Acute Hydroxychloroquine (Plaquenil®) Ingestion by Young Children

210 ence range for the i-STAT device (Abbott Point of Care Inc., Princeton, NJ). There was a trend to a decrease in minute ventilation in the subjects with chest or back exposures (two devices), although it did not reach statistical significance. The ECG changes only reflected some increased vagal tone after the discharge. There were no important rhythm changes. In 4 of the 6 subjects, the echocardiographer was able to determine that the rhythm during discharge was sinus. In 2 subjects, motion artifact precluded this. One of these subjects had a heart rate during the exposure of 79 beats/min, not suggesting electrical capture. Conclusion: Five-second, simultaneous, multiple exposures to the TASER Shock Wave device do not seem to have significant deleterious effects on human physiology, except for a moderate increase in CK. Funding: TASER International provided partial funding for this study. Drs. Dawes and Ho are external medical consultants to the company, and stockholders.

#905 (#25) Dawes 䡺 THE NEURO-ENDOCRINE EFFECTS OF THE TASER X26 CONDUCTED ELECTRICAL WEAPON. D. Dawes, Lompoc Valley Medical Center, Lompoc, California; J. Ho, J. Miner, Hennepin County Medical Center, Minneapolis, Minnesota. Introduction: This is the first study to examine the human stress response to a conducted electrical weapon (CEW), oleoresin capsicum, a cold-water tank immersion, and a defensive tactic drill. Methods: Subjects received either a 5-s exposure from the TASER X26 (TASER International Inc., Scottsdale, AZ) CEW with the probes fired into the back from 7 feet, a 5-s spray of oleoresin capsicum (OC), a skin and mucous membrane irritant, to the eyes, a 45-s exposure of the hand and forearm in a 0°C cold water tank, or a 1-min defensive tactics drill. Salivary alpha-amylase, a measure of the sympatheticadrenal-medulla axis of the human stress response (vs. sympathetic tone), and salivary cortisol, a measure of the hypothalamus-pituitary-adrenal axis of the human stress response, was collected by passive drool before and after the exposures and analyzed by Salimetrics, Inc. (State College, PA). Results: Fifty-three subjects were enrolled, with 16 each in the CEW and cold-water tank groups, and 10 each in the OC and defensive tactics groups. The mean ages were 43 years for the cold-water tank group, 35 years for the CEW group, 28 years for the OC group, and 45 years for the defensive tactics drill. The defensive tactics drill resulted in the greatest change in salivary alpha-amylase at 10 –15 min, with a change of 63.8 U/mL. OC was next, with a change of 37.4. The CEW and cold-water tank immersion did not seem particularly activating. OC had the greatest change in salivary cortisol at 15–20 min, with a change of 0.5 ␮g/dL. The CEW was next, with a change of 0.38, and the defensive tactics drill after that with a change of 0.25. The defensive tactics drill had the greatest delayed change from baseline in cortisol, with a change of 0.47. The cold-water tank immersion did not seem particularly activating. Conclusion: Our preliminary data suggest that physical exer-

The Journal of Emergency Medicine tion during custodial arrest may be most activating of the human stress response. Funding: TASER International provided partial funding for this project. Drs. Dawes and Ho are external consultants to the company and stockholders.

