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Effect of electric shock therapy on local tissue reaction to poisonous snake venom injection in rabbits
narcotic deaths in the western United States in the period 1984 to 1985. We report the first outbreak of narcotic overdoses in the East involving 3MF, which occurred in Allegheny County, Pennsylvania, in 1988. Emergency physicians became suspicious of 3MF use following an unusual increase in narcotic overdoses presenting to the ED coupled with screens negative for opiates, despite dramatic responses to naloxone. Specific testing was positive for indicators of fentany] derivatives in some cases. We reviewed 85,246 patient visits to our ED over the 24-month period January 1987 to December 1988 for epidemiologic study. Patients were included if they met the criteria of a suspected unintentional narcotic overdose, but excluded if not given naloxone. A cluster was defined as a period with a statistically significant increase in overdoses above the expected number for an interval of equal length. Although there were no significant clinical differences in case presentation over the study period, there was a statistically significant, 12-fold increase in overdoses during the September to November 1988 cluster (mean, 13 per month versus 1.05 per month, P < .001 Wilcoxon rank sum test). A dramatic increase in unintentional drug overdose deaths occurred in the county during this cluster. Investigations found 3MF present in street drugs and paraphernalia. A total of 18 fentanyl-positive unintentional drug overdose deaths, predominantly male (89%) and black (56%), age range 19 to 44 years (mean, 34.9), were reported by the county coroner (13 during cluster). Narcotic overdoses and unintentional drug overdose deaths declined sharply with confiscation of the clandestine 3MF lab. We conclude that it is important for emergency physicians to recognize early that overdoses responsive to naloxone with inconsistent routine toxicologic screens may be due to a fentanyl analogue.
58 Effect of Electric Shock Therapy on Local Tissue Reaction to Poisonous Snake Venom Injection in Rabbits C Stoud, H Amon, T Wagner, JL Falk/Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida; Division of Emergency Medicine, Department of Surgery, University of Florida College of Medicine, Gainesville
This study evaluated the effect of locally applied electric current on local tissue damage resulting from snake venom injection. Female New Zealand White rabbits were anesthetized with 100 mg intraperitoneal pentobarbital. Proximal hind legs were shaved, cleansed, and injected subcutaneously with 1 mg/kg fresh venom harvested from Eastern Diamondback rattlesnakes (Crotalus adamanteous). Animals were randomly assigned to be shocked (group A) or sham-shocked (group B). Four two-second discharges each delivering 1,800 V, 8.18 amps direct current were administered directly through the injection site at ten-second intervals, ten minutes after venom injection, Lesions were measured at 12, 24, and 48 hours after injection by applying calipers across the edges of the short and long axis of the bullous lesions by an observer blinded t o the randomization scheme. Area of the lesions was calculated and indexed for bocly weight. Lesion sizes between the groups were compared using the unpaired two-tailed t test. Three animals died within 24 hours. Data are reported as mean _+SM.
Short Axis (cm) A B P
Group LongAxis (cm) A B P
Area Index (cn~/kg) A B P
Time (hr) 12 24 48
2.4+02. 2.9+_0.4 .29 3.1+0.3 3.1+_0.3 .11 2.8+0.7 4.0+1.1.31 .31 2.5_+0.4 3.3_+0.3 .13 3.5+0.5 3.9+_0.4 .56 3.3+0.8 5.3+1.1.16 .16 4.6+0.4 4.6-+0.7 .99 7.2-+0.76.6+_0.8 .57 11.9+1.5 11.5--2.4.88 .88
In this rabbit model we were unable to confirm previous anecdotal reports of the efficacy of electric shock therapy in ameliorating local tissue destruction resulting from snake envenomation. Further study of this treatment using technical variations is warranted before discarding it as useless.
59 Acute Iron Poisoning in Children: Evaluation of the Predictive Value of Clinical and Laboratory Parameters NA Schonfeld, AJ Haftel/Childrens Hospital of Los Angeles, Los Angeles, California
Ingestion of iron-containing preparations is the fifth most common toxic ingestion in children. The clinical severity is usually correlated to the maximum serum iron level attained within the first six hours after ingestion. Minimal toxicity is found with iron levels below 300 ~tg/dL. Many hospitals, however, do not 18:4 April 1989
provide iron levels on an emergency basis. One hundred hospitals with 24-hour emergency services were surveyed, and only 50% could provide an iron level in less t h a n six hours. This study evaluated whether certain clinical and laboratory parameters could be used to predict serum iron level and, therefore, the severity of acute iron ingestion in children. The records of children who presented to the Childrens Hospital of Los Angeles emergency department from 1978 to 1985 for acute iion ingestion were reviewed. One hundred four children were seen in the ED for acute iron ingestion during that period; 94 were included in the study. Th 9 age range was 11 months to 6.5 years, with a mean of 30 months. Peak serum iron levels ringed from 38 to 923 #g/dL, with a mean of 272 ~tg/dL. Five laboratory or clinical parameters significantly (P < .0l) correlated with serum iron levels of 300 ~tg/dL or greater: age on presentation of less than 2 years; vomiting; WBC count in excess of 13,000 mL; anion gap greater than 16 mEq/L; or the presence of radiopaque densities on abdominal flat plate radiography. Of these five risk factors, no child in the study with zero risk factors had a level of 300 ~tg/L or more. Conversely, all children with two or more of these risk factors had levels in excess of 300 ~tg/L. The clinical and laboratory parameters of age at presentation, presence of vomiting, WBC count, anion gap, and KUB appearance can be used to identify children at risk for toxic serum levels of iron.
