- Email: [email protected]
396 Variability in Antivenom Treatment in Snake Envenomations Between Two Major Tertiary Care Emergency Departments
Research Forum Abstracts or ZPD were evaluated and those with compete vital signs (SBP, HR & SaO2) recorded before and 4 hours after administration of SGAs were selected for inclusion. Variables extracted were patient age, vitals, use of benzodiazepines within 30 min of SGA, and alcohol intoxication. Vital signs prior to medication and the lowest values within 4h after were used for comparisons. Descriptive statistics are reported for mean change in SBP, HR and SaO2. Differences in mean change in vitals were evaluated with ANOVAs. Results: A total of 852 patient visits were included (758 unique patients), average age was 44 (range 15-97) and 590 (69.2%) patients were male; 69.5% of patients received RSP, 24.3% OZP, 5.8% QTP and 0.5% 0% ZPD. Average decreases in vitals were: SBP 8.3 mm Hg, HR 5.8 bpm, SaO2 0.25% which is to be expected as patients calm. There were no significant differences in decreases in systolic BP between medications (F(3,848)¼1.9, P¼.13). Thirty-four (4%) of patients became hypotensive defined as SBP 95mmHg, consisting of 8.2% of QTP patients, 4.3% of OZP, 0% of ZPD, and 3.5% of RSP. Postadmin SaO2 92% was seen only in 3 patients, all of whom had risperidone, and only 1 of whom had benzodiazepines. Adjunctive benzodiazepines were used in 190 (22.3%) cases at an average dose of 1.8mg of Ativan or its equivalent. Of the 34 patients with hypotension, only 7 received adjunctive benzodiazepines. Alcohol use was present in in 18.4% of QTP, 25% of ZPD, 11.8% of RSP, and 7.2% of OZP visits. Only 4 alcohol-using patients (2 OZP, 2 RSP) became hypotensive. The average BAL was 152 mg/dl with no significant differences between medication groups (F(3,570)¼2.1, P¼.11). Conclusion: Risperidone is the most frequently prescribed of oral SGAs in the ED setting. Oral SGAs are infrequently given to alcohol intoxicated patients. Oral SGAs are used with benzodiazepines >20% of the time. Average change in vital signs for oral SGAs are largely similar between groups.
394
Three-Factor Prothrombin Complex Concentrate for Correction of Warfarin-Induced Coagulopathy in High Risk Central Nervous System Bleeding
Ching BC, Ng V/Alameda County Medical Center, Highland General Hospital, Oakland, CA
Background: Life-threatening bleeding in the central nervous system (CNS) due to a warfarin-induced coagulopathy is a common problem facing emergency practitioners across the country. In addition to frozen plasma (FP), prothrombin complex concentrate (PCC) is an option for reversal. An INR less than 1.7 is considered adequate reversal of warfarin induced coagulopathy for bleeding in critical areas (eg, CNS, eye). Until recently, only three-factor PCC was available in the United States. Objective: To review the experiences of a high-volume urban trauma center using three-factor PCC (ProfilNine SD) to reverse coumadin-induced coagulopathies in patients with life-threatening CNS bleeding. Methods: A retrospective case series was conducted in a large urban trauma center in the US. Patients who had life-threatening CNS hemorhage and received three-factor PCC to correct their warfarin-induced coagulopathy were selected. Data collected included initial INR, post-reversal INR, time from administration of PCC to postreversal INR, use of FP and use of vitamin K. All PCC was dosed using a strict weightbased pharmacy protocol of 50 international units/kilogram. Results: Thirty-four patients chronically anticoagulated with warfarin (mean INR 3.85, median 2.75, mode 2.1, SD 3.04, range 1.5-14.3) presenting with acute subdural hemorrhage, 16 14 12
INR
10
subarachnoid hemorrhage or both were administered PCC. Three (9%) received PCC alone, nine (26%) received PCC and FP, nine (26%) received PCC and Vitamin K, and eight (23.5%) received PCC, FP and Vitamin K. Post-PCC INRs were obtained over a variety of time periods, all within 24 hours of PCC adminsiration. All post-PCC INRs corrected to 2.4 or lower (mean INR 1.4, median 1.3, mode 1.2, SD 0.3, range 1.1-2.4). Conclusion: Three-factor PCC was successful in correcting warfarin-induced coagulopathy in patients chronically anticoagulated with warfarin with high risk CNS bleeding.
395 396
Withdrawn
Variability in Antivenom Treatment in Snake Envenomations Between Two Major Tertiary Care Emergency Departments
Ward KN, Wortley AG, Quackenbush EB, Gerardo CJ/University of North Carolina Hospital, Chapel Hill, NC; Duke University Hospital, Durham, NC
Study Objective: Approximately 8,000 people a year in the United States are reported to the CDC as sustaining venomous snake bites. Copperhead envenomations comprised 41% of these bites in 2011 and are the predominant poisonous snake in the Southeastern United States. Unlike rattlesnake envenomation, there is limited evidence regarding treatment in copperhead predominant populations. Controversy exists as to the appropriateness and effectiveness of treatment in this population, creating the potential for wide practice variation amongst providers and emergency departments (EDs). Our objective is to compare the rates of antivenom use for snakebite between two similar large academic EDs within the same geographic region. Methods: We performed a retrospective chart review of patients presenting to two large academic EDs located 11 miles apart, from April 1, 2009 to October 31, 2012. Both EDs are located in copperhead predominant areas. All patients presenting with reported snakebites were included. An initial search of the final ED diagnosis for ICD-9 Codes 989.5 (toxic effect of venom) and E905.0 (venomous snakes and lizards causing poisoning and toxic reactions) to find all snake envenomation patients presenting during the study period was performed. Continuous variables were summarized using means, standard deviations as appropriate. Frequencies and proportions were used to describe categorical data with confidence intervals of the proportions. The primary outcome was the proportion of patients receiving antivenom during their initial visit. A Fisher’s exact test was used to compare antivenom use between sites. Secondary outcomes included immediate allergic reactions, surgery and unplanned return visits. Results: Two hundred and forty-six eligible patients were analyzed, 142 from site 1 and 104 from site 2. There are similar demographics at both sites. The mean age overall and at both sites was 37 years (SD 20.1). There were 44% (108/246) females overall, 40% (57/142) site 1 and 49% (51/104) site 2. At site 1, 5.6% (8/142) of the patients were taking antiplatelet medications as compared with 9.6% (10/104) at site 2. Only 1 patient reported anticoagulation use and 4 had chronic extremity disorders. Sixty-one percent (86/142) of patients at site 1 sustained a copperhead snakebite as compared with 74% (77/104) at site 2. There were 3.5% versus 3.8% presenting as dry bites, 60.5% versus 49% minimal grade, 35% versus 46% moderate grade, and 0.7% versus 1% severe grade envenomations at site 1 and site 2 respectively (P¼.02). Forty-nine percent (120/246) of all patients received antivenom. There was significant variation between site 1 and site 2; 21.8% (31/142) (95% CI 0.16, 0.29) and 83.7% (87/104) (95% CI 0.75, 0.90), P<.0001. Of the 118 patients who received antivenom, 14.4% (17/118) had allergic reactions, with one classified as severe. There was only 1 surgery. Site 1 had more unplanned return visits at 10% versus 0% (P¼.004). Conclusions: Wide practice variation exists in the use of antivenom in copperhead predominant populations. Antivenom use should depend on its effectiveness and the patient’s clinical presentation, rather than facility-related practice patterns. Further evidence is necessary to better align antivenom use in locales where copperhead snakebites predominate.
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Outcomes of Unintentional Pediatric Ingestions in a Pediatric Emergency Department Observation Unit: Which Ingestion is Most Likely to Lead to an Admission?
Ojo AO, Alam S, Shenoi R/Baylor College of Medicine/Texas Childrens Hospital, Houston, TX; Baylor College of Medicine, Houston, TX
2 0 pre-PCC
Volume 64, no. 4s : October 2014
post-PCC
Background: Unintentional overdose or drug ingestion is a common emergency department (ED) presentation accounting for 1-3% of all ED visits. Eighty percent are
Annals of Emergency Medicine S141
394
Three-Factor Prothrombin Complex Concentrate for Correction of Warfarin-Induced Coagulopathy in High Risk Central Nervous System Bleeding
Ching BC, Ng V/Alameda County Medical Center, Highland General Hospital, Oakland, CA
Background: Life-threatening bleeding in the central nervous system (CNS) due to a warfarin-induced coagulopathy is a common problem facing emergency practitioners across the country. In addition to frozen plasma (FP), prothrombin complex concentrate (PCC) is an option for reversal. An INR less than 1.7 is considered adequate reversal of warfarin induced coagulopathy for bleeding in critical areas (eg, CNS, eye). Until recently, only three-factor PCC was available in the United States. Objective: To review the experiences of a high-volume urban trauma center using three-factor PCC (ProfilNine SD) to reverse coumadin-induced coagulopathies in patients with life-threatening CNS bleeding. Methods: A retrospective case series was conducted in a large urban trauma center in the US. Patients who had life-threatening CNS hemorhage and received three-factor PCC to correct their warfarin-induced coagulopathy were selected. Data collected included initial INR, post-reversal INR, time from administration of PCC to postreversal INR, use of FP and use of vitamin K. All PCC was dosed using a strict weightbased pharmacy protocol of 50 international units/kilogram. Results: Thirty-four patients chronically anticoagulated with warfarin (mean INR 3.85, median 2.75, mode 2.1, SD 3.04, range 1.5-14.3) presenting with acute subdural hemorrhage, 16 14 12
INR
10
subarachnoid hemorrhage or both were administered PCC. Three (9%) received PCC alone, nine (26%) received PCC and FP, nine (26%) received PCC and Vitamin K, and eight (23.5%) received PCC, FP and Vitamin K. Post-PCC INRs were obtained over a variety of time periods, all within 24 hours of PCC adminsiration. All post-PCC INRs corrected to 2.4 or lower (mean INR 1.4, median 1.3, mode 1.2, SD 0.3, range 1.1-2.4). Conclusion: Three-factor PCC was successful in correcting warfarin-induced coagulopathy in patients chronically anticoagulated with warfarin with high risk CNS bleeding.
