2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Construction and validation of prognostic model for ICU mortality in cardiac arrest patients: an interpretable machine learning modeling approach

BACKGROUND

The incidence and mortality of cardiac arrest (CA) is high. We developed interpretable machine learning models for early prediction of ICU mortality risk in patients diagnosed with CA.

METHODS

Data from the Medical Information Mart for Intensive Care (MIMIC-IV, version 2.2) was randomized to training set (0.7) and internal validation set (0.3), and data from eICU(version 2.0.1) was used as external validation set. Five models including Logistic Regression (LR), Random Forest (RF), K Nearest Neighbor (KNN), Decision Tree (DT), and Extreme Gradient Boost (XGBoost) were developed. The model with the largest area under the Receiver Operating Characteristic (ROC) curve (AUC) and good performance in other features was defined as the best model, and Shapley Additive Explanations (SHAP) was used to improve the interpretability of the optimal model.

RESULTS

A total of 1088 patients from MIMIC-IV, and 3542 patients from eICU were included. Seven variables were selected to construct models by Least Absolute Shrinkage and Selection Operator (LASSO) regression. The RF model was the best predictive model with AUC and 95% CI at 0.83 (0.78-0.88) in internal validation set, and 0.71(0.68-0.74) in external validation set. SHAP analysis found that the variables that had a high impact on the risk of ICU death were minimal Glasgow Coma Scale (GCS), base excess, anion gap, and urine output.

CONCLUSION

RF is the optimal model for predicting the risk of ICU death in CA patients. The development of this model is important for early identification and intervention of CA patients who are at risk of dying in the ICU.

Naloxone dosing in the era of synthetic opioids: Applying the Goldilocks principle

The opioid overdose epidemic remains a critical public health crisis. In recent years, synthetic opioids like fentanyl and nitazenes, have driven a sharp rise in deaths. Naloxone, an opioid receptor antagonist, has been established as a key intervention for reversing opioid overdoses and saving lives. However, there remains a critical need to optimize naloxone dosing strategies. This article examines the challenges of both under-dosing and over-antagonism in naloxone administration, emphasizing the importance of a tailored approach to overdose management. A 'just the right dose' approach is essential for minimizing the risks of over-antagonism while still reversing opioid overdose. This involves starting with a modest naloxone dose and carefully titrating it based on the patient's response, considering factors such as opioid type, overdose severity, and opioid tolerance. A tailored approach to naloxone dosing may present challenges for non-medically trained responders but it can ensure that as many people as possible receive the right dose of naloxone when they need it. Training programs should also emphasize the importance of first aid and supportive care, including airway management and alerting emergency services, as well as careful monitoring of the patient's response.

Influencing factors and predictive indicators of return of spontaneous circulation in in-hospital cardiac arrest

Background

In-hospital cardiac arrest (IHCA) refers to the occurrence of cardiac arrest in hospitalized patients requiring chest compressions and/or defibrillation, with only about one-third of patients achieving return of spontaneous circulation (ROSC) after cardiopulmonary resuscitation. Pan-immune-inflammation value (PIIV) is an indicator assessing the overall inflammatory status within the body, but the relationship between PIIV and ROSC remains unclear.

Objective

This study aims to analyze the occurrence of ROSC and its influencing factors, and investigate the predictive value of PIIV, in order to provide insights for clinical prevention and treatment.

Methods

Clinical data of IHCA patients admitted to our hospital were retrospectively collected. Patients were divided into the ROSC group and non-ROSC group based on whether spontaneous circulation was restored after cardiopulmonary resuscitation. Multivariate logistic regression was used to analyze factors affecting ROSC, and the receiver operating characteristic (ROC) curve was employed to calculate the area under the curve (AUC) to evaluate the predictive value of PIIV.

Results

168 patients' clinical data were collected, including 62 patients with ROSC and 106 with non-ROSC. The results of multivariate logistic regression analysis showed that the duration of cardiopulmonary resuscitation, adrenaline dosage, blood lactate (Lac), and PIIV were independent influencing factors for ROSC in IHCA patients (P < 0.05). The ROC curve analysis revealed that the AUC of PIIV for predicting ROSC in IHCA patients was 0.805 (95% CI: 0.720-0.891), with an optimal cutoff value of 395.3, sensitivity of 83.33%, and specificity of 70.37%.

Conclusion

PIIV demonstrates valuable application in predicting ROSC in IHCA patients.

Effectiveness and tolerability of methylthioninium chloride (methylene blue) for the treatment of methemoglobinemia: twenty-four years of experience at a single poison center

INTRODUCTION

Despite the widely accepted use of methylthioninium chloride (methylene blue) to treat methemoglobinemia, data regarding clinical outcomes are sparse. We sought to better elucidate the efficacy and tolerability of methylthioninium chloride.

METHODS

We identified all cases reported to the New York City Poison Center from 2000 to 2024 in which methylthioninium chloride was administered for methemoglobinemia. We extracted clinical data from these cases, which we assessed using primarily descriptive statistics.

