Methotrexate-Induced Epidermal Necrosis 

Christopher L Kennedy, DO, John A Thompson, MD

Background: Methotrexate-induced epidermal necrosis (MEN) is a rare and potentially fatal mucocutaneous reaction that clinically mimics Steven-Johnsons syndrome/toxic epidermal necrolysis (TEN). It presents as painful dusky macules that may progress to full epidermal detachment. Methods: This a case of a 63-year-old female who was admitted to Guam-Regional Medical (GRMC) Center for skin infection and pancytopenia after starting methotrexate (MTX) for psoriasis. She was started on 10 mg/weekly of MTX without folic acid supplementation; one week later she was seen at GRMC-ED for a soft tissue skin infection and started on TMP-SMX. Two weeks after starting MTX she was admitted for a desquamating rash covering >70% of her body. There were no concerns for acute MTX ingestion as the patient's daughter, who controls her medications, confirmed the once-a-week dosing of MTX. This case was complicated by geographical and social constrictions to include no burn unit at GRMC, and patient did not possess an identification card for travel off the island. Hemodialysis was considered but not performed due to lack of available nephrologist. With no burn unit available, she was started on leucovorin q6h for treatment. During her hospitalization she had seral labs to include MTX concentrations and a skin biopsy performed. Results: On day of admission, she was noted to have pancytopenia with a WBC 3,000 cells/mL, Hg of 6 g/dL, and platelet count of 81,000 plt/mL. Her renal function showed a creatine (Cr) of 3.4 mg/dL with baseline of 2.0 mg/dL and BUN of 41 mg/dL. She had a nadir with a WBC 600 cells/mL, platelet 19,000 plt/mL. During her hospitalization, she received five units of pRBC’s for anemia. Her MTX concentration the day after admission was 0.09 µM/L, and slowly cleared to 0.04 µM/L two weeks after admission. A punch biopsy was performed and resulted with “vacuolar alteration, which is associated with a sparse lymphocytic infiltrate and dyskeratotic keratinocytes (Civatte bodies) at the dermal/epidermal junction.” Conclusion: MEN is a rare cutaneous disorder that displays keratinocyte dystrophy on histopathology. Risk factor for MEN include age >60, chronic kidney disease, and high initial dose of MTX without folic acid supplementation. This case highlights the importance of considering these risk factors in a patient started on standard therapeutic methotrexate dosing. 

Phenobarbital Brain Death Mimic with Serial Concentrations 

Christopher L Kennedy, DO,  John A Thompson, MD 

Background: Phenobarbital is a sedative hypnotic that has multiple clinical indications and is classically used as an antiepileptic for seizure management. Phenobarbital increases the duration of time that chloride channels are open, causing CNS depression. Other barbiturates, specifically pentobarbital, are reported as brain death mimic xenobiotics. Methods: This is a case of a 75-year-old female with past medical history of depression and epilepsy maintained on valproic acid and phenobarbital who presented with decreased mental status and no brainstem reflexes on physical exam. Results: The patient presented with agonal respirations and was emergently intubated. Family provided collateral information of an argument prior to the last time she was seen three days prior. During her ED evaluation, serum concentrations of her anti-epileptic medication were obtained. Her valproic acid was subtherapeutic at 16 µg/mL (50-100 µg/mL) and her arrival phenobarbital concentration was supratherapeutic at 81.8 µg/mL (15-40 µg/mL). Multidose activated charcoal (MDAC) was initiated along with a sodium bicarbonate infusion. She was discussed with nephrology for consideration of dialysis and admitted to the MICU. During her admission, she continued to receive MDAC and sodium bicarbonate infusion. An EEG was performed which showed diffuse cortical slowing, no epileptic activity. The patient’s phenobarbital concentration peaked at 95.9 µg/mL ten hours following her arrival. Approximately 48 hours after hospitalization, she began to have a gag reflex and was successfully extubated later that day with a normal neurologic exam. Her phenobarbital concentration near the time of extubation had improved to 42.1 µg/mL. Conclusion: Despite general understanding of barbiturates as potential brain death mimics, previous reviews on xenobiotics brain death mimics have not recorded a case involving phenobarbital. We present a case of a patient with absent brainstem reflexes in the setting of phenobarbital overdose that made a full neurologic recovery. 

