A Case Report of Massive Acetaminophen Poisoning Treated with a Novel “Triple Therapy”: N-Acetylcysteine, 4-Methylpyrazole, and Hemodialysis

Massive acetaminophen (N-acetyl-p-aminophenol; APAP) ingestion is characterized by a rapid onset of mitochondrial dysfunction, including metabolic acidosis, lactemia, and altered mental status without hepatotoxicity which may not respond to the standard doses of N-acetylcysteine (NAC). A 64-year-old woman without medical history presented comatose after an ingestion of 208 tablets of Tylenol PM™ (APAP 500 mg and diphenhydramine 25 mg). The initial APAP concentration measured 1,017 µg/mL (therapeutic range 10-30 µg/mL), and elevated anion gap metabolic acidosis, lactemia, and 5-oxoprolinemia were detected. High-dose intravenous (IV) NAC, 4-methylpyrazole (4-MP), and hemodialysis (HD) were initiated. She was transferred to a liver transplant center and continued both NAC and HD therapies until complete resolution of metabolic acidosis and coma without developing hepatitis. She was discharged without sequelae. This is the fourth highest APAP concentration recorded in a surviving patient. Moreover, this is the first report of a novel “triple therapy” using NAC, 4-MP, and HD in the setting of massive APAP ingestion that presents with coma, elevated anion gap metabolic acidosis, and lactemia. Emergency physicians should recognize these critically ill patients and consider high-dose NAC, 4-MP, and HD to be initiated in the emergency department (ED)

Lack of Gender Differences in Prevalence of Homelessness in the Emergency Department.

Background: Concordant with the NIH policy on the inclusion of women in clinical research, and their support of analyses that address potential sex and gender differences, researchers are focusing more on assessing outcomes by sex. Objective(s): We set out to assess gender differences in the prevalence of homelessness in the Emergency Department (ED). Material/Methods: From 5/2015-2/2016, ED patients were approached to take a five-question homelessness screening survey. To participate, patients had to be: 18 years or older, speak English, have capacity, not be critically ill, and be willing to participate. Results: 4494 subjects met inclusion criteria; 99 surveys were excluded (took the survey before). 4395 subjects were analyzed. The mean age of subjects was 50.8 years (SD 20.5) and 2,557 (58.2%) were women. No difference in the rate of homelessness was observed between male and female participants with 135 men out of 1,835 (7.4%) and 173 out of 2,557 (6.8%) women screening positive, (p = 0.472). The mean age of those screening positive for homelessness was 40.9 years (SD 15.9); the mean age of men screening positive was 42.4 years (SD = 16.2) and women was 43.7 years (SD 16.9). Both men (N = 41) and women (N = 40) admitted they had slept outside, in an abandoned building, in their car, a shelter or a motel due to financial hardship. Conclusions: We did not observe differences in the rate of homelessness between men and women who screened positive for homelessness in the ED. These data combat stereotypes that this social issue is a problem primarily affecting male populations. Public health interventions aimed at homeless populations should be cognizant that both genders are dealing with this burden. A deeper understanding of the demographics of homelessness may allow for better access to medical treatment since women have different health care needs than men

Perception and Practice Among Emergency Medicine Health Care Providers Regarding Discharging Patients After Opioid Administration

Abstract Purpose This study aimed to determine the current attitudes, perceptions, and practices of emergency medicine providers and nurses (RNs) regarding the discharge of adult patients from the emergency department (ED) after administration of opioid analgesics. Methods A cross-sectional survey was administered at 3 hospital sites with a combined annual ED census of \u3e180,000 visits per year. All 59 attending emergency physicians (EPs), 233 RNs, and 23 advanced practice clinicians (APCs) who worked at these sites were eligible to participate. Findings Thirty-five EPs (59.3%), 88 RNs (37.8%), and 14 APCs (60.9%) completed the survey for an overall response rate of 51.75%. Most respondents were female (95 [69.9%]). The factor ranked most important to consider when discharging a patient from the ED after administration of opioids was the patient’s functional status and vital signs (median, 2.00; interquartile range, 2.00–3.50). More RNs (84 [96.6%]) than EPs (29 [82.9%]) reported that developing an ED policy or guideline for safe discharge after administration of opioids is important to clinical practice (P = 0.02). Only 8 physicians (23.5%) reported that they did not prescribe intramuscular morphine, and 15 (42.9%) reported that they did not prescribe intramuscular hydromorphone. EPs (7 [20.0%]) and RNs (3 [3.4%]) differed in regard to whether they were aware if any patients to whom they administered an opioid had experienced an adverse drug-related event (P = 0.01). Most EPs (24 [68.6%]) and RNs (54 [61.4%]) believed that the decision for patient discharge should be left to both the emergency medicine provider and the RN. Implications Most study participants believed that developing a policy or guideline for safe discharge after administration opioids in the ED is important to clinical practice. Only a few physicians reported that they did not prescribe intramuscular hydromorphone or morphine. Most participants believed the discharge decision after administration of opioids in the ED should be primarily determined by both the emergency medicine provider and the RN

Clinical and Demographic Parameters of Patients Treated Using a Sepsis Protocol

Purpose The purpose of this study was to investigate potential differences by sex in the demographic and clinical characteristics of patients treated utilizing a sepsis electronic bundle order set. Risk factors for in-hospital mortality were also assessed. Methods Data on patients in whom the sepsis order set was initiated in the emergency department over a 16-month period were entered into the hospital database. Data were analyzed for differences by sex in demographic and clinical factors, treatment modalities, and in-hospital mortality. The Bonferroni correction was applied to account for multiple comparisons; α was set at 0.006 for sex differences. Findings A total of 2204 patients were included. Male and female cohorts were similar with regard to a variety of demographic and clinical factors, including age, Emergency Severity Index (ESI) levels 1 and 2, time to disposition, appropriateness of antibiotics, and total fluids given by weight. The ESI is an assessment score ranging from 1 to 5 (1 is emergent). There were modest differences in the source of infection (genitourinary was 4% more common in women; P = 0.03) and mode of arrival (men were 4% more likely to arrive by ambulance; P = 0.03). These differences did not achieve our predefined α of 0.006 when the Bonferroni correction was applied. Factors associated with in-hospital mortality were advanced age, arrival by ambulance, and an ESI level of 1 or 2 (all, P \u3c 0.01). Implications Women were more likely to have a genitourinary cause of sepsis and less likely to arrive by ambulance. Risk factors of in-hospital mortality were older age, arrival by ambulance, and an ESI level of 1 or 2, but not sex