Fatal Tension Hemothorax Combined with Exanguination: A Rare Complication of Neurofibromatosis

Neurofibromatosis (NF) is a common autosomal dominant disorder that can be subdivided into type 1, type 2, and schwannomatosis. Patients with NF1 typically develop café-au-lait spots, scoliosis, and benign neurofibromas. In addition, NF1 predisposes to vascular complications including stenosis, arterial ectasia, and aneurysms. Here, we report the case of an otherwise healthy 32-year-old man who developed a fatal tension hemothorax due to vertebral artery aneurysm rupture. Based on the available literature, we discuss the presentation, workup, and available therapeutic approaches to this complication of neurofibromatosis

Time is Money: The True Cost of Helicopter EMS (HEMS)

Background: Multiple studies have been published that attempt to examine relevant outcomes of utilizing helicopter transport over traditional ground-based emergency medical services (EMS). Unfortunately, these studies suffer from poor methodology and are confounded by substantial differences in training and expertise of the personnel involved in the medical transfer. The EMS system in Central Massachusetts is unique in that when a physician from an outside hospital calls for an HEMS transport, the pilot determines if weather conditions permit to fly without having any further knowledge about the patient. If flying is deemed unsafe, the helicopter personnel will retrieve the patient by traditional ground ambulance. This allowed us to compare these two transfer modalities while eliminating the confounder of crew expertise. We hypothesize that the overall mortality of these inter-facility transfers is comparable, regardless of mode of transport and diagnoses, if accompanied by highly-trained and experienced personnel. Purpose: This study aimed to delineate the advantages of helicopter transport (HEMS) over ground transport (GEMS) of critically ill patients undergoing inter-facility transfers. Methods: We performed a retrospective chart review of 2,129 patients that were transferred from an outside hospital to our tertiary care center in Central Massachusetts by a Helicopter EMS (HEMS) crew between January of 2010 and April of 2017. These patients were either transferred by ground ambulance or helicopter ambulance. Transfers occurred by ground ambulance in limited cases where HEMS was grounded due to poor weather. In these instances, the Helicopter crew, consisting of a paramedic and flight nurse, staffed a ground ambulance to complete the transfer. Furthermore, we identified 655 patients that were transferred directly from the scene of the emergency, but these patients were excluded due to inability to standardize for transport distance. After categorizing 1,323 patients that were transferred by HEMS and 151 patients that were transferred by GEMS, patients were matched to their respective All Patients Refined Diagnosis Related Group (APR-DRG) and In-Hospital Mortality data. Scalar and categorical outcomes were analyzed T-Test or Fishers exact test respectively. Sub-group analyses were completed by categorizing patients by diagnosis or APR-DRG severity level. Results: The use of Helicopter EMS significantly reduced the time to definitive care over Ground EMS by at least twenty-one minutes, but no-more than one hour and seventeen minutes depending on the location of the requesting hospital. We found no statistical difference in the age or gender of the population transferred by either HEMS or GEMS. However, the population transferred by GEMS had significantly increased APR-DRG Severity and Risk of Mortality scores over the population transferred by HEMS. Despite this finding, there was no difference in in-hospital mortality between the two transfer modalities. Subgroup analysis did not show any significant difference in mortality based on diagnosis or APR- DRG classification. Conclusions: Despite the significant reduction in the time to definitive care through the utilization of HEMS, there was no statistically significant survival benefit conferred to critically ill patients undergoing inter-facility transfers. This suggests that the transport methodology may be of secondary importance to the level of training of the providers who are delivering the care en route

A dangerous chase: severe neurocognitive impairment and death following smoked heroin

We report the case of a 25-year-old man with acute encephalopathy following inhalation of heroin pyrolysate vapors, a practice known as “chasing the dragon”

Fatal Tension Hemothorax Combined with Exanguination: A Rare Complication of Neurofibromatosis