Acetaminophen Toxicity with Bactrian Hump Pharmacokinetics Treated Without Need For Repeat N-Acetylcysteine Bolus 

Daniel Tirado, MD, Shana Kusin, MD

Background: Large acetaminophen (APAP) overdoses, or those with coingestants associated with slowing of GI transit, can rarely exhibit Bactrian (“double hump”) pharmacokinetics. We present a case in which APAP overdose showed Bactrian pharmacokinetics and was successfully treated with N-acetylcysteine (NAC) without repeat boluses at peak concentrations. Methods: This is a case report of a 73-year-old female with a history of prior suicide attempts who was found altered by her family 12 hours from last known well. Per EMS, she had agonal respirations and received 2 mg naloxone without improvement. She was taken to an emergency department where vital signs were notable for BP 86/51, HR 115, T 35.7C, O2 saturation of 88% on RA, and was subsequently intubated for airway protection. She was started on vasopressors as well as midazolam and fentanyl infusions for sedation. Initial APAP resulted at 173 mcg/ml with AST 855, ALT 582, and INR 1.2. The patient was started on standard dosing of IV NAC per Oregon Poison Center (OPC) recommendations, and serial APAP levels were obtained. Her APAP level decreased to 57 mcg/ml at 24 hours from arrival but then increased to 256 mcg/ml at 45 hours. The OPC recommended a repeat loading dose of NAC followed by increasing the infusion rate to 12.5 mg/kg/hr; however, this was not performed by the treating physician, and her dosing remained unchanged. Her APAP level decreased to 18 mcg/ml at 85 hours; rose to 70 mcg/ml at 101 hours with AST 45 and ALT 281; again decreased to 28 mcg/ml at 112 hours; it increased again to 102 mcg/ml at 117 hours with AST 38, ALT 252, and INR 1.2. For the remainder of her course, the serum APAP downtrended consistently and became undetectable 143 hours from the initial time of arrival. A urine drug screen had resulted positive for benzodiazepines and opiates, with negative urine fentanyl confirmatory testing. Salicylate and ethanol levels were negative. Results: Despite the treating physician’s deviation from OPC recommendations to adjust the NAC dosing in response to unusual “double hump” pharmacokinetics, the patient successfully recovered. Conclusions: APAP bactrian hump pharmacokinetics may not require repeat NAC bolus for successful treatment. In this instance, opioid toxicity may have contributed to delayed sporadic absorption. Limitations include lack of confirmation of the amount of APAP ingested or any coingestants. 

Iatrogenic Hyponatremia after High-Dose Insulin Euglycemic Therapy 

Daniel Tirado, MD, Christopher Kennedy, DO, B. Zane Horowitz, MD 

Background: High-dose insulin euglycemic therapy (HDIET) serves as an adjunctive treatment for patients with xenobiotic-induced cardiogenic shock. Although hypoglycemia is a known adverse effect of HDIET upon initiation, fluid and electrolyte status must also be considered. We present a case in which HDIET was used as an adjunct to multiple vasopressors that resulted in fluid overload and profound hyponatremia. Methods: This is a case report of a 55-year-old male who presented to a community emergency department after intentional ingestion of amlodipine, atenolol, lisinopril, and hydrochlorothiazide. Arrival vital signs were BP 96/58, HR 99, T 36.4C, RR 32, and O2 saturation at 94% on room air. He became progressively hypotensive despite fluid resuscitation and was started on an epinephrine infusion. Poison control was consulted who recommended using vasopressors, calcium, methylene blue, and HDIET if point of care (POC) ultrasound demonstrated poor cardiac function. The patient was intubated for worsening respiratory status. Initial labs were notable for a sodium of 131 and creatinine of 2.71 (no prior labs were available to refer to baseline). Due to increasing vasopressor requirements, he was started on HDIET with no POC ultrasound performed. An initial bolus of 99 units of insulin was given with subsequent infusion at 5 units/kg/hr. He received over 34 liters (L) of fluid including 2L from the insulin infusion, 8.5L from dextrose-containing fluids, and 18.2L of free water over 23 hours. Repeat labs showed decreasing sodium with nadir of 114 at 22 hours and creatinine that increased to 3.01 with associated oliguria and a physical exam notable for anasarca. He was transferred to a tertiary care facility where he was cannulated for ECMO. Nephrology was consulted, and CRRT was initiated in series with ECMO. The patient was ultimately on ECMO for 5 days, and he suffered no neurological sequelae despite rapid fluctuations in serum sodium concentrations. Results: HDIET serves as an adjunct therapy in xenobiotic-induced cardiogenic shock. Although it is an effective therapy in correct patients, it is not without adverse effects. Conclusion: HDIET may serve as an effective adjunct to manage overdose of cardiac medications. However, fluid volume administration, urinary output, and electrolytes must be closely monitored, as excessive free fluid can lead to hyponatremia. 