RESULTS

A total of 185 cases were included. The median methemoglobin level was 29% (IQR: 19-42%). Implicated xenobiotics were most frequently volatile nitrites (41%), local anesthetics (15%), and dapsone (11%). The median methylthioninium chloride dose was 1 mg/kg (IQR: 1-2 mg/kg; range: 0.5-4 mg/kg). Multiple doses of methylthioninium chloride were administered in 11% of cases, with a median total dose of 2 mg/kg (IQR: 2-3 mg/kg), the majority of which were associated with volatile nitrites (n = 7) or dapsone (n = 6). Improvement after administration of methylthioninium chloride was reported in 98% of cases (95% CI: 96-100%). Adverse effects attributable to methylthioninium chloride were reported in nine cases (4.9%; 95% CI: 4.6-5.1%), including one instance of hemolysis. Glucose-6-phosphate dehydrogenase activity was found to be deficient in two of seven patients tested, only one of whom did not improve after methylthioninium chloride. Two deaths occurred in this series, both associated with sodium nitrite exposure.

DISCUSSION

Most patients with methemoglobinemia improved after 1-2 mg/kg of methylthioninium chloride, supporting current treatment recommendations. Despite few instances of glucose-6-phosphate dehydrogenase activity testing, major adverse effects attributable to methylthioninium chloride were extremely rare. A relatively large proportion of cases receiving multiple doses were associated with dapsone exposure.

CONCLUSIONS

In this series, methylthioninium chloride was both efficacious and well tolerated in patients with methemoglobinemia, with a single dose of 1-2 mg/kg being sufficient to treat most patients.

Extracorporeal cardio-pulmonary resuscitation in a patient with missed diagnosis of sodium nitrite intoxication

INTRODUCTION

Critical poisoning with sodium nitrite (NaNO2) can present challenges in promptly identifying and managing acute methemoglobinemia.

CASE REPORT

We report the case of an overt self-intoxication by an initially unknown agent, leading to cardiac arrest. Despite prodromal signs of cyanosis, coma, desaturation, and hypotension, methemoglobinemia went unrecognized during extracorporeal cardiopulmonary resuscitation (ECPR) as the point-of-care test failed to provide methemoglobin levels, leading to untreated methemoglobinemia. The blood flowing through the oxygenator notably maintained the same brown colour. Return of spontaneous circulation was never achieved, and the patient was declared dead after 60 min of unsuccessful resuscitation. Cause of death by means of NaNO2 voluntary ingestion was later clarified and confirmed by postmortem finding of elevated nitrite and nitrate concentration.

CONCLUSIONS

This case highlights the risk of failure of ECPR in the context of cardiac arrest due to methemoglobinemia, emphasizing the critical need for prompt recognition of the causative agent and early administration of antidotes.

Hemoadsorption Therapy for Calcium Channel Blocker Overdose at a Tertiary-level Intensive Care Unit: A Retrospective Study

Objective

To describe the burden of calcium channel blocker (CCB) overdose at a tertiary intensive care unit (ICU).

Design and setting

Retrospective study of patients admitted to the ICU with CCB overdose from 2020 to 2022.

Participants

Adult participants with clinically confirmed CCB overdose.

Main outcome

Admission frequency, management strategies, and patient outcomes.

Results

A total of 1719 ICU admissions over the study period, 24 (1.4%) had CCB overdose with a case fatality rate of 12.5% (3/24). Interventions included mechanical ventilation (MV) (71%), vasopressors (92%), high-dose insulin euglycemic therapy (HIET) (71%), calcium (42%), methylene blue (4%), and fluid therapy (100%). Thirteen patients (54%) received hemoadsorption therapy (HA), and eleven received standard of care (SoC) based on current guidelines. The resin hemoadsorption group had a higher SAPS II score (p = 0.002), and a greater total maximal vasopressor dose (p = 0.001) than SoC group. The HA group also had a lower admission mean arterial pressure (MAP), (p = 0.014), a greater MAP increase at 48 hours (p = 0.044), and a longer ICU length of stay (LOS) (p = 0.004) compared to the SoC group. There was one death in the HA group (7.7%) and two in the SoC group (18.2%).

Conclusion

Calcium channel blocker overdose is an important and life-threatening cause of toxicology admissions in the ICU. Modern resin HA may contribute to improved hemodynamic stability providing a safe and important rescue therapy in cases with refractory shock. Well-designed studies are required to confirm its role in enhancing drug clearance thereby improving the hemodynamic state and clinical outcomes.

How to cite this article

Omar S, Shukla V, Khan AB, Dangor Z. Hemoadsorption Therapy for Calcium Channel Blocker Overdose at a Tertiary-level Intensive Care Unit: A Retrospective Study. Indian J Crit Care Med 2025;29(2):130-136.

