January
Volume 1: Issue 4


"Tox Talks"

Iron toxicity remains a common toxidrome in the emergency department and is the leading cause of pediatric overdose death under age 6. Its antidote, defuroxamine, was recently designated by the Antidote Summit Authorship Group (Ann Emerg Med, Sept. 2009) as a medicine recommended for availability within 60 minutes of every emergency department in the country.

A slew of media attention over pediatric overdoses in the early 1990s initially prompted a 1997 FDA mandate for single-pill packaging of all pills containing over 30mg of elemental iron. However, a 2003 challenge by the Nutritional Health Alliance (NHA), an association including manufacturers and distributers of dietary supplements, led the FDA to reverse their ruling. Iron supplements no longer require special packaging, nor carry overdose warnings.

Iron pills thus offer a readily-available method of intentional and unintentional overdose. Toxicity begins as 10-12mg/kg of elemental iron (not mg/kg of vitamin). Prenatal vitamins contain about 65mg elemental iron, while pediatric vitamins contain 15-20mg elemental iron.

Iron is a strong redox reagent. Acute toxicity progresses in five phases, with mild overdose typically occurring in the first phase. Phase one (0.5-2h) includes direct corrosive toxicity of the GI mucosa with abdominal pain, hematemesis and hematochezia. Phase two (6-24h) latency shows silent metabolic acidosis. Phase three (12-24h) is shock, secondary to severe necrosis, fluid loss and metabolic acidosis. This is when patients die. Phase four (2-3d) is hepatotoxicity. Phase five (2-8wk) is obstruction due to GI scarring.

Management is supportive, with abdominal X-ray (to look for pill fragments), serum iron levels and an ABG. Defuroxamine is indicated for serum iron >500g/dL and/or symptoms of shock.

More key points:

  • Activated charcoal does NOT WORK for metals.
  • Liquid and chewable iron often DO NOT show up on X-ray. This does NOT exclude ingestion.
  • Iron creates a gap acidosis (MUDPILES).
  • Measure serum iron at 4-6 hours s/p ingestion (time of peak absorption).
  • Use iron chelation by defuroxamine for shock or serum iron >500g/dL.
  • Defuroxamine is SAFE IN PREGNANCY. Neither it, nor iron, transfers to the fetus.

References:

  1. Dart R, Borron S et al. "Expert Consensus Guidelines for Stocking of Antidotes in Hospitals That Provide Emergency Care." Ann of Em. Vol 54, No 3. Sept 2009.
  2. Peronne, J. "Chap. 40: Iron" Goldfrank's Toxicologic Emergencies, 8th ed. 2006.
Critical Care Pearl

Mild Therapeutic Hypothermia in Out-of-Hospital Cardiac Arrest
Therapeutic hypothermia (TH) is the only intervention that has been shown to improve outcomes in comatose patients with out-of-hospital cardiac arrest. TH is now recommended by the American Heart Association (AHA) for the treatment of neurological injury when the initial cardiac rhythm is ventricular fibrillation. The benefits of TH are not clearly established when the initial cardiac rhythm is asystole or PEA or when the arrest is due to a noncardiac cause such as asphyxia or drug overdose.

Due to the similarities between post cardiac arrest state and severe sepsis, early goal-directed hemodynamic optimization (EGDHO) combined with TH has been shown by Gaieski to improve outcome when compared to historic patients who would have been eligible for the combined therapy. Intravenous cooling techniques provide the requisite temperature of 32-34 degrees Celsius for 12-24 hours after arrest.

Conversely, TH has not been shown to reduce infarct size in patients undergoing PCI.

References:

  1. Bernard SA. "Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia." N Engl J Med - 21-FEB-2002; 346(8): 557-63.
  2. "Hypothermia after cardiac arrest: Expanding the therapeutic scope "Critical Care Medicine - Volume 37, Issue 7 Suppl (July 2009).
  3. Gaieski DF. "Early goal-directed hemodynamic optimization combined with therapeutic hypothermia in comatose survivors of out-of-hospital cardiac arrest."- Resuscitation - 01-APR-2009; 80(4): 418-24.
  4. "Therapeutic hypothermia for acute myocardial infarction: Past, present, and future" Critical Care Medicine - Volume 37, Issue 7 Suppl (July 2009).