Methotrexate neurotoxicity presenting as hemiparesis with adverse response to IV aminophylline 

Horowitz KM, MD, B. Zane Horowitz MD  

BACKGROUND: High-dose methotrexate (8-12 g/m2) has been used to treat pediatric osteosarcomas and leukemia. Leucovorin is often administered as a rescue therapy to avoid toxicity from these large doses. In 3-15% of these treatments, the patient may develop acute stroke-like neurologic deficits. Various treatment regimens have been proposed for this manifestation, including IV aminophylline, which also has potential toxicity. CASE REPORT: A 14-year-old boy presented for acute onset left-sided weakness and left facial droop 6 days after receiving his 10th week of 12 g/m2 methotrexate with leucovorin infusion for osteosarcoma. He had been admitted for this session of chemotherapy due to a history of mucositis and slow clearance of methotrexate after prior treatments. He was discharged after 4 days when his methotrexate concentration was 0.09 umol/L. He had no deficits at a pre-operative appointment 2 days later but, that evening, developed abnormal sensations in his left arm followed by progressive left-sided hemiparesis and left facial droop. CT and MR imaging at an outside ED revealed no evidence of stroke, but MRI suggested a demyelinating process. Methotrexate concentration at that time was 0.05 umol/L. The patient was transferred for Pediatric Oncology and Toxicology consultation with concern for methotrexate neurotoxicity. At the receiving hospital, leucovorin was initiated at 10 mg/m2 every 6 hours and later increased to every 3 hours due to persistence of neurologic deficits. Examination revealed left facial droop and 0/5 left upper and lower extremity strength with preserved sensation. There was no mucositis or rash. Repeat MRI demonstrated a well-circumscribed diffusion-restricted lesion in the posterior right frontal lobe (see image). CASE CONTINUED At 16:00 on hospital day 1, IV aminophylline was started at 125 mg (2.5 mg/kg) every 6 hours. At 03:00 on hospital day 2, the patient reported anxiety and involuntary twitching to the nursing staff. At 11:30, after receiving his fourth aminophylline infusion, he developed dysarthria, confusion, uncontrollable shaking of the right-sided extremities (left still immobile), and appeared distressed. IV benzodiazepines and diphenhydramine were administered. EEG revealed no seizure activity. Repeat MRI demonstrated bilateral areas of restricted diffusion. The patient’s hemiparesis and facial droop had not improved but there were no new right-sided deficits. Aminophylline was discontinued with concern for adverse effect. His twitching and dysarthria eventually resolved and did not recur. Methotrexate concentration was <0.05 umol/L on hospital day 3. The patient underwent surgical resection of his tumor on hospital day 8. Physical examination prior to surgery revealed 4/5 strength of his left extremities and resolution of facial droop. CONCLUSION Hemiparesis with associated MRI findings can occur following high-dose methotrexate with leucovorin rescue even after serum methotrexate concentrations have decreased. Use of IV aminophylline has been proposed as a treatment option for methotrexate neurotoxicity, but can result in methylxanthine toxicity, including symptoms similar to what this patient developed. 

Respiratory compromise from PR protonitazine 

Horowitz KM, MD, Thompson JA, MD 

BACKGROUND: 2-benzylbenzimidazole opioids (also known as “nitazenes”) are potent synthetic opioid agonists that have recently emerged as illicit substances and have been implicated in overdose deaths. These drugs are often found in powders that can be injected, inhaled, or swallowed. Rectal administration is an uncommon route of administration that could be dangerous given the rapid absorption by the rectal mucosa and potential for low first pass metabolism particularly if administered in the lower aspect of the rectum. In this case, rectal administration resulted in profound opioid agonist effects, including respiratory compromise and sedation, that responded to naloxone. CASE REPORT: A 41-year-old woman with a history of depression was found unconscious at home after using protonitazene. She purchased the powder from a website that advertised itself as a distributor of scientific research materials. Due to concerns about the substance’s potency, she reportedly attempted to use a small amount of powder, which she measured onto the tip of her little finger and administered it rectally. She was subsequently found unresponsive by her husband. When EMS arrived, the patient was hypoxic and demonstrated poor respiratory effort but had a pulse. Two doses of 2mg IV naloxone were administered and the patient’s respiratory rate improved, and she regained consciousness. She denied any history of previously using nitazenes, any co-ingestions, and any intent for self-harm. Comprehensive drug testing was positive for N-pyrrolidino-protonitazene (the metabolite of protonitazene). No parent compound was detected. Fentanyl, barbiturates, or THC were not detected. The patient was monitored for 6 hours without recurrence of symptoms, need of additional naloxone, or hemodynamic instability. DISCUSSION: Protonitazene and similar compounds are being used as recreational substances. Despite their development in the 1950s, little is known about the pharmacokinetics of nitazenes. Given their potent mu opioid effects, these agents carry a risk for respiratory compromise although rectal administration has not previously been reported as a route associated with rapid-onset respiratory compromise as in this case. CONCLUSION: Protonitazene is a potent mu-opioid receptor agonist that can cause respiratory depression even upon rectal administration. 