Outbreak of carbofuran and bifenthrin poisoning in siblings after ingestion of contaminated food in KSA: Clinical management and public health implications

Background

Pesticide poisoning remains a major global health concern contributing to an estimated 371,594 deaths annually. Both accidental and deliberate pesticide exposure, particularly in developing countries, pose challenges to public health systems. In KSA, pesticide poisoning is prevalent, and insecticides such as carbamates and organophosphates are the primary culprits.

Case presentation

Four cases of acute poisoning caused by the ingestion of contaminated shawarma sandwiches containing carbofuran and bifenthrin, a carbamate and pyrethroid mixture, respectively, are described. The affected individuals, all siblings, exhibited varying degrees of cholinergic symptoms, including muscle fasciculations, excessive secretions, and respiratory distress. Despite their severe symptoms, three patients had normal or low-normal acetylcholinesterase levels, probably because of individual variability, delayed testing, or improper sample handling. One patient exhibited diminished acetylcholinesterase activity, thus suggesting severe inhibition; pancreatitis was a further complication that contributed to delayed recovery. Early clinical management included atropine, pralidoxime, and botulinum antitoxin, because of initial suspicion for botulism. Toxicological analysis confirmed carbofuran poisoning, and food safety investigations identified improper pesticide use in food preparation areas.

Conclusion

The reported cases underscore the importance of timely toxicological consultation, proper testing, and appropriate sample handling to guide treatment of pesticide-related poisoning. These findings highlight the crucial need for adherence to WHO regulations and monitoring of pesticide use, as well as strict food safety practices to prevent future outbreaks. The successful multidisciplinary approach to managing these cases demonstrates the critical role of coordinated efforts between clinical teams and public health authorities in addressing such public health threats.

Regional readiness for sodium nitrite-induced methemoglobinemia: availability of methemoglobin testing and methylthioninium chloride (methylene blue) stocking in the Upper Midwestern United States

INTRODUCTION

Sodium nitrite is a potent oxidizer, which may precipitate rapidly lethal methemoglobinemia. Prompt diagnosis and treatment may salvage otherwise fatal cases. It is unclear if emergency departments are prepared for increasing cases. We describe the availability and geographic distribution of real-time methemoglobin testing and methylthioninium chloride (methylene blue) availability in three contiguous United States.

METHODS

This is a cross-sectional survey of hospitals served by a regional poison center in the Upper Midwestern United States. Hospitals were identified by cross-referencing poison center, health department, and state trauma databases. We queried methemoglobin testing capabilities of each site as well as immediate methylthioninium chloride availability. Resulting data are described with descriptive statistics, and predictors of testing and treatment availability are evaluated in multivariable logistic regression.

RESULTS

We identified 320 hospitals with emergency care, analyzing 228 (71.3%) after exclusions. Real-time methemoglobin testing was available at 56 sites (30.6% of 183 respondents). Of hospitals describing methylthioninium chloride availability, 59.4% (130/219) reported having it on-site. A significant difference in real-time methemoglobin testing existed across largest and smallest population strata in adjusted analysis (OR: 64.6: 95% CI: 4.1-1,037). Similarly disparate availability of methylthioninium chloride was observed. Spatial distribution of methemoglobin testing and methylthioninium chloride availability demonstrated notable urban-rural disparities.

DISCUSSION

These data demonstrate a wide disparity in the availability of real-time methemoglobin testing and methylthioninium chloride availability, suggesting that the region is ill-prepared to care for severe methemoglobinemia. Our analysis points to a disconnect between our current poison center recommendations and the capacities of our consulting institutions.

CONCLUSIONS

We demonstrate urban-rural disparities in diagnostic and therapeutic capacity for the management of acute methemoglobinemia in this region, as well as significant geographic variations in methylthioninium chloride stocking and poisoning preparedness. Poison centers must therefore maintain an awareness of antidote availability for this emerging toxicological emergency.

Exploring hypertension-linked diseases: a comprehensive review of innovative drug combinations with enhanced therapeutic potential

Hypertension, a prevalent cardiovascular condition affecting a substantial portion of the global population, remains a formidable health challenge associated with a multitude of complications. This review article provides a comprehensive examination of hypertension, its various complications, and the emergence of a novel management technique that shows promising potential in transforming the therapeutic landscape. Over the years, conventional treatment approaches, encompassing lifestyle modifications, dietary interventions, and pharmacotherapy, have been the mainstay in managing hypertension. However, these strategies fall short in achieving optimal blood pressure control and preventing complications in a significant number of patients. Consequently, the medical community has ventured into exploring innovative management techniques to tackle this unmet medical need. The focal point of this review centers on the emergence of a new management technique for hypertension that exhibits promise in preclinical and clinical studies. The latest research findings shed light on the efficacy and safety of this innovative approach, which encompasses pharmaceutical agents, medical devices, and non-invasive interventions. Through critical analysis and discussion, we explore the potential impact of these novel strategies on hypertension management and patient outcomes. In conclusion, this review article provides a comprehensive overview of hypertension, its complications, and the promising emergence of innovative management techniques. By acknowledging the complexity of hypertension and the potential of new therapeutic avenues, we aspire to pave the way for improved patient care, enhanced quality of life, and ultimately, the mitigation of hypertension-related morbidity and mortality.