60 PolymyxinB for Experimental Shock From Meningococcal Endotoxin G Baldwin, G Caputo, G Alpert, J Parsonett, G Siber, M Baskin,.G Fleisher/The Children's Hospital, Harvard Medical School, Boston, Massachusetts
One third of children with meningococcemia develop shock and die. Polymyxin B has been reported to ameliorate endotoxic shock due to Escherichia coli by binding endotoxin. We performed dose titration curves with meningococcal endotoxin and studied the effect on meningococcal endotoxin-induced shock in a rabbit model. Femoral arterial and venous lines were placed, and rabbits received IV saline, endotoxin (10 ug/kg), or polymyxin B (5 mg/kg) 30 minutes prior to endotoxin. Pulse, respiration, mean arterial pressure, arterial blood gases, and levels of endotoxin and tumor necrosis factor were monitored. Rabbits receiving endotoxin (six of six with seven of seven without polymyxin B) but not saline (zero of five) developed shock as indicated by tachycardia, bradypnea, hypotension, metabolic acidosis, and death by 24 hours.
Time After Endotoxin(min) 0 120 Pulse Respirations MAP Pulse Respirations MAP Saline 212 Endotoxin (mg/kg) 224 Binding endotoxin with polymyxin B 221
228
91
212"
160"
103"
260
92
305
108
81
267
92
308
84
89
The group receiving polymyxin B did not differ (P > .05) from the one treated with binding endotoxin (Table, *P < .05). Endotoxin and tumor necrosis factor levels were undetectable in controls and peaked at 1 to 20 ng for endotoxin and !,100 to 1,600 U for tumor necrosis factor (0.1 mL) in the endotoxin-treated groups. We did not show protection by polymyxin B in meningococcal endotoxin shock.
61 Bacteremia in Children With Otitis Media SA Schutzman, S Petrycki, GR Fleisher/The Children's Hospital, Harvard Medical School, Boston, Massachusetts
Occult bacteremia occurs in 3 % to 5 % of young febrile children with no apparent source of infection and carries a risk of suppurative complications. Although otitiS media is a frequent occurrence, the incidence of associated bacteremia has not been well studied. To quantitate the incidence of bacteremia in otitis media, charts were reviewed from consecutive patients seen November 1987 to March 1988 in The Children's Hospital emergency department, ages 3 to 36 months, who had temperatures of 39 C or more and who were diagnosed with isolated clinical otitis media. Seven hundred forty-eight patients were identified. Blood cultures were obtained from 421 patients (56 % ), and all were treated with oral antibiotics. The mean temperature of children who had blood cultures Was 39.8 C versus 39.6 C in those who did not (P< .001). Mean ages of those with and without blood cultures were 14.1 and 17.6 months, respectively (P< .001). Fourteen of 421 patients (3.3%) who had
Annals of Emergency Medicine
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58 Effect of Electric Shock Therapy on Local Tissue Reaction to Poisonous Snake Venom Injection in Rabbits C Stoud, H Amon, T Wagner, JL Falk/Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida; Division of Emergency Medicine, Department of Surgery, University of Florida College of Medicine, Gainesville
This study evaluated the effect of locally applied electric current on local tissue damage resulting from snake venom injection. Female New Zealand White rabbits were anesthetized with 100 mg intraperitoneal pentobarbital. Proximal hind legs were shaved, cleansed, and injected subcutaneously with 1 mg/kg fresh venom harvested from Eastern Diamondback rattlesnakes (Crotalus adamanteous). Animals were randomly assigned to be shocked (group A) or sham-shocked (group B). Four two-second discharges each delivering 1,800 V, 8.18 amps direct current were administered directly through the injection site at ten-second intervals, ten minutes after venom injection, Lesions were measured at 12, 24, and 48 hours after injection by applying calipers across the edges of the short and long axis of the bullous lesions by an observer blinded t o the randomization scheme. Area of the lesions was calculated and indexed for bocly weight. Lesion sizes between the groups were compared using the unpaired two-tailed t test. Three animals died within 24 hours. Data are reported as mean _+SM.
Short Axis (cm) A B P
Group LongAxis (cm) A B P
Area Index (cn~/kg) A B P
Time (hr) 12 24 48
2.4+02. 2.9+_0.4 .29 3.1+0.3 3.1+_0.3 .11 2.8+0.7 4.0+1.1.31 .31 2.5_+0.4 3.3_+0.3 .13 3.5+0.5 3.9+_0.4 .56 3.3+0.8 5.3+1.1.16 .16 4.6+0.4 4.6-+0.7 .99 7.2-+0.76.6+_0.8 .57 11.9+1.5 11.5--2.4.88 .88
In this rabbit model we were unable to confirm previous anecdotal reports of the efficacy of electric shock therapy in ameliorating local tissue destruction resulting from snake envenomation. Further study of this treatment using technical variations is warranted before discarding it as useless.