Jellyfish envenomation resulting in an elevated troponin without cardiac dysfunction in Saipan 

Horowitz KM, MD, Trieu C, Hughes A, MD

Background: Multiple species of Cubozoa (box jellyfish) are associated with severe systemic manifestations and cardiac injury, particularly those of the order Carybdeida (ex. Carukia barnesi, Alatina (formerly Carybdea) alata). Cases have been reported in Australia, Indonesia, Thailand, Hawaii, Florida, and the Caribbean, but not previously in Saipan, where A. alata and Copula (formerly Carybdea) sivickisi are common. Methods: This case describes a jellyfish envenomation in Saipan with elevated high-sensitivity troponin despite resolution of symptoms and lack of electrocardiographic or echocardiographic evidence of ongoing cardiac dysfunction. Results: A 15-year-old 75 kg male was stung on the right elbow by an unidentified, 3-4-tentacled, “white jellyfish” while spearfishing at night in late summer. Thirty minutes later, he arrived at the hospital reporting “crushing" chest pain, shortness of breath, nausea, vomiting, and muscle cramping of the neck, back, and stomach. Initial vital signs were pulse 116 bpm, blood pressure 135/78 mmHg, respirations 22 per minute, and 100% oxygen saturation on room air. On examination, he appeared in acute distress with facial flushing, diaphoresis, tachycardia with bounding peripheral pulses, and small faintly erythematous macules on the right elbow. No lower extremity edema or abnormal breath sounds were noted. Topical acetic acid, IV fentanyl, and IV acetaminophen relieved the elbow pain. High-sensitivity troponin I was 85.4 pg/mL one hour after arrival. Electrocardiography showed sinus tachycardia with normal intervals and no signs of ischemia. CXR demonstrated no pulmonary edema. Labs demonstrated serum creatinine 1.20 mg/dL, normal electrolytes, and normal transaminases. A 14-substance urine drug screen was negative. Symptoms resolved after administration of ondansetron, diazepam, and normal saline. Troponin concentrations continued to rise, peaking at 108.9 pg/mL twelve hours after arrival. An echocardiogram showed normal ventricular size and function with 71% ejection fraction and no pericardial effusion. The patient remained asymptomatic and hemodynamically stable during admission. His troponin decreased to 90.7 pg/mL prior to discharge on hospital day two. Conclusion: Cardiotoxicity following jellyfish envenomation has not previously been reported in Saipan. This may reflect rarity or underreporting. Although not identified as the cause, A. alata is known to be in the region and has been associated with cardiac injury, possibly via direct venom effect or catecholamine excess. The marked troponin elevation without persistent symptoms, electrocardiographic or echocardiographic evidence of abnormal cardiac function, or significant renal dysfunction was unexpected. As a single case report without an identified jellyfish species, conclusions are limited. 

Effect of VA ECMO on Vasopressor Requirements and Organ Perfusion in Verapamil Overdose 