Current Concepts in Fluid Resuscitation and Vasopressor Use in Cirrhosis

Critically ill patients with cirrhosis and liver failure do not uncommonly have hypotension due to multifactorial reasons, which include a hyperdynamic state with increased cardiac index (CI), low systemic vascular resistance (SVR) due to portal hypertension, following the use of beta-blocker or diuretic therapy, and severe sepsis. These changes are mediated by microvascular alterations in the liver, systemic inflammation, activation of renin-angiotensin-aldosterone system, and vasodilatation due to endothelial dysfunction. Haemodynamic assessment includes measuring inferior vena cava indices, cardiac output (CO), and SVR using point-of-care ultrasound (POCUS), arterial waveform analysis, pulmonary artery pressures, and lactate clearance to guide fluid resuscitation. Fluid responsiveness reflects the ability of fluid bolus to increase the CO and is assessed effectively by POCUS, passive leg raises manoeuvre, and dynamic tests such as pulse pressure and stroke volume variation in spontaneously breathing and mechanically ventilated patients. Albumin has pleiotropic benefits through anti-inflammatory properties besides its standard action on oncotic pressure and volume expansion in patients with cirrhosis but has the potential for precipitating pulmonary oedema. In conclusion, fluid therapy in critically ill patients with liver disease is a complex and dynamic process that requires individualized management protocols to optimize patient outcomes.

Mixed Cardiogenic-Vasodilatory Shock: Current Insights and Future Directions

This state-of-the-art review describes the potential etiologies, pathophysiology, and management of mixed shock in the context of a proposed novel classification system. Cardiogenic-vasodilatory shock occurs when cardiogenic shock is complicated by inappropriate vasodilation, impairing compensatory mechanisms, and contributing to worsening shock. Vasodilatory-cardiogenic shock occurs when vasodilatory shock is complicated by myocardial dysfunction, resulting in low cardiac output. Primary mixed shock occurs when a systemic insult triggers both myocardial dysfunction and vasoplegia. Regardless of the etiology of mixed shock, the hemodynamic profile can be similar, and outcomes tend to be poor. Identification and treatment of both the initial and complicating disease processes is essential along with invasive hemodynamic monitoring given the evolving nature of mixed shock states. Hemodynamic support typically involves a combination of inotropes and vasopressors, with few data available to guide the use of mechanical circulatory support. Consensus definitions and novel treatment strategies are needed for this dangerous condition.

Prolonged QRS duration in patients with acute poisoning occurs both xenobiotics and with low level of potassium: a single-center retrospective case control study

Prolongation of QRS duration (prolonged QRS) is associated with severe outcomes in non-tricyclic antidepressant poisoning. However, factors other than xenobiotics affecting QRS duration have not yet been investigated. Hence, this study aimed to identify factors contributing to prolonged QRS. This study was a single-center retrospective case control study. Patients who had overdosed on drugs or orally ingested xenobiotics that they would not normally ingest orally were included in the study. Patients were divided into two groups: prolonged QRS and normal QRS. Subsequently, these groups were compared. We performed a logistic regression analysis with the factors extracted by comparison as explanatory variables and prolonged QRS as the objective variable. In total, 108 patients were analyzed; 19 belonged to the prolonged QRS group. In the prolonged QRS group, factors such as male sex, low level of potassium, and xenobiotic ingestion resulted in prolonged QRS. In a logistic regression analysis, significant differences were observed in terms of male sex (odds ratio [OR], 27.00; 95% confidence interval [CI], 5.93-123.00; p<0.001), xenobiotics ingested that resulted in prolonged QRS (OR, 8.55; 95% CI, 1.84-39.70; p<0.001), and potassium levels (OR, 0.15; 95% CI, 0.03-0.88; p=0.035). Ingestion of sodium channel blockers, male sex, and low level of potassium may contribute to prolonged QRS.

2024 American Heart Association and American Red Cross Guidelines for First Aid

Codeveloped by the American Heart Association and the American Red Cross, these guidelines represent the first comprehensive update of first aid treatment recommendations since 2010. Incorporating the results of structured evidence reviews from the International Liaison Committee on Resuscitation, these guidelines cover first aid treatment for critical and common medical, traumatic, environmental, and toxicological conditions. This update emphasizes the continuous evolution of evidence evaluation and the necessity of adapting educational strategies to local needs and diverse community demographics. Existing guidelines remain relevant unless specifically updated in this publication. Key topics that are new, are substantially revised, or have significant new literature include opioid overdose, bleeding control, open chest wounds, spinal motion restriction, hypothermia, frostbite, presyncope, anaphylaxis, snakebite, oxygen administration, and the use of pulse oximetry in first aid, with the inclusion of pediatric-specific guidance as warranted.