59 Acute Iron Poisoning in Children: Evaluation of the Predictive Value of Clinical and Laboratory Parameters NA Schonfeld, AJ Haftel/Childrens Hospital of Los Angeles, Los Angeles, California
Ingestion of iron-containing preparations is the fifth most common toxic ingestion in children. The clinical severity is usually correlated to the maximum serum iron level attained within the first six hours after ingestion. Minimal toxicity is found with iron levels below 300 ~tg/dL. Many hospitals, however, do not 18:4 April 1989
provide iron levels on an emergency basis. One hundred hospitals with 24-hour emergency services were surveyed, and only 50% could provide an iron level in less t h a n six hours. This study evaluated whether certain clinical and laboratory parameters could be used to predict serum iron level and, therefore, the severity of acute iron ingestion in children. The records of children who presented to the Childrens Hospital of Los Angeles emergency department from 1978 to 1985 for acute iion ingestion were reviewed. One hundred four children were seen in the ED for acute iron ingestion during that period; 94 were included in the study. Th 9 age range was 11 months to 6.5 years, with a mean of 30 months. Peak serum iron levels ringed from 38 to 923 #g/dL, with a mean of 272 ~tg/dL. Five laboratory or clinical parameters significantly (P < .0l) correlated with serum iron levels of 300 ~tg/dL or greater: age on presentation of less than 2 years; vomiting; WBC count in excess of 13,000 mL; anion gap greater than 16 mEq/L; or the presence of radiopaque densities on abdominal flat plate radiography. Of these five risk factors, no child in the study with zero risk factors had a level of 300 ~tg/L or more. Conversely, all children with two or more of these risk factors had levels in excess of 300 ~tg/L. The clinical and laboratory parameters of age at presentation, presence of vomiting, WBC count, anion gap, and KUB appearance can be used to identify children at risk for toxic serum levels of iron.
60 PolymyxinB for Experimental Shock From Meningococcal Endotoxin G Baldwin, G Caputo, G Alpert, J Parsonett, G Siber, M Baskin,.G Fleisher/The Children's Hospital, Harvard Medical School, Boston, Massachusetts
One third of children with meningococcemia develop shock and die. Polymyxin B has been reported to ameliorate endotoxic shock due to Escherichia coli by binding endotoxin. We performed dose titration curves with meningococcal endotoxin and studied the effect on meningococcal endotoxin-induced shock in a rabbit model. Femoral arterial and venous lines were placed, and rabbits received IV saline, endotoxin (10 ug/kg), or polymyxin B (5 mg/kg) 30 minutes prior to endotoxin. Pulse, respiration, mean arterial pressure, arterial blood gases, and levels of endotoxin and tumor necrosis factor were monitored. Rabbits receiving endotoxin (six of six with seven of seven without polymyxin B) but not saline (zero of five) developed shock as indicated by tachycardia, bradypnea, hypotension, metabolic acidosis, and death by 24 hours.
Time After Endotoxin(min) 0 120 Pulse Respirations MAP Pulse Respirations MAP Saline 212 Endotoxin (mg/kg) 224 Binding endotoxin with polymyxin B 221
228
91
212"
160"
103"
260
92
305
108
81
267
92
308
84
89
The group receiving polymyxin B did not differ (P > .05) from the one treated with binding endotoxin (Table, *P < .05). Endotoxin and tumor necrosis factor levels were undetectable in controls and peaked at 1 to 20 ng for endotoxin and !,100 to 1,600 U for tumor necrosis factor (0.1 mL) in the endotoxin-treated groups. We did not show protection by polymyxin B in meningococcal endotoxin shock.
61 Bacteremia in Children With Otitis Media SA Schutzman, S Petrycki, GR Fleisher/The Children's Hospital, Harvard Medical School, Boston, Massachusetts
Occult bacteremia occurs in 3 % to 5 % of young febrile children with no apparent source of infection and carries a risk of suppurative complications. Although otitiS media is a frequent occurrence, the incidence of associated bacteremia has not been well studied. To quantitate the incidence of bacteremia in otitis media, charts were reviewed from consecutive patients seen November 1987 to March 1988 in The Children's Hospital emergency department, ages 3 to 36 months, who had temperatures of 39 C or more and who were diagnosed with isolated clinical otitis media. Seven hundred forty-eight patients were identified. Blood cultures were obtained from 421 patients (56 % ), and all were treated with oral antibiotics. The mean temperature of children who had blood cultures Was 39.8 C versus 39.6 C in those who did not (P< .001). Mean ages of those with and without blood cultures were 14.1 and 17.6 months, respectively (P< .001). Fourteen of 421 patients (3.3%) who had
Annals of Emergency Medicine
447/167