Colleen Cowdery, MD, Christopher Kennedy, DO

Background: Calcium channel blocker overdose may cause bradycardia and hypotension refractory to maximal therapy. A prior multicenter retrospective review of verapamil overdoses found that verapamil concentration > 2.27 mg/L upon ICU admission had a statistically significant mortality odds ratio of 2.76. Mortality from verapamil ingestion has been reported with blood concentrations as low as 0.9 mg/L. We present a verapamil overdose case treated successfully with VA ECMO. Hypothesis: Was initiation of VA ECMO associated with improvement in organ perfusion and decreased vasopressor requirement in a patient with high serum verapamil concentrations? Methods: This is a single patient chart review. A 56-year-old female with bipolar disorder ingested 7.2 g of immediate release verapamil and presented 30 minutes later with somnolence, bradycardia, and hypotension. Upon arrival, her mean arterial pressure was 46 mmHg and her heartrate <40. Hypotension was refractory to intravenous fluids, high dose pressors, and intravenous pacing. Six hours post-ingestion, she was cannulated for VA ECMO (21Fr R CFA arterial cannula, 25Fr L CFV drainage cannula, 7Fr R SFA distal perfusion cannula) with a blood flow rate of 4.8 L/min (BSA: 2.47 m2). Organ perfusion was indirectly measured with urine output and lactic acid. Total vasopressor use was calculated using the Norepinephrine Equivalence (NEE) scale. Serial verapamil concentrations were measured by LC/MS. Results: Initial verapamil concentration prior to cannulation was 3.5 mg/L (reference 0.12-0.40 mg/L); over the first 24 hours it decreased but remained >1.0 mg/L. In the three hours preceding cannulation, vasopressor use increased 270% from 0.45 to 1.22 μg/kg/min, urine output was 0.45 mL/kg/hr, and lactate was 12.1 mmol/L. Following cannulation, her vasopressor requirements decreased by 37% by three hours, 67% by six hours, and 96% by 12 hours down to 0.04 μg/kg/min. Urine output increased to 9.5 mL/kg/hr in the two hours post-cannulation, then stabilized at 2-2.5 mL/kg/hr. Lactate began to downtrend at 4 hours post-cannulation. Conclusion: VA ECMO cannulation was beneficial for the stabilization and survival of this critically ill verapamil overdose patient. Our patient’s initial verapamil concentration of 3.5 mg/L, rising lactic acid, and refractory hypotension were prognostic of a poor outcome. Following cannulation, organ perfusion rapidly improved and her vasopressor requirements significantly decreased and were nearly discontinued after 12 hours. Given her elevated verapamil concentrations during this period, this improvement is likely due to VA ECMO intervention. 

Caffeine clearance data utilizing in-line AAVV hemodialysis attached to VA ECMO outflow cannula 

Colleen Cowdery, MD, Courtney Temple, MD

Background: Severe methylxanthine toxicity causes recurrent seizures and ventricular dysrhythmias. We present a pediatric caffeine overdose with multiple cardiac arrests treated with ACLS, intravenous lipid emulsion, VA ECMO, and hemodialysis. Caffeine extraction and clearance data are reported. Hypothesis: Is in-line ECMO-hemodialysis an effective strategy to decrease serum caffeine concentrations? Case Report: This is a single patient chart review. A previously healthy 13-year-old ingested 6g of caffeine (115mg/kg) and developed recurrent seizures and ventricular dysrhythmias. Multiple cardiac arrests were successfully treated with ACLS, intravenous lipid emulsion, VA ECMO (18Fr R CFA, 19Fr R CFV, and 5Fr antegrade R SFA distal perfusion catheter), and hemodialysis. The hemodialysis circuit was attached to the VA ECMO circuit in AAVV arrangement pre/post oxygenator. Two 4h sessions of hemodialysis were performed with blood flow rates of 300 mL/min and dialysate flow rates of 600 mL/min; blood flow rate during session two was decreased to 200 mL/min due to ECMO pressure issues. Ultrafiltration was not performed given brisk diuresis. Serial serum caffeine concentrations were drawn. Based on the patient’s weight (52.2 kg), a volume of distribution (Vd) of 0.7 L/kg for caffeine, and a pre-hemodialysis serum caffeine concentration of 52.6mg/L, the estimated drug burden immediately pre-hemodialysis was 1.92g. Following hemodialysis session one, plasma caffeine concentration decreased 77% down to 12 mg/L. Following hemodialysis session two, it lowered an additional 70% to 3.6 mg/L. The caffeine plasma extraction ratio during hemodialysis session one was 0.5. The hemodialysis caffeine clearance rate was 99.6 mL/min. The patient was discharged to rehabilitation on day 20 with no major neurologic sequelae. Discussion: Hemodialysis effectively decreased caffeine concentrations in this critically ill patient. The hemodialysis clearance rate of 99.6 mL/min represents a 147% increase from previously documented endogenous caffeine clearance of 0.078 L/h/kg, which would equal 67.9 mL/min for our patient. Dialysis clearance rates improve with increasing blood flow, increasing dialysate flow, or increasing ultrafiltration rate. For this patient, connecting the hemodialysis circuit directly to the VA ECMO circuit allowed for higher blood flow rates in this hemodynamically unstable patient and reduced the crowding of cannulations in her extremities. A limitation of this single case report is the absence of urine caffeine concentrations, making direct comparison of endogenous vs extracorporeal removal not possible. Conclusion: Hemodialysis is an effective method of caffeine removal. Attaching ECTR directly to ECMO may allow for higher blood flow rates in critically ill patients, increasing clearance rates of dialyzable substances. 