Nuclear factor erythroid 2-related factor-mediated signaling alleviates ferroptosis during cerebral ischemia-reperfusion injury

Cardiac arrest (CA) is a significant challenge for emergency physicians worldwide and leads to increased morbidity and mortality rates. The poor prognosis of CA primarily stems from the complexity and irreversibility of cerebral ischemia-reperfusion injury (CIRI). Ferroptosis, a form of programmed cell death characterized by iron overload and lipid peroxidation, plays a crucial role in the progression and treatment of CIRI. In this review, we highlight the mechanisms of ferroptosis within the context of CIRI, focusing on its role as a key contributor to neuronal damage and dysfunction post-CA. We explore the crucial involvement of the nuclear factor erythroid 2-related factor (Nrf2)-mediated signaling pathway in modulating ferroptosis-associated processes during CIRI. Through comprehensive analysis of the regulatory role of Nrf2 in the cellular responses to oxidative stress, we highlight its potential as a therapeutic target for mitigating ferroptotic cell death and improving the neurological prognosis of patients experiencing CA. Furthermore, we discuss interventions targeting the Kelch-like ECH-associated protein 1/Nrf2/antioxidant response element pathway, including the use of traditional Chinese medicine and Western medicine, which demonstrate potential for attenuating ferroptosis and preserving neuronal function in CIRI. Owing to the limitations in the safety, specificity, and effectiveness of Nrf2-targeted drugs, as well as the technical difficulties and ethical constraints in obtaining the results related to the brain pathological examination of patients, most of the studies focusing on Nrf2-related regulation of ferroptosis in CIRI are still in the basic research stage. Overall, this review aims to provide a comprehensive understanding of the mechanisms underlying ferroptosis in CIRI, offering insights into novel therapeutics aimed at enhancing the clinical outcomes of patients with CA.

Cardiovascular toxicity in antitumor therapy: biological and therapeutic insights

The evolution of antitumor therapies has significantly improved cancer prognosis but has concurrently resulted in cardiovascular toxicities. Understanding the biological mechanisms behind these toxicities is crucial for effective management. Immunotherapy-related cardiovascular toxicities are primarily mediated by immune cells and secreted cytokines. Chemotherapy may cause cardiovascular damage through autophagy disruption and mitochondrial dysfunction. Targeted therapies can induce toxicity through endothelin-1 (ET-1) production and cardiac signaling disruption. Radiotherapy may lead to cardiomyopathy and myocardial fibrosis by affecting endothelial cells, triggering inflammatory responses and accelerating atherosclerosis. This review provides insights into these mechanisms and strategies, aiming to enhance the clinical prevention and treatment of cardiovascular toxicities.

Assessment of Respiratory Health Implications of Vaping: A Systematic Review of Toxicity Mechanisms and Adverse Effects of Electronic Nicotine Delivery Systems

E-cigarettes are thought to aid in tobacco smoking cessation, but there are concerns about their overall effectiveness and safety for the general population, particularly adults. This review aims to investigate the mechanisms of toxicity and adverse effects of e-cigarettes on the respiratory system, comparing these effects with those of conventional smoking. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed on PubMed, Embase, and the Cochrane Library using keywords, controlled vocabulary, and text words, with the following criteria: studies published in English from 2014 to 2024, open access, peer-reviewed, and full-text availability. Study selection, quality assessment, and data extraction were carried out by two independent reviewers. The Cochrane Risk of Bias 2.0 tool was used to evaluate the risk of bias in included randomized controlled trials, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool was employed to assess the strength of evidence and determine its generalizability. Electronic nicotine delivery systems (ENDS) have diverse mechanisms of toxicity, including inflammation, hypoxia, cardiovascular stress, and metabolic changes. Reported adverse effects include cough, throat irritation, nausea, and hemodynamic changes. However, ENDS are associated with fewer risks compared to conventional cigarette smoking. ENDS users experience fewer respiratory and cardiovascular issues and have lower levels of biomarkers such as NNAL and CO compared to traditional smokers. Additionally, ENDS are more effective than nicotine replacement therapy (nicotine patches) for smoking cessation, particularly in pregnant women. The side effects of ENDS and nicotine-free vaping are similar to those of conventional smoking in pregnant women, with the exception of a lower birth weight among newborns exposed to ENDS (p < 0.05). ENDS present a complex balance of benefits and risks regarding respiratory health. While there are adverse effects, ENDS are considered less detrimental than conventional smoking and a viable option for smoking cessation. Longitudinal studies are needed to evaluate their safety with long-term use (>16 weeks). Policymakers and health practitioners should use these findings to develop balanced public health policies that weigh the benefits of ENDS against potential health risks, enabling informed decision-making for users.

Outcomes of Out-of-Hospital Cardiac Arrest Patients Who Received Naloxone in an Emergency Medical Services System With a High Prevalence Of Opioid Overdose

BACKGROUND

Opioid-associated out-of-hospital cardiac arrest (OA-OHCA) is a subset of cardiac arrests that could benefit from measures outside of standard Advanced Cardiac Life Support (ACLS), such as naloxone.