RSA Advocacy: Health Care Reform in 2010

The House and Senate passed their own versions of health care reform late in 2009. Currently, they are two separate bills that worked their way through the various committees in the separate chambers of the U.S. Congress. The two bills have countless significant differences, but in order to make the bills law, they must be melded into one single bill that each chamber of Congress then passes by a simple majority vote. However, the recent election in Massachusetts has put this process in doubt.

The process by which the bills are melded is called "conference committee" when members from both chambers meet to work out the differences. This typically involves both Republican and Democrat senators and congressmen. Though a conference committee is the typical standard for approving bills, the White House and Democratic congressional leaders had come to an agreement to bypass a formal conference in favor of informal meetings among Democrats. This would prevent Republicans from offering amendments and delaying a vote with debates about resolutions.

With the election of Republican Scott Brown in Massachusetts to the Senate, the health care reform bills are in limbo. The ultimate conference committee bill will have to go back to each chamber of congress, and in order to be passed, the Senate needs 60 votes to end debate before a simple majority vote. With a Republican replacing the late Senator Ted Kennedy, Democrats no longer have a "super majority" needed to prevent a filibuster.

Despite all of activity around health care reform in 2009, a flurry of activity is expected in the new year!


Save the Date

Mark your calendar, and book your travel! This year's Scientific Assembly will be held at Caesars Palace in Las Vegas, NV, February 15-17, 2010. Join us for a resident track, student track and social! For more information, go to http://www.aaem.org/education/scientificassembly/.


See You in Vegas: Our Favorite Desert Oasis!

Join AAEM and AAEM/RSA at the 16th Annual Scientific Assembly in Las Vegas, Nevada, February 15-17, 2010. The AAEM/RSA events at Scientific Assembly include:

Sunday, February 14th

Monday, February 15th

Tuesday, February 16th


Emergency Medicine in the Popular Press

"The U.S. House votes to boost Medicare pay to doctors." Read more at: http://www.reuters.com/article/idUSTRE5AI5H220091119?feedType=RSS

"Trauma especially deadly for uninsured." Read more at: http://www.reuters.com/article/idUSTRE5AF5IQ20091116?feedType=RSS

New CPR rules improve survival. "No mouth-to-mouth required in new CPR rules." See why: http://www.msnbc.msn.com/id/23884566


Image of the Month

The deep sulcus sign, which is associated with occult pneumothorax, appears on supine chest X-ray as a deepening of the costophrenic angle and is seen when air tracks anteriorly and/or laterally in a sub-pulmonary location along the pleural space (Kong A, Radiology 228:415-6, 2003; Gordon, R, Radiology 136:25-7, 1980). This image is from a 66-year old male restrained driver in an auto versus tree MVC, who presented to the ED intoxicated, with multiple deformities of his extremities and complaining of left-sided chest pain with deep inspiration. His airway was clear; he had equal breath sounds heard bilaterally and a normal oxygen saturation without obvious crepitus or chest wall tenderness. His supine CXR, shown above, revealed a right-sided deep sulcus sign with multiple broken ribs on the left; upon CT evaluation, he was noted to have a large right-sided pneumothorax, requiring chest tube placement. Take home pearl: consider pneumothorax in any blunt trauma patient presenting with a deep sulcus sign seen on a supine CXR!

Sundeep R. Bhat, MD; Stanford/Kaiser EM Residency


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Your Leadership

We welcome your comments and suggestions. Feel free to get in touch with your elected leaders:

President
Michael Ybarra, MD

Vice President
Alicia Pilarski, DO

Immediate Past-President
Megan Boysen, MD

Secretary/Treasurer
Cyrus Shahpar, MD MPH MBA

At-large Board Members
Heather Jimenez, MD
Jennifer Kanapicki, MD
Jeff Pinnow, MD
Ryan Shanahan, MD
Sandra Thomasian, MD

Medical Student Council President
Jamie "Akiva" Kahn

Modern Resident Contributors

Copy Editor: Teresa Matejovsky Ross, MD

Special thanks to this month's contributors: Dr. Sundeep Bhat, Jonathan Hopkins MSIV, Dr. Teresa Matejovsky Ross and Dr. Michael Ybarra


Interested in writing?

E-mail submissions to: info@aaemrsa.org

Please submit articles by January 30th for the February/March edition.

In the subject line please indicate: "Tox Talk", "Critical Care Pearl", "Board Review", "Journal Club", "Image of the Month", or submit any new articles you would like us to consider!