False-positive Urine Fentanyl Screen in a Patient with Intentional Trazodone Ingestion 

Colleen Cowdery MD, Emma Cassidy MD, B. Zane Horowitz MD 

Background:  In response to changing trends in the illicit drug market, healthcare facilities are rapidly moving to expand their standard drug screens to include fentanyl. Trazodone metabolite meta-chlorophenyl piperazine (mCPP) has previously been reported to cause a false-positive urine screen for amphetamine, however, there are no previous case reports of trazodone or its metabolites causing false-positive fentanyl testing. We report a case of intentional overdose of trazodone with a false-positive fentanyl urine screen. Case Report:  A teenage patient presented to the emergency department with mild sedation after an intentional ingestion of a family member's trazodone. The patient was not on any medications chronically and presented with a single-product trazodone ingestion, with no access to other medications or evidence for co-ingestions. A urine drug screen performed as part of routine care was positive for fentanyl. The urine screen used at this facility is the SEFRIA™ fentanyl urine immunoassay. The patient has no history of opioid or illicit drug ingestion and denied any known exposure to fentanyl. Quantitative testing for fentanyl and trazodone were sent to confirm exposure. On confirmatory testing, the patient had a urine trazodone level of 2.4 mcg/mL and mCPP level of 0.40 mcg/mL by LC/MS. Fentanyl and norfentanyl were undetectable by LC/MS. Discussion:  According to the SEFRIA™ product insert, the manufacturer reports 0.01% cross-reactivity with trazodone (cross-reactivity tested at 10 mcg/mL) and a 0.001% cross-reactivity with mCPP (cross-reactivity tested at 100 mcg/mL) in spiked urine testing. Trazodone and mCPP levels in the patient’s urine were lower than the levels tested for cross-reactivity on spiked urine assays according to manufacturer’s product information. Further studies should determine if trazodone can cause the same interference in other fentanyl assays, or at routine therapeutic concentrations. This report is limited as it represents a single case in the setting of an intentional ingestion. Conclusions: We report a false-positive SEFRIA™ fentanyl urine immunoassay after symptomatic, intentional ingestion of trazodone. Patients presenting with intentional ingestions are routinely screened for drugs of abuse, and a false-positive drug screen can be a cause for concern and confusion during clinical care. As fentanyl screens are rapidly added to routine drug testing, providers and medical toxicologists should be aware of possible false-positive results caused by common pharmaceuticals on fentanyl urine assays. 

Baclofen-Induced Encephalopathy in CKD with Therapeutic Serum Concentration 

Jeffrey Phillips, MD, Colleen Cowdery, MD 

Background: Baclofen is a GABA-B agonist that is 85% renally cleared unchanged. Dosing reduction is necessary for patients with estimated glomerular filtration rate (eGFR) of 30-60 mL/min/1.73m2 and avoidance recommended in patients with eGFR of less than 30 mL/min/1.73m2. Baclofen crosses the blood brain barrier readily and is well known to produce profound central nervous system (CNS) depression in overdose or in patients with decreased renal function. Here we present a CKD patient with significant encephalopathy despite serum baclofen concentrations within the therapeutic range, which has been reported as 0.08-0.40 mcg/mL. Case Report: A 72-year-male with past history of CKD stage IV (eGFR 18 mL/min/1.73m2) and type 1 diabetes mellitus presented with altered mental status (AMS) three days after initiation of oral baclofen 10mg three times daily. The patient arrived obtunded and only moaning to painful stimuli. The patient’s workup was negative for other causes of AMS. A urine drug screen was negative. The patient’s mentation remained unchanged for the first three days of admission. Baclofen concentrations drawn on hospital days 2 and 3 likewise remaining unchanged at 0.14 mcg/mL, showing no clearance of baclofen. Hemodialysis was initiated on the third evening for progressively worsening renal function, after which the patient’s mentation improved. Post-dialysis, serum baclofen concentration decreased to 0.03 mcg/mL and the patient’s mentation continued to improve with two subsequent treatments with hemodialysis. The patient confirmed that no other new medications or substances had been taken except for the baclofen which he had taken