STUDY OBJECTIVES

In this study, we sought to examine whether OHCA patients chosen for naloxone therapy by emergency medical services (EMS) clinicians in a system with high rates of opioid overdose would have increased rates of return of spontaneous circulation (ROSC) and survival to hospital discharge.

METHODS

The study took place in an urban EMS system with a high prevalence of opioid overdose. Paramedics could administer naloxone in cardiac arrest in addition to ACLS. It was often administered based on clinical gestalt for suspected OA-OHCA. The outcomes of OHCA patients who received naloxone were compared against those who received usual care in both an adjusted and unadjusted fashion. Lastly, we created a logistic regression model to test for an independent association of naloxone administration on ROSC and survival to hospital discharge.

RESULTS

A consecutive sample of 769 OHCA patients was obtained, of which 175 (23%) received naloxone. On average, patients who received naloxone had significantly fewer comorbidities and were younger. There was no difference in ROSC, survival to hospital discharge, or modified Rankin Scores. Using logistic regression modeling, there was no statistically significant effect of naloxone administration on these outcomes.

CONCLUSION

OHCA patients who received naloxone, despite being younger and having fewer comorbidities, had similar outcomes compared to those who received usual care. The difference in baseline characteristics suggests that paramedic gestalt reasonably selected for OA-OHCA.

Characterizing Utilization and Outcomes of Digoxin Immune Fab for Digoxin Toxicity

BACKGROUND

Digoxin is a widely prescribed drug for congestive heart failure and atrial fibrillation. Digoxin has a narrow therapeutic index and toxicity can develop quite easily. Digoxin immune fab (DIF) is an effective treatment for toxicity, however there are limited studies characterizing its impact on clinical outcomes in real-world clinical practice.

OBJECTIVES

The aim of this study was to identify factors and healthcare outcomes associated with digoxin immune fab (DIF) treatment in patients with confirmed/suspected digoxin toxicity.

METHODS

An IRB-approved retrospective chart review of digoxin toxic patients (2011-2020) presenting at an academic healthcare system was conducted. Demographic and clinical data were collected. Patients were stratified by DIF treatment versus non-DIF treatment. DIF utilization patterns (appropriate, use when not indicated, or underutilized) were determined using pre-defined criteria. Severe digoxin toxicity was defined as having one or more of the following: mental status disturbances, antiarrhythmic therapy, acute renal impairment or dehydration, serum digoxin concentration (SDC) > 4 ng/mL, or serum K+ > 5 mEq/mL. Logistic multivariable regression analysis evaluated factors associated with DIF use. All statistical analyses were performed in R version 4.1.

RESULTS

Data from 96 patients (non-DIF treated group = 49; DIF treated group = 47) were analyzed. DIF was used appropriately in 70 patients (73%), underutilized in 19 (20%), and administered to 7 (7%) patients when it was not indicated. Several clinical parameters differentiated the DIF from the non-DIF group (p < 0.05) including higher mean SDC (3.41 ± 1.63 vs 2.87 ± 1.17), higher mean potassium (5.33 ± 1.48 vs 4.55 ± 0.87), more toxicity severity (85% vs 49%), and more likely to require cardiac pacing (26% vs 4%). Digoxin toxicity resolved sooner in the DIF group (coefficient - 0.702, 95% CI - 1.137 to - 0.267) (p < 0.01) and they had shorter intensive care unit lengths of stay (12.4 ± 20.3 vs 24.4 ± 28.7 days; p = 0.018). The all-cause mortality rate in patients appropriately managed with DIF therapy versus those patients where DIF was underutilized was 11% and 21%, respectively.

CONCLUSIONS

Based on our study population, DIF therapy appears to be beneficial in limiting duration of toxicity and intensive care unit lengths of stay in digoxin toxic patients. Although DIF was appropriately utilized in most cases, there was a relatively high proportion of cases in which DIF treatment was either underutilized or not indicated.

Extracorporeal membrane oxygenation combined with hemoperfusion to assist in the rescue of aconitine poisoning: A case report

Extracorporeal membrane oxygenation (ECMO) has been widely used as a clinical bridge for cardiopulmonary failure. We recently used combined veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and haemoperfusion to successfully treat a patient with acute aconitine poisoning. The patient was admitted to the Emergency Intensive Care Unit (EICU) in a state of coma and shock. Her received comprehensive treatment, including haemoperfusion and anti-shock therapy. 40 minutes after admission, the patient experienced sudden respiratory and cardiac arrest. After conventional defibrillation and cardiopulmonary resuscitation proved ineffective, veno-arterial ECMO was immediately initiated. One hour after initiation of VA-ECMO, the patient's heart rhythm stabilised to sinus rhythm. After 33 h of supportive care, the patient was awake, haemodynamically stable and the VA-ECMO was successfully removed. The patient made full recovery 7 days after admission.

