33% to 10 mg/kg every 12 hours (h) for 4 doses (2nd to 5th doses). Starting with the 6th dose, 4MP is returned to 15 mg/kg every 12 h. During hemodialysis (HD), 4MP is given every 4 h. If the most recent 4MP dosing is ⬎ 6 h ago, then a dose should be given before starting HD. At the end of HD, if the most recent dose of 4MP is ⬎ 3 h ago, another full dose of 4MP should be given; if the most recent dose of 4MP is ⬍ 3 h ago, a 1⁄2 dose of 4MP should be given. The purpose of this study is to investigate the frequency and types of medication errors (ME) that occur during 4MP administration and the impact of these errors on persistent or worsening acidosis. Methods: We searched 2 hospital pharmacy databases on patients who received 4MP between 1-1-98 and 7-31-08. All patients who received 4MP in our study period were included. There were no other inclusion or exclusion criteria. A chart review was performed and a case report form was used for data collection. We define 4MP ME as any of the following conditions: 1) 4MP was given ⱖ 13 h apart; 2) the 2nd, 3rd, 4th or 5th dose is ⬍ 30% or ⬎ 35% decrease from the first dose; 3) the 6th dose is not the same as the first dose; or 4) incorrect frequency and/or dosage while the patient is on HD. The data were extracted by three data abstractors who were blinded to the purpose of the study and trained in data abstraction. Results: Of the 83 patients whose charts were examined; a total of 149 4MP doses were given; 25 patients received ⱖ 2 doses (totaling 66 doses in those patients). Of the 25 patients, 11 (44%) received 4MP ⱖ 13 h apart at least once, and 13 (52%) received improper dosage at least once. Of the 66 doses, 53 (80%) had timing errors (TE) and 20 (30%) had dosing errors (DE). Of the 20 DE, 17 (85%) received excessive 4MP. Of the 83 patients, 15 received HD and a total of 43 4MP doses. Of the 15 patients, 14 (93%) had at least one ME, representing 29 (67%) of the 43 dosings. No patient developed persistent or worsening acidosis secondary to 4MP ME. Conclusion: Limitations in our study include data abstraction errors and lack of patient’s weight preventing accurate weight-based dosing calculations. Our study suggests that in patients who received ⱖ 2 doses of 4MP, TE is the most common ME. Of the smaller portion of ME due to DE, most involved excessive 4MP dosing. The errors were not associated with worsening acidosis.
362
Coagulopathy in Pediatric Copperhead Snakebites
Anderson BW, Horwitz DA, Mullins ME/Washington University School of Medicine, St. Louis, MO; St. Louis University School of Medicine, St. Louis, MO
Study Objectives: The evaluation and management of known copperhead, Agkistrodon contortrix, snakebites remains somewhat controversial despite more recent literature asserting the lack of significant systemic and coagulopathic effects. It is quite common to see multiple, serial coagulation studies followed on these patients. In this study we determine the incidence of coagulopathy in pediatric copperhead snakebites.
S114 Annals of Emergency Medicine
Methods: We performed an institutional review board-approved, retrospective chart review of all pediatric venomous snakebites over the past fifteen years presenting to St. Louis Children’s Hospital, a large, urban tertiary care facility. Cases were identified by querying billing data using ICD-9 codes for venomous snakebites and lizards E905.0, nonvenomous snakebites E906.2, and toxic effects of venom 989.5. From this list of cases, nonvenomous snakebites and bites or stings from other animals were excluded. The remaining individual charts were then reviewed noting the following: patient demographics including age, sex, zip code; whether the type of snake was identified with certainty, presumptively identified, or unknown; location of bite on patient; laboratory assessment of coagulation parameters; presence of clinical bleeding complications. Results: Our search yielded 428 patient records of which 338 were excluded. We reviewed the 89 remaining charts coded as venomous reptile bites. Of these 89 charts, we excluded 11 charts including 3 re-admissions for secondary closure after fasciotomy, 1 dry bite, 1 iguana bite, 1 miscoded chart, 1 admission for delayed wound complications after initial admission elsewhere, 3 charts which were inaccessible due to microfilm malfunction, and 1 definite rattlesnake bite. The final data set included 78 venomous snakebites, of which 18 were positively identified as copperheads, 36 were presumptively identified as copperheads, and 24 were unknown. In no case did clinically apparent bleeding complications develop. Mean and median values for most abnormal coagulation studies for each patient by degree of certainty were: positively identified copperheads PT 12.9/13, PTT 30.6/30.3, INR 1.08/1.06, Plt’s 265/259, fibrinogen 226/229; presumptively identified copperheads PT 13.7/14.1, PTT 29.6/29.2, INR 1.09/1.09, Plt’s 270/252 fibrinogen 263/258, and c) unknown PT 14.2/14.4, PTT 30/30, INR 1.1/1.1, Plt’s 291/275, fibrinogen 293/289. One outlier in the “unknown” category had INR ⬎8, PT ⬎65, PTT ⬎150, Plt’s 187 but no clinical bleeding complications. This patient was bitten by an unknown “black snake” believed by the toxicology consultant to be a rattlesnake and was excluded from the above data analysis. Conclusion: In snakebites known with certainty to be from copperheads, it is safe to forego coagulation testing thereby saving significant money and patient discomfort.