Neurofibromatosis (NF) is a common autosomal dominant disorder that can be subdivided into type 1, type 2, and schwannomatosis. Patients with NF1 typically develop café-au-lait spots, scoliosis, and benign neurofibromas. In addition, NF1 predisposes to vascular complications including stenosis, arterial ectasia, and aneurysms. Here, we report the case of an otherwise healthy 32-year-old man who developed a fatal tension hemothorax due to vertebral artery aneurysm rupture. Based on the available literature, we discuss the presentation, workup, and available therapeutic approaches to this complication of neurofibromatosis

Case Files of the University of Massachusetts Toxicology Fellowship: Does This Smoke Inhalation Victim Require Treatment with Cyanide Antidote

Cyanide toxicity is common after significant smoke inhalation. Two cases are presented that provide framework for the discussion of epidemiology, pathogenesis, presenting signs and symptoms, and treatment options of inhalational cyanide poisoning. An evidence-based algorithm is proposed that utilizes point-of-care testing to help physicians identify patients who benefit most from antidotal therapy

Cannabinoid toxicity in pediatrics

PURPOSE OF REVIEW: The advent of legalized cannabis in multiple regions of the United States has rendered the drug more accessible to pediatric patients. Pediatricians and Pediatric Emergency Medicine Providers face new challenges in counseling both patients and their parents, diagnosing exploratory ingestions of cannabinoids in toddlers, and managing complications of prolonged, heavy cannabis use in adolescents. The purpose of this review article is to provide clinicians a succinct summary of recent literature regarding tetrahydrocannabinol (THC) pharmacokinetics, pharmacodynamics, impacts on development, as well as presentations of acute and chronic toxicity. RECENT FINDINGS: Many young children being admitted to the hospital for cannabis toxicity have been exposed to high concentration products, such as edibles, resins, or vaping fluid. These products contain extremely high concentrations of cannabinoids, and lead to sedation, respiratory depression, and other adverse effects. Chronic toxicity associated with cannabis consumption includes neurocognitive changes and cannabinoid hyperemesis syndrome. SUMMARY: Clinicians should provide guidance for pediatric patients and their caregivers to reduce the risk of accidental cannabis exposure, particularly with high concentration products. In addition, clinicians should consider chronic cannabis exposure when evaluating certain complaints, such as chronic vomiting or educational performance at school

Drug-induced hyperlactatemia

BACKGROUND: Hyperlactatemia is common in critically ill patients and has a variety of etiologies. Medication toxicity remains an uncommon cause that providers often fail to recognize. In this article, we review several medications that cause hyperlactatemia in either therapeutic or supratherapeutic dosing. When known, the incidence, mortality, pathophysiology, and treatment options are discussed. METHODS: We performed a literature search using PUBMED and Google Scholar for English language articles published after 1980 regarding medication induced hyperlactatemia and its management. Our search string resulted in 798 articles of which 138 articles met inclusion criteria and were relevant to the topic of our review. CONCLUSIONS: Hyperlactatemia is a relatively rare but life-threatening toxicity of various medication classes. Discontinuation of the drug is always advised, and some toxicities are subject to specific antidotal treatment. If there is no apparent medical cause for hyperlactatemia (sepsis, hypotension, hypoxia), clinicians should consider a toxicological etiology

Unsuspected Clenbuterol Toxicity in a Patient Using Intramuscular Testosterone

Clenbuterol is a beta-agonist that has been abused by fitness-oriented individuals for muscle growth and weight loss. We report a case of a 46-year-old man who presented tachycardic, hypokalemic, and hyperglycemic after injecting testosterone obtained from Brazil. He developed refractory hypotension and was started on an esmolol infusion for suspected beta-agonist toxicity. Laboratory analysis showed a detectable clenbuterol serum concentration. Analysis of an unopened ampule contained boldenone undecylenate, clenbuterol, and vitamin E. This case illustrates a novel exposure that caused beta-agonist toxicity and was treated successfully with rapid-onset beta blocker