The association of early naloxone use with outcomes in non-shockable out-of-hospital cardiac arrest

STUDY OBJECTIVE

Evaluate the association between early naloxone use and outcomes after out-of-hospital cardiac arrest (OHCA) with initial non-shockable rhythms.

METHODS

This study was a secondary analysis of data collected in the Portland Cardiac Arrest Epidemiologic Registry, a database containing details of emergency medical services (EMS)-treated OHCA cases in the Portland, Oregon metropolitan region. Eligible patients had non-traumatic OHCA with an initial non-shockable rhythm and received naloxone by EMS or law enforcement prior to IV/IO access (exposure group). The primary outcome was ROSC at emergency department (ED) arrival. Secondary outcomes included survival to admission, survival to hospital discharge, and cerebral performance category score ≤2 at discharge (good neurologic outcome). We performed multivariable logistic regressions adjusting for age, sex, arrest location, witness status, bystander interventions, dispatch to EMS arrival time, initial rhythm, and county of arrest.

RESULTS

There were 1807 OHCA cases from 2018 to 2021 meeting eligibility criteria, with 57 receiving naloxone before vascular access. Patients receiving naloxone prior to vascular access attempts had higher adjusted odds (aOR [95% CI]) of ROSC at any time (2.14 [1.20-3.81]), ROSC at ED arrival (2.14 [1.18-3.88]), survival to admission (2.86 [1.60-5.09]), survival to discharge (4.41 [1.78-10.97]), and good neurologic outcome (4.61 [1.74-12.19]).

CONCLUSIONS

Patients with initial non-shockable OHCA who received law enforcement or EMS naloxone prior to IV/IO access attempts had higher adjusted odds of ROSC at any time, ROSC at ED arrival, survival to admission, survival to discharge, and good neurologic outcome.

EDucated: The emergency medicine pharmacotherapy literature of 2023

The purpose of this article is to summarize pharmacotherapy related emergency medicine (EM) literature indexed in 2023. Articles were selected utilizing a modified Delphi approach. The table of contents from pre-determined journals were reviewed and independently evaluated via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by paired authors. Pharmacotherapy-related publications deemed to be GRADE 1A and 1B were reviewed by the collective group for inclusion in the review. In all, this article summarizes and provides commentary on the potential clinical impact of 13 articles, 6 guidelines, and 5 meta-analyses covering topics including guideline releases and updates on rapid sequence intubation in the critically ill, managing cardiac arrest or life-threatening toxicity due to poisoning, and management of major bleeding following trauma. Also discussed are ongoing controversies surrounding fluid resuscitation, time and treatment modalities for ischemic stroke, steroid use in community-acquired pneumonia, targeted blood product administration, and much more.

An in vitro study to determine the impact of lipid emulsion on partitioning of a broad spectrum of drugs associated with overdose

Background

Intravenous lipid emulsion is recognised as a therapy for rescue in cases of local anaesthetic toxicity, but its use in reversing overdose or toxicity related to other drugs remains the subject of debate. This in vitro study sought to expand our understanding of the importance of partitioning in determining the impact of intravenous lipid emulsion on aqueous free drug concentrations.

Methods

Twenty-seven drugs and associated metabolites were screened for the ability of intravenous lipid emulsion to reduce the amount of free drug in the aqueous phase, using specialised cassettes designed for this purpose. The relative amount of drug equilibrating across the membrane from plasma to phosphate-buffered saline was measured, using liquid chromatography-mass spectrometry, at a 6 h timepoint in plasma samples treated with intravenous lipid emulsion and paired, untreated controls.

Results

The data obtained were plotted against measures of partition (LogP and cLogD7.4) and with log-transformed non-protein bound drug. There were significant inverse correlations between the capacity for intravenous lipid emulsion to reduce drug detected in the phosphate-buffered saline compartment and LogP and cLogD7.4, and a direct association with log [non-protein-bound drug]. However, a number of drugs showed substantial variance between different plasma samples.

Conclusions

Modulation of free drug in the aqueous compartment is broadly predictable by the partition coefficient, although ramipril was identified to be an outlier in this regard. Further mechanistic and clinical exploration is merited to establish a standardised protocol for lipid emulsion therapy.

Assessing the readability, reliability, and quality of artificial intelligence chatbot responses to the 100 most searched queries about cardiopulmonary resuscitation: An observational study