363
Obese Dosing Adjustments for Selected Antimicrobials in the Emergency Department
Fuentes JM, Mullins ME/Washington University School of Medicine in St. Louis, St. Louis, MO; Washington University in St. Louis, St. Louis, MO
Study Objective: The Centers for Disease Control and Prevention have reported a dramatic increase in obesity over the past 20 years in the United States, making obesity a public health crisis. Emergency physicians should be aware of pharmacokinetic and pharmacodynamic changes in the obese population. We evaluated whether our institution’s emergency physicians are adhering to dose adjustment for selected antibiotics based on guidelines from our antibiotic utilization review (AUR) committee. Methods: From January to March 2008, we performed a retrospective review of patients at an urban level I trauma center. All patients studied had a weight ⬎100 kg; a body mass index ⬎40 kg/m2; and received cefazolin, cefepime, or ciprofloxacin in the emergency department. Based on AUR guidelines, the initial dose regardless of creatinine clearance should be 2 g IV for cefazolin or cefepime and 800 mg IV or 750 mg PO for ciprofloxacin. If patients did not receive the prior dosing for these antibiotics, the dose was considered to not adhere to the guidelines. Results: A total of 1,072 patients met the study criteria, and 30 received more than one antibiotic. A total of 503, 293, and 306 doses of cefepime, cefazolin, and ciprofloxacin were given, respectively. The guidelines for cefepime, cefazolin, and ciprofloxacin were not adhered to for 455 (90.5%), 281 (95.9%), and 302 (98.7%) doses, respectively, while the guidelines were adhered to for 48 (9.5%), 12 (4.1%) and 4 (1.3%) doses, respectively. Conclusions: Antimicrobial dose adjustment in the severely obese population rarely occurs in the emergency department. Failure to dose-adjust antibiotics in this population can lead to inadequate treatment and also may promote resistance to antimicrobials.
364
Acid Base Status as a Predictor of Severity in Salicylate Toxicity
Levine M, Gresham C, Brooks DE, Lansburg J, Kania R, Thomas SH/Banner Good Samaritan Medical Center, Phoenix, AZ; University of Oklahoma, Tulsa, OK
Study Objectives: We sought to determine if the acid base status on presentation to the emergency department (ED) could be used as a marker of severity of salicylate
Volume , . : September
Research Forum Abstracts toxicity. Furthermore, we attempted to determine if intubation was temporally associated with death, as has been previously suggested. Methods: We reviewed the charts of all patients admitted to an in-patient toxicology service for salicylate (SAL) toxicity over an 8-year period. Patients were excluded if the peak SAL level was less than 40 mg/dL. For patients with multiple admissions with salicylate toxicity, only the first visit was included in the analysis. The main outcome measurement was a composite endpoint of death, permanent neurologic disability, or hemodynamic instability (as defined by use of a vasopressor). Data were abstracted onto a pre-designed data collection sheet. We used both univariate and multivariate regression analysis to assess significance of included variables. Results: We identified 127 unique patient encounters and were able to retrieve 122 full records. One patient died, and one suffered permanent disability. Eight patients required vasopressors and nineteen patients received hemodialysis. The median (IQR) age was 24 (18 –38) years. The median (IQR) peak SAL concentration was 63.9 (52.3–74.8) mg/dL; the highest SAL level was 152 mg/dL. Among the 122 patients, sixteen patients were intubated and received mechanical ventilation. The median (IQR) peak SAL concentration among those patient receiving mechanical ventilation was 70.2 (52.3– 80.1). Among these patients, only one patient died. This patient developed non-cardiogenic pulmonary edema, and despite dialysis, died several hours after intubation from hypoxia attributed to the pulmonary edema. His oxygenation saturation on 100% FiO2 at the time of death was 67% on an arterial blood gas. The SAL level at the time of death was 36 mg/dL. The median (IQR) initial pH was 7.45 (7.42–7.49). Each increase in pH of 0.01 was associated with decreased odds of reaching the composite endpoint (OR 0.90; 95% CI 0.84 – 0.96; p⫽0.003). Similarly, for each increase in the serum CO2 of 1 mmol/L, there is a 23% reduction in likelihood of reaching the endpoint (OR 0.77; 95% CI 0.63– 0.95; p⫽0.01). Even after adjusting for age and peak SAL concentration, the pH still remained an important predictor of reaching the composite endpoint (OR 0.92; 95% CI 0.85– 0.98; p⫽0.02). Conclusion: In this study, we found acidosis was associated with worse outcomes, even after adjusting for other factors, such as age and peak SAL concentration. Patients presenting with acidosis had worse outcomes. Despite frequent teaching that intubation is harmful, with aggressive ventilator management, we did not observe any deaths immediately after intubation.
365
Fatal Toxicity From Nucleoside Reverse Transcriptase Inhibitor Use: Factors Implicated With Symptomatic Hyperlactemia Emergencies
Leung L, Manini A, Wilson D/Mount Sinai School of Medicine, New York, NY; Edendale Hospital, Pietermaritzburg, South Africa
Background: In South Africa, first-line therapy for HIV includes a nucleoside reverse transcriptase inhibitor (NRTI). Chronic NRTI use is associated with symptomatic hyperlactemia emergencies due to inhibition of mitochondrial DNA polymerase gamma, a potentially fatal complication. Study Objectives: To derive factors associated with fatality from NRTI-related symptomatic hyperlactatemia emergencies in African HIV patients. Methods: Design/Setting: We performed a retrospective cohort study at Edendale Hospital, a 900-bed university hospital in South Africa over 4 years (2005–2008). Subjects: Patients were included who had symptomatic hyperlactatemia emergencies, defined as: chronic NRTI use; ED lactate ⬎ 4.0 mmol/L; absence of infectious source; and symptoms requiring admission. We excluded those with incomplete follow-up data (n⫽6) and inter-hospital transfers (n⫽2). Observations: The primary outcome was in-hospital fatality. Data included demographics, medical history, NRTI duration, blood pressure, symptom duration, and relevant laboratory data (lactate, A-a gradient, anion gap, WBC, and creatinine). Statistical analysis with SPSS software included chi-squared and t-test. Results: Of 79 patients who met inclusion/exclusion criteria (38.2⫹/⫺10.5, 97% female) there were 46 fatalities (58%). Factors significantly associated with death were: lactate ⬎ 10 mmol/L (p⫽0.03), pH ⬍ 7.2 ( p⫽0.02), and altered mental status (defined as GCS ⬍14) (p⫽0.029). Using the t-test, factors significantly associated with death were: MAP (p⫽0.039), pH (p⬍0.001), lactate (p⬍0.001), HCO3 (p⫽0.002), CO2 (p⫽0.007), and GCS (p⬍0.05). Conclusion: In this derivation study, NRTI-related symptomatic hyperlactatemia emergencies occurred predominantly in females. Mortality was associated with severely elevated lactate (⬎10mmol/L), degree of acidosis, altered mental status, and MAP on presentation. We recommend increased monitoring and further prospective study of these high risk groups.
Volume , . : September
366
Clinical Experience of Continuous Renal Replacement Therapy as an Extracorporeal Elimination Performed by Emergency Physicians in Patients With Poisoning
Park E/Ajou University Medical Center, Suwon, Kyoung-Gi Do, Republic of Korea
Study Objectives: Extracorporeal elimination of drugs is a critical part in the management of poisonings, although indications and optimal method remain a matter of debate. The aim of this study is to report our clinical experiences of continuous renal replacement therapy (CRRT) as an extracorporeal elimination in patients with poisoning performed by emergency physicians. Methods: This study was retrospective consecutive study in patients who underwent CRRT by emergency physicians from acute poisoning. Characteristics, kind of drugs, and the method of extracorporeal elimination were analyzed by reviewing the patients’ chart. Results: During 11 months, 26 patients with acute poisoning underwent extracorporeal elimination (2 patients; intermittent hemodialysis, 24 patients; CRRT). The time from decision to performing extracorporeal elimination was 206.0⫾36.8 in intermittent hemodialysis, 62.9⫾8.5 in continuous venoveno hemodiafiltration (CVVHDF), and 56.6⫾6.8 minutes in charcoal hemoperfusion. In patients with CRRT, CVVHDF were conducted in 10 patients (3 patients; valproic acid, 2 patients; lithium, 1 patient; salicylates, 1 patient; methanol) and charcoal hemoperfusion by using CRRT in 14 patients (13 patients; paraquat, 1 patient; dapsone). In 12 patients of requirement of hemodialysis due to severe poisoning, 8 patients underwent CRRT because of their unstable vital sign. Three patients in 13 patients with paraquat poisoning were survival. Conclusion: CRRT was effective method of extracorporeal elimination in patients with acute poisoning, especially in cases of unstable vital signs and requirement of early start of extracorporeal elimination according to chracteristics of drug.
367
Are Venous Carboxyhemoglobin Levels Being Utilized by Physicians?
Bloomer C, Kairam N, Fiesseler F, Riggs R, Salo D/Morristown Memorial Hospital, Morristown, NJ; UMDNJ- Robert Wood Johnson Medical School, New Brunswick, NJ
Background: Carbon monoxide (CO) is the most common toxic gas encountered in the emergency department. Data suggests that arterial carboxyhemoglobin (COHgb) levels are equivalent to those obtained venously, without the increased pain and difficulty. Study Objectives: To determine the utilization of arterial versus venous COhgb levels obtained in patients exposed to carbon monoxide. Methods: Design: A multi-center retrospective emergency department (ED) cohort study. Setting: 23 New Jersey and New York EDs. Subjects: Consecutive patients with the ED diagnosis of toxic effect of CO, identified from January 1, 2000 to October 31, 2006 had manual chart review performed. Statistics: Mann-Whitney and Chi Square with a preset alpha of 0.05. Results: Out of 4.2 million consecutive patients in the 23 EDs, 1131 ED patients were identified with ICD9 of toxic effects of carbon monoxide. Mean age was 31 yrs (SD ⫹/⫺ 20) and 53% were female. CO levels were documented in 548 patient charts. Of these, arterial draws were documented in 43% (n⫽231), venous in 6% (n⫽34), and not able to be determined in 51% (n⫽283). The average arterial COhgb was 9.8 (95% CI ⫹/⫺ 2.7) versus 11 (95% CI ⫹/⫺ 3.6) in the venous arm (p⫽0.67). Median age in years was 27 (SD ⫹/⫺ 19) those obtained venously and 35 (SD ⫹/⫺ 19) in arterially drawn. Of patients receiving arterial draws 15% (n⫽37) were admitted, versus 11% (n⫽4) of those receiving venous draws (p⫽0.03). Yearly percentage of known draws that were arterial from 2000-2006 were: 26/26 (100%), 23/27 (85%), 27/35 (77%), 50/58 (86%), 35/40 (87%), 38/45 (84%), and 32/34 (94%), respectively. Conclusions: A large number of patients suspected of CO intoxication are still receiving unnecessary arterial draws.
368
Diphenhydramine Increases Lethality in a Porcine Model of Intravenous Rattlesnake Envenomation
Sekhon N, Fish L, Brewer KL, O’Rourke D, Meggs WJ/Brody School of Medicine, Greenville, NC
Study Objectives: Cardiovascular collapse is rarely seen in rattlesnake envenomations but can occur immediately after the snakebite. Intravenous
Annals of Emergency Medicine S115
361
Medication Errors Occurring in Fomepizole Administration
Wong S, King R, Molai S, Fleishman J, Commons B, Labat M, Kleinschmidt K/ University of Texas Southwestern Medical Center, Dallas, TX; Medical Center of Lewisville, Lewisville, TX
Study Objective: Fomepizole (4MP) is an antidote for methanol and ethylene glycol toxicities. The first dose of 4MP is 15 mg/kg; the maintenance dose is decreased 33% to 10 mg/kg every 12 hours (h) for 4 doses (2nd to 5th doses). Starting with the 6th dose, 4MP is returned to 15 mg/kg every 12 h. During hemodialysis (HD), 4MP is given every 4 h. If the most recent 4MP dosing is ⬎ 6 h ago, then a dose should be given before starting HD. At the end of HD, if the most recent dose of 4MP is ⬎ 3 h ago, another full dose of 4MP should be given; if the most recent dose of 4MP is ⬍ 3 h ago, a 1⁄2 dose of 4MP should be given. The purpose of this study is to investigate the frequency and types of medication errors (ME) that occur during 4MP administration and the impact of these errors on persistent or worsening acidosis. Methods: We searched 2 hospital pharmacy databases on patients who received 4MP between 1-1-98 and 7-31-08. All patients who received 4MP in our study period were included. There were no other inclusion or exclusion criteria. A chart review was performed and a case report form was used for data collection. We define 4MP ME as any of the following conditions: 1) 4MP was given ⱖ 13 h apart; 2) the 2nd, 3rd, 4th or 5th dose is ⬍ 30% or ⬎ 35% decrease from the first dose; 3) the 6th dose is not the same as the first dose; or 4) incorrect frequency and/or dosage while the patient is on HD. The data were extracted by three data abstractors who were blinded to the purpose of the study and trained in data abstraction. Results: Of the 83 patients whose charts were examined; a total of 149 4MP doses were given; 25 patients received ⱖ 2 doses (totaling 66 doses in those patients). Of the 25 patients, 11 (44%) received 4MP ⱖ 13 h apart at least once, and 13 (52%) received improper dosage at least once. Of the 66 doses, 53 (80%) had timing errors (TE) and 20 (30%) had dosing errors (DE). Of the 20 DE, 17 (85%) received excessive 4MP. Of the 83 patients, 15 received HD and a total of 43 4MP doses. Of the 15 patients, 14 (93%) had at least one ME, representing 29 (67%) of the 43 dosings. No patient developed persistent or worsening acidosis secondary to 4MP ME. Conclusion: Limitations in our study include data abstraction errors and lack of patient’s weight preventing accurate weight-based dosing calculations. Our study suggests that in patients who received ⱖ 2 doses of 4MP, TE is the most common ME. Of the smaller portion of ME due to DE, most involved excessive 4MP dosing. The errors were not associated with worsening acidosis.
362
Coagulopathy in Pediatric Copperhead Snakebites
Anderson BW, Horwitz DA, Mullins ME/Washington University School of Medicine, St. Louis, MO; St. Louis University School of Medicine, St. Louis, MO
Study Objectives: The evaluation and management of known copperhead, Agkistrodon contortrix, snakebites remains somewhat controversial despite more recent literature asserting the lack of significant systemic and coagulopathic effects. It is quite common to see multiple, serial coagulation studies followed on these patients. In this study we determine the incidence of coagulopathy in pediatric copperhead snakebites.
S114 Annals of Emergency Medicine
Methods: We performed an institutional review board-approved, retrospective chart review of all pediatric venomous snakebites over the past fifteen years presenting to St. Louis Children’s Hospital, a large, urban tertiary care facility. Cases were identified by querying billing data using ICD-9 codes for venomous snakebites and lizards E905.0, nonvenomous snakebites E906.2, and toxic effects of venom 989.5. From this list of cases, nonvenomous snakebites and bites or stings from other animals were excluded. The remaining individual charts were then reviewed noting the following: patient demographics including age, sex, zip code; whether the type of snake was identified with certainty, presumptively identified, or unknown; location of bite on patient; laboratory assessment of coagulation parameters; presence of clinical bleeding complications. Results: Our search yielded 428 patient records of which 338 were excluded. We reviewed the 89 remaining charts coded as venomous reptile bites. Of these 89 charts, we excluded 11 charts including 3 re-admissions for secondary closure after fasciotomy, 1 dry bite, 1 iguana bite, 1 miscoded chart, 1 admission for delayed wound complications after initial admission elsewhere, 3 charts which were inaccessible due to microfilm malfunction, and 1 definite rattlesnake bite. The final data set included 78 venomous snakebites, of which 18 were positively identified as copperheads, 36 were presumptively identified as copperheads, and 24 were unknown. In no case did clinically apparent bleeding complications develop. Mean and median values for most abnormal coagulation studies for each patient by degree of certainty were: positively identified copperheads PT 12.9/13, PTT 30.6/30.3, INR 1.08/1.06, Plt’s 265/259, fibrinogen 226/229; presumptively identified copperheads PT 13.7/14.1, PTT 29.6/29.2, INR 1.09/1.09, Plt’s 270/252 fibrinogen 263/258, and c) unknown PT 14.2/14.4, PTT 30/30, INR 1.1/1.1, Plt’s 291/275, fibrinogen 293/289. One outlier in the “unknown” category had INR ⬎8, PT ⬎65, PTT ⬎150, Plt’s 187 but no clinical bleeding complications. This patient was bitten by an unknown “black snake” believed by the toxicology consultant to be a rattlesnake and was excluded from the above data analysis. Conclusion: In snakebites known with certainty to be from copperheads, it is safe to forego coagulation testing thereby saving significant money and patient discomfort.
363
Obese Dosing Adjustments for Selected Antimicrobials in the Emergency Department
Fuentes JM, Mullins ME/Washington University School of Medicine in St. Louis, St. Louis, MO; Washington University in St. Louis, St. Louis, MO
Study Objective: The Centers for Disease Control and Prevention have reported a dramatic increase in obesity over the past 20 years in the United States, making obesity a public health crisis. Emergency physicians should be aware of pharmacokinetic and pharmacodynamic changes in the obese population. We evaluated whether our institution’s emergency physicians are adhering to dose adjustment for selected antibiotics based on guidelines from our antibiotic utilization review (AUR) committee. Methods: From January to March 2008, we performed a retrospective review of patients at an urban level I trauma center. All patients studied had a weight ⬎100 kg; a body mass index ⬎40 kg/m2; and received cefazolin, cefepime, or ciprofloxacin in the emergency department. Based on AUR guidelines, the initial dose regardless of creatinine clearance should be 2 g IV for cefazolin or cefepime and 800 mg IV or 750 mg PO for ciprofloxacin. If patients did not receive the prior dosing for these antibiotics, the dose was considered to not adhere to the guidelines. Results: A total of 1,072 patients met the study criteria, and 30 received more than one antibiotic. A total of 503, 293, and 306 doses of cefepime, cefazolin, and ciprofloxacin were given, respectively. The guidelines for cefepime, cefazolin, and ciprofloxacin were not adhered to for 455 (90.5%), 281 (95.9%), and 302 (98.7%) doses, respectively, while the guidelines were adhered to for 48 (9.5%), 12 (4.1%) and 4 (1.3%) doses, respectively. Conclusions: Antimicrobial dose adjustment in the severely obese population rarely occurs in the emergency department. Failure to dose-adjust antibiotics in this population can lead to inadequate treatment and also may promote resistance to antimicrobials.
364
Acid Base Status as a Predictor of Severity in Salicylate Toxicity
Levine M, Gresham C, Brooks DE, Lansburg J, Kania R, Thomas SH/Banner Good Samaritan Medical Center, Phoenix, AZ; University of Oklahoma, Tulsa, OK
Study Objectives: We sought to determine if the acid base status on presentation to the emergency department (ED) could be used as a marker of severity of salicylate
Volume , . : September
Research Forum Abstracts toxicity. Furthermore, we attempted to determine if intubation was temporally associated with death, as has been previously suggested. Methods: We reviewed the charts of all patients admitted to an in-patient toxicology service for salicylate (SAL) toxicity over an 8-year period. Patients were excluded if the peak SAL level was less than 40 mg/dL. For patients with multiple admissions with salicylate toxicity, only the first visit was included in the analysis. The main outcome measurement was a composite endpoint of death, permanent neurologic disability, or hemodynamic instability (as defined by use of a vasopressor). Data were abstracted onto a pre-designed data collection sheet. We used both univariate and multivariate regression analysis to assess significance of included variables. Results: We identified 127 unique patient encounters and were able to retrieve 122 full records. One patient died, and one suffered permanent disability. Eight patients required vasopressors and nineteen patients received hemodialysis. The median (IQR) age was 24 (18 –38) years. The median (IQR) peak SAL concentration was 63.9 (52.3–74.8) mg/dL; the highest SAL level was 152 mg/dL. Among the 122 patients, sixteen patients were intubated and received mechanical ventilation. The median (IQR) peak SAL concentration among those patient receiving mechanical ventilation was 70.2 (52.3– 80.1). Among these patients, only one patient died. This patient developed non-cardiogenic pulmonary edema, and despite dialysis, died several hours after intubation from hypoxia attributed to the pulmonary edema. His oxygenation saturation on 100% FiO2 at the time of death was 67% on an arterial blood gas. The SAL level at the time of death was 36 mg/dL. The median (IQR) initial pH was 7.45 (7.42–7.49). Each increase in pH of 0.01 was associated with decreased odds of reaching the composite endpoint (OR 0.90; 95% CI 0.84 – 0.96; p⫽0.003). Similarly, for each increase in the serum CO2 of 1 mmol/L, there is a 23% reduction in likelihood of reaching the endpoint (OR 0.77; 95% CI 0.63– 0.95; p⫽0.01). Even after adjusting for age and peak SAL concentration, the pH still remained an important predictor of reaching the composite endpoint (OR 0.92; 95% CI 0.85– 0.98; p⫽0.02). Conclusion: In this study, we found acidosis was associated with worse outcomes, even after adjusting for other factors, such as age and peak SAL concentration. Patients presenting with acidosis had worse outcomes. Despite frequent teaching that intubation is harmful, with aggressive ventilator management, we did not observe any deaths immediately after intubation.
365
Fatal Toxicity From Nucleoside Reverse Transcriptase Inhibitor Use: Factors Implicated With Symptomatic Hyperlactemia Emergencies
Leung L, Manini A, Wilson D/Mount Sinai School of Medicine, New York, NY; Edendale Hospital, Pietermaritzburg, South Africa
Background: In South Africa, first-line therapy for HIV includes a nucleoside reverse transcriptase inhibitor (NRTI). Chronic NRTI use is associated with symptomatic hyperlactemia emergencies due to inhibition of mitochondrial DNA polymerase gamma, a potentially fatal complication. Study Objectives: To derive factors associated with fatality from NRTI-related symptomatic hyperlactatemia emergencies in African HIV patients. Methods: Design/Setting: We performed a retrospective cohort study at Edendale Hospital, a 900-bed university hospital in South Africa over 4 years (2005–2008). Subjects: Patients were included who had symptomatic hyperlactatemia emergencies, defined as: chronic NRTI use; ED lactate ⬎ 4.0 mmol/L; absence of infectious source; and symptoms requiring admission. We excluded those with incomplete follow-up data (n⫽6) and inter-hospital transfers (n⫽2). Observations: The primary outcome was in-hospital fatality. Data included demographics, medical history, NRTI duration, blood pressure, symptom duration, and relevant laboratory data (lactate, A-a gradient, anion gap, WBC, and creatinine). Statistical analysis with SPSS software included chi-squared and t-test. Results: Of 79 patients who met inclusion/exclusion criteria (38.2⫹/⫺10.5, 97% female) there were 46 fatalities (58%). Factors significantly associated with death were: lactate ⬎ 10 mmol/L (p⫽0.03), pH ⬍ 7.2 ( p⫽0.02), and altered mental status (defined as GCS ⬍14) (p⫽0.029). Using the t-test, factors significantly associated with death were: MAP (p⫽0.039), pH (p⬍0.001), lactate (p⬍0.001), HCO3 (p⫽0.002), CO2 (p⫽0.007), and GCS (p⬍0.05). Conclusion: In this derivation study, NRTI-related symptomatic hyperlactatemia emergencies occurred predominantly in females. Mortality was associated with severely elevated lactate (⬎10mmol/L), degree of acidosis, altered mental status, and MAP on presentation. We recommend increased monitoring and further prospective study of these high risk groups.
Volume , . : September
366
Clinical Experience of Continuous Renal Replacement Therapy as an Extracorporeal Elimination Performed by Emergency Physicians in Patients With Poisoning
Park E/Ajou University Medical Center, Suwon, Kyoung-Gi Do, Republic of Korea
Study Objectives: Extracorporeal elimination of drugs is a critical part in the management of poisonings, although indications and optimal method remain a matter of debate. The aim of this study is to report our clinical experiences of continuous renal replacement therapy (CRRT) as an extracorporeal elimination in patients with poisoning performed by emergency physicians. Methods: This study was retrospective consecutive study in patients who underwent CRRT by emergency physicians from acute poisoning. Characteristics, kind of drugs, and the method of extracorporeal elimination were analyzed by reviewing the patients’ chart. Results: During 11 months, 26 patients with acute poisoning underwent extracorporeal elimination (2 patients; intermittent hemodialysis, 24 patients; CRRT). The time from decision to performing extracorporeal elimination was 206.0⫾36.8 in intermittent hemodialysis, 62.9⫾8.5 in continuous venoveno hemodiafiltration (CVVHDF), and 56.6⫾6.8 minutes in charcoal hemoperfusion. In patients with CRRT, CVVHDF were conducted in 10 patients (3 patients; valproic acid, 2 patients; lithium, 1 patient; salicylates, 1 patient; methanol) and charcoal hemoperfusion by using CRRT in 14 patients (13 patients; paraquat, 1 patient; dapsone). In 12 patients of requirement of hemodialysis due to severe poisoning, 8 patients underwent CRRT because of their unstable vital sign. Three patients in 13 patients with paraquat poisoning were survival. Conclusion: CRRT was effective method of extracorporeal elimination in patients with acute poisoning, especially in cases of unstable vital signs and requirement of early start of extracorporeal elimination according to chracteristics of drug.
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Are Venous Carboxyhemoglobin Levels Being Utilized by Physicians?
Bloomer C, Kairam N, Fiesseler F, Riggs R, Salo D/Morristown Memorial Hospital, Morristown, NJ; UMDNJ- Robert Wood Johnson Medical School, New Brunswick, NJ
Background: Carbon monoxide (CO) is the most common toxic gas encountered in the emergency department. Data suggests that arterial carboxyhemoglobin (COHgb) levels are equivalent to those obtained venously, without the increased pain and difficulty. Study Objectives: To determine the utilization of arterial versus venous COhgb levels obtained in patients exposed to carbon monoxide. Methods: Design: A multi-center retrospective emergency department (ED) cohort study. Setting: 23 New Jersey and New York EDs. Subjects: Consecutive patients with the ED diagnosis of toxic effect of CO, identified from January 1, 2000 to October 31, 2006 had manual chart review performed. Statistics: Mann-Whitney and Chi Square with a preset alpha of 0.05. Results: Out of 4.2 million consecutive patients in the 23 EDs, 1131 ED patients were identified with ICD9 of toxic effects of carbon monoxide. Mean age was 31 yrs (SD ⫹/⫺ 20) and 53% were female. CO levels were documented in 548 patient charts. Of these, arterial draws were documented in 43% (n⫽231), venous in 6% (n⫽34), and not able to be determined in 51% (n⫽283). The average arterial COhgb was 9.8 (95% CI ⫹/⫺ 2.7) versus 11 (95% CI ⫹/⫺ 3.6) in the venous arm (p⫽0.67). Median age in years was 27 (SD ⫹/⫺ 19) those obtained venously and 35 (SD ⫹/⫺ 19) in arterially drawn. Of patients receiving arterial draws 15% (n⫽37) were admitted, versus 11% (n⫽4) of those receiving venous draws (p⫽0.03). Yearly percentage of known draws that were arterial from 2000-2006 were: 26/26 (100%), 23/27 (85%), 27/35 (77%), 50/58 (86%), 35/40 (87%), 38/45 (84%), and 32/34 (94%), respectively. Conclusions: A large number of patients suspected of CO intoxication are still receiving unnecessary arterial draws.
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Diphenhydramine Increases Lethality in a Porcine Model of Intravenous Rattlesnake Envenomation
Sekhon N, Fish L, Brewer KL, O’Rourke D, Meggs WJ/Brody School of Medicine, Greenville, NC
Study Objectives: Cardiovascular collapse is rarely seen in rattlesnake envenomations but can occur immediately after the snakebite. Intravenous
Annals of Emergency Medicine S115