395 396
Withdrawn
Variability in Antivenom Treatment in Snake Envenomations Between Two Major Tertiary Care Emergency Departments
Ward KN, Wortley AG, Quackenbush EB, Gerardo CJ/University of North Carolina Hospital, Chapel Hill, NC; Duke University Hospital, Durham, NC
Study Objective: Approximately 8,000 people a year in the United States are reported to the CDC as sustaining venomous snake bites. Copperhead envenomations comprised 41% of these bites in 2011 and are the predominant poisonous snake in the Southeastern United States. Unlike rattlesnake envenomation, there is limited evidence regarding treatment in copperhead predominant populations. Controversy exists as to the appropriateness and effectiveness of treatment in this population, creating the potential for wide practice variation amongst providers and emergency departments (EDs). Our objective is to compare the rates of antivenom use for snakebite between two similar large academic EDs within the same geographic region. Methods: We performed a retrospective chart review of patients presenting to two large academic EDs located 11 miles apart, from April 1, 2009 to October 31, 2012. Both EDs are located in copperhead predominant areas. All patients presenting with reported snakebites were included. An initial search of the final ED diagnosis for ICD-9 Codes 989.5 (toxic effect of venom) and E905.0 (venomous snakes and lizards causing poisoning and toxic reactions) to find all snake envenomation patients presenting during the study period was performed. Continuous variables were summarized using means, standard deviations as appropriate. Frequencies and proportions were used to describe categorical data with confidence intervals of the proportions. The primary outcome was the proportion of patients receiving antivenom during their initial visit. A Fisher’s exact test was used to compare antivenom use between sites. Secondary outcomes included immediate allergic reactions, surgery and unplanned return visits. Results: Two hundred and forty-six eligible patients were analyzed, 142 from site 1 and 104 from site 2. There are similar demographics at both sites. The mean age overall and at both sites was 37 years (SD 20.1). There were 44% (108/246) females overall, 40% (57/142) site 1 and 49% (51/104) site 2. At site 1, 5.6% (8/142) of the patients were taking antiplatelet medications as compared with 9.6% (10/104) at site 2. Only 1 patient reported anticoagulation use and 4 had chronic extremity disorders. Sixty-one percent (86/142) of patients at site 1 sustained a copperhead snakebite as compared with 74% (77/104) at site 2. There were 3.5% versus 3.8% presenting as dry bites, 60.5% versus 49% minimal grade, 35% versus 46% moderate grade, and 0.7% versus 1% severe grade envenomations at site 1 and site 2 respectively (P¼.02). Forty-nine percent (120/246) of all patients received antivenom. There was significant variation between site 1 and site 2; 21.8% (31/142) (95% CI 0.16, 0.29) and 83.7% (87/104) (95% CI 0.75, 0.90), P<.0001. Of the 118 patients who received antivenom, 14.4% (17/118) had allergic reactions, with one classified as severe. There was only 1 surgery. Site 1 had more unplanned return visits at 10% versus 0% (P¼.004). Conclusions: Wide practice variation exists in the use of antivenom in copperhead predominant populations. Antivenom use should depend on its effectiveness and the patient’s clinical presentation, rather than facility-related practice patterns. Further evidence is necessary to better align antivenom use in locales where copperhead snakebites predominate.
8
397
6 4
Outcomes of Unintentional Pediatric Ingestions in a Pediatric Emergency Department Observation Unit: Which Ingestion is Most Likely to Lead to an Admission?
Ojo AO, Alam S, Shenoi R/Baylor College of Medicine/Texas Childrens Hospital, Houston, TX; Baylor College of Medicine, Houston, TX
2 0 pre-PCC
Volume 64, no. 4s : October 2014
post-PCC
Background: Unintentional overdose or drug ingestion is a common emergency department (ED) presentation accounting for 1-3% of all ED visits. Eighty percent are
Annals of Emergency Medicine S141