This study aimed to evaluate the readability, reliability, and quality of responses by 4 selected artificial intelligence (AI)-based large language model (LLM) chatbots to questions related to cardiopulmonary resuscitation (CPR). This was a cross-sectional study. Responses to the 100 most frequently asked questions about CPR by 4 selected chatbots (ChatGPT-3.5 [Open AI], Google Bard [Google AI], Google Gemini [Google AI], and Perplexity [Perplexity AI]) were analyzed for readability, reliability, and quality. The chatbots were asked the following question: "What are the 100 most frequently asked questions about cardio pulmonary resuscitation?" in English. Each of the 100 queries derived from the responses was individually posed to the 4 chatbots. The 400 responses or patient education materials (PEM) from the chatbots were assessed for quality and reliability using the modified DISCERN Questionnaire, Journal of the American Medical Association and Global Quality Score. Readability assessment utilized 2 different calculators, which computed readability scores independently using metrics such as Flesch Reading Ease Score, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook, Gunning Fog Readability and Automated Readability Index. Analyzed 100 responses from each of the 4 chatbots. When the readability values of the median results obtained from Calculators 1 and 2 were compared with the 6th-grade reading level, there was a highly significant difference between the groups (P < .001). Compared to all formulas, the readability level of the responses was above 6th grade. It can be seen that the order of readability from easy to difficult is Bard, Perplexity, Gemini, and ChatGPT-3.5. The readability of the text content provided by all 4 chatbots was found to be above the 6th-grade level. We believe that enhancing the quality, reliability, and readability of PEMs will lead to easier understanding by readers and more accurate performance of CPR. So, patients who receive bystander CPR may experience an increased likelihood of survival.

Trends in presumed drug overdose out-of-hospital cardiac arrests in San Francisco, 2015-2023

INTRODUCTION

Estimates of the prevalence of drug-related out of hospital cardiac arrest (OHCA) vary, ranging from 1.8% to 10.0% of medical OHCA. However, studies conducted prior to the recent wave of fentanyl deaths likely underestimate the current prevalence of drug-related OHCA. We evaluated recent trends in drug-related OHCA, hypothesizing that the proportion of presumed drug-related OHCA treated by emergency medical services (EMS) has increased since 2015.

METHODS

We conducted a retrospective analysis of OHCA patients treated by EMS providers in San Francisco, California between 2015 and 2023. Participants included OHCA cases in which resuscitation was attempted by EMS. The study exposure was the year of arrest. Our primary outcome was the occurrence of drug-related OHCA, defined as the EMS impression of OHCA caused by a presumed or known overdose of medication(s) or drug(s).

RESULTS

From 2015 to 2023, 5044 OHCA resuscitations attended by EMS (average 561 per year) met inclusion criteria. The median age was 65 (IQR 50-79); 3508 (69.6%) were male. The EMS impression of arrest etiology was drug-related in 446/5044 (8.8%) of OHCA. The prevalence of presumed drug-related OHCA increased significantly each year from 1% in 2015 to 17.6% in 2023 (p-value for trend = 0.0001). After adjustment, presumed drug-related OHCA increased by 30% each year from 2015-2023.

CONCLUSION

Drug-related OHCA is an increasingly common etiology of OHCA. In 2023, one in six OHCA was presumed to be drug related. Among participants less than 60 years old, one in three OHCA was presumed to be drug related.

Acute opioid overdose in pediatric patients

Recent increases in pediatric and adolescent opioid fatalities mandate an urgent need for early consideration of possible opioid exposure and specific diagnostic and management strategies and interventions tailored to these unique populations. In contrast to adults, pediatric methods of exposure include accidental ingestions, prescription misuse, and household exposure. Early recognition, appropriate diagnostic evaluation, along with specialized treatment for opioid toxicity in this demographic are discussed. A key focus is on Naloxone, an essential medication for opioid intoxication, addressing its unique challenges in pediatric use. Unique pediatric considerations include recognition of accidental ingestions in our youngest population, critical social aspects including home safety and intentional exposure, and harm reduction strategies, mainly through Naloxone distribution and education on safe medication practices. It calls for a multifaceted approach, including creating pediatric-specific guidelines, to combat the opioid crisis among children and to work to lower morbidity and mortality from opioid overdoses.

Cyanide poisoning after bitter almond ingestion: "A rare case report"

We present a case of a 36-year-old woman with a history of three suicide attempts who had ingested approximately 40 bitter almonds in a suicidal act, leading to her admission to the emergency department of a regional hospital due to complaints of vomiting. Upon arrival, she exhibited confusion, and her vital signs were recorded as follows: pulse rate = 117 beats/min, blood pressure = 160/85 mmHg, oxygen saturation = 95%, respiratory rate = 16, temperature = 37°C. The patient venous blood gas analysis manifested severe metabolic acidosis (pH = 6.92, pO2 = 43 mmHg, HCO3 = 8.6 mmol/L, pCO2 = 42.7 mmHg, base excess = -25.9 mmol/L). Four hours later, she became unconscious and she was intubated. Gastric lavage and a single dose of 60 g of activated charcoal and sodium bicarbonate were administered. In the referral hospital, sodium nitrite was given due to the severity of the poisoning, and norepinephrine infusion was initiated to manage hypotension. Within a day, the patient regained consciousness, underwent extubation, and after 72 h was discharged and subsequently transferred to psychiatric care for further treatment. This case underscores the critical, life-threatening implications of cyanide toxicity following the ingestion of bitter almonds, highlighting the efficacy of supportive measures such as gastric lavage, activated charcoal, and sodium bicarbonate. Furthermore, it emphasizes the successful application of sodium nitrite monotherapy in managing this condition.