#909 (#27) Browne 䡺 CLINICAL EFFECTS FOLLOWING ACUTE PREGABALIN (LYRICA®) INGESTION BY YOUNG CHILDREN. Brandon A. Browne, David L. Morgan, Doug J. Borys, Rhandi Stanford, Scott and White Hospital, Texas A&M College of Medicine, Central Texas Poison Center, Temple, Texas. Background: Pregabalin (Lyrica®; Pfizer Inc., New York, NY) has been available in the United States only since 2005, and it is indicated for the treatment of seizures and pain in adults. In June 2007, it became the only medication approved by the Food and Drug Administration for the treatment of fibromyalgia in adults. Although it has become a common prescription medication, there have been no published reports on its adverse effects in children. Objective: The purpose of this study was to determine the clinical effects of accidental pregabalin ingestion by young children. Methods: Retrospective, observational study of one state’s poison centers’ calls of exposures to pregabalin from January 2006 through September 2008 for children under 6 years of age. Results: There were 57 children who met the inclusion criteria. They were 3 months to 5 years of age, and they ingested 25 to 400 mg. Fifty-one subjects (89.5%; 95% confidence interval [CI] 78.9%– 95.1%) had no clinical symptoms. The only symptoms noted were lethargy (9.8%) and ataxia (7.0%). There were no deaths or major clinical effects (0%; 95% CI 0%– 6.3%). Only 12 (21.1%) children received activated charcoal, and none received gastric lavage or syrup of ipecac. Most (68.4%) children were managed in an emergency department, and 4 (7.0%) were admitted for observation (2 to the intensive care unit). None remained in the hospital longer than 1 day. Conclusion: This is the first study of pregabalin’s clinical effects in young children, but it is limited by its retrospective nature, the small number of subjects, and its reliance on caller information. Because none of these children had a major adverse effect, it is likely that more of them could be safely managed at home. More studies are needed to determine the appropriate emergency management of this age group.

#910 (#28) Letsinger 䡺 ACUTE HYDROXYCHLOROQUINE (PLAQUENIL®) INGESTION BY YOUNG CHILDREN. Terry J. Letsinger, David L. Morgan, Douglas J. Borys, Scott and White Hospital, Temple, Texas. Introduction: Hydroxychloroquine (Plaquenil®; sanofiaventis Inc., Bridgewater, NJ) is a derivative of chloroquine used in the treatment and prophylaxis of malaria, rheumatoid arthritis, and systemic lupus erythematosus. Although chloroquine has been associated with significant toxicity from ingestion of one pill in young children, no reports have evaluated the clinical effects of accidental hydroxychloroquine ingestions in children. Many authors suggest that hydroxychloroquine, like chloroquine, should be considered toxic with ingestion of one

CEMC Abstracts pill. The objective of this study was to determine the clinical effects of accidental hydroxychloroquine ingestion by young children. Methods: Retrospective, observational study of one state’s poison center calls of exposures to hydroxychloroquine from January 2000 through October 2008 for children under 6 years of age. Results: 38 children met the inclusion criteria. Of these, 20 had a visually confirmed ingestion, 14 were uncertain, and 4 were later confirmed non-ingestions. Age ranged from 1 to 5 years. Ingestion quantity ranged from 50 to 400 mg. Five (13.16%) children developed signs or symptoms including emesis (n ⫽ 2), tachycardia (n ⫽ 1), stomachache (n ⫽ 1), agitation (n ⫽ 1), seizures (n ⫽ 1), altered mental status (n ⫽ 1), hypokalemia (n ⫽ 1), and rash (n ⫽ 1). Activated charcoal was administered to 14 (36.8%) children; 19 (50%) children were evaluated at a health care facility. Only 1 (2.63%) child developed significant toxicity requiring admission to a Pediatric Intensive Care Unit. After ingestion of one 200-mg pill (18.2 mg/kg), she developed sinus tachycardia, prolonged QRS, hypokalemia, emesis, altered mental status, and seizures. She was treated with benzodiazepines, potassium supplementation, intravenous fluid, and antiemetics, and was discharged home after resolution of symptoms and normalization of her electrocardiogram 4 days later. Conclusion: This is the first study of hydroxychloroquine’s clinical effects in young children. It is limited by retrospective nature, the small number of subjects, and reliance on caller information. Accidental hydroxychloroquine ingestion in children younger than 6 years of age is a rare event. Significant toxicity can develop after ingestion of one pill by children under 6 years of age.

#949 (#32) Meltzer 䡺 ADMINISTRATION OF ORAL CONTRAST IN TRIAGE. Andrew C. Meltzer, MD, Scott Osborn, MD, John Howell, MD, Frederick Place, MD, Derek A. T. Cummings, PHD, Glenn Druckenbrod, MD, Inova Fairfax Hospital, Washington, DC. Background: The increasing availability and speed of computed tomography (CT) has led to reliance on this imaging modality for emergency department (ED) patients with undifferentiated abdominal pain (UAB). Once oral radiocontrast is administered, however, a 90 –120-min delay ensues before the CT scan is accomplished. Oral contrast administered in triage might shorten total ED stays. Objective: We hypothesized that some clinical variables are significantly associated with the need for CT scan in patients with UAB. Methods: This was a prospectively gathered, retrospective chart review at one suburban ED with an annual census of 85,000. The clerical staff photocopied charts of patients of all ages presenting with the pre-determined chief complaints related to, and including, abdominal pain. Information was extracted from 335 continuous patient records by two data collectors. There were 25 independent variables. Multiple logistic regression was used to analyze the data. The outcome variable was a physician’s decision to order an oral contrast abdominal CT scan. We used stepwise elimination and addition based on likelihood ratios to identify the most

211 parsimonious model. Results: The ages of patients ranged from ⬍ 1 year to 94 years, with an average of 34.6 years. Using univariate logistic regression, four variables were independently associated with the outcome: age (odds ratio [OR] 1.02 per year, 95% confidence interval [CI] 1.01– 1.04), triage pain score (OR 1.19 per score, 95% CI 1.10 – 1.29), history of abdominal surgery (OR 2.42, 95% CI 1.38 – 4.24), and tenderness (OR 4.08, 95% CI 2.38 –7.04). The most parsimonious model identified by multiple logistic regression included nine covariates: age, sex, triage pain score, history of abdominal surgery, chief complaint, fever, previous history of same pain, radiation of pain, and tenderness. The positive predictive value of the most parsimonious model is 75.2%, the negative predictive value 59.9%, the specificity 74.1%, and the sensitivity 51.2%. Although statistically distinguishable from the most parsimonious model, a reduced model using only age, triage pain score, and the presence of tenderness performed almost as well, with sensitivity 83.0%, specificity 50.3%, positive predictive value 68.1%, and negative predictive value 69.8%. This reduced model may be feasible to implement in the ED setting. Conclusion: There is a subgroup of patients receiving contrast that can be readily identified by their presenting signs and symptoms. This study uncovered three significant criteria, setting up a validating, prospective study; we will employ these criteria in triage with time-to-patient-disposition as the primary outcome measure.

#967 (#34) Kapoor 䡺 HYPOTENSION IS A POOR PREDICTOR OF CARDIAC TAMPONADE IN PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT. Tushar Kapoor, MD, Michael Locurto, MD, Gino A. Farina, MD, Robert Silverman, MD, Long Island Jewish Medical Center, New Hyde Park, New York. Background: Cardiac tamponade is a life-threatening disease process in which there is accumulation of fluid within the pericardial sac resulting in increase in intrapericardial pressure (Figure 1). It can be further categorized as either acute or chronic, depending upon the speed with which the fluid accumulates, and thus it presents with a wide range of symptoms. Classic medical school teaching says that tamponade presents with Beck’s triad: distended neck veins, muffled heart sounds, and hypotension. However, prior studies have described normotensive or hypertensive cases of tamponade. But because the data were not collected from the Emergency Department (ED), the hemodynamic spectrum may not be similar to patients presenting to the ED. We believe that the incidence of normotensive and hypertensive tamponade is higher than previously reported even in the more acute ED setting. Methods: We conducted a retrospective chart review between January 2002 and December 2007 of patients presenting to the ED and discharged from the hospital with a diagnosis of cardiac tamponade. Presenting signs, symptoms, vital signs, past history, electrocardiograms, echocardiogram reports, chest X-ray reports, and amount of fluid removed from the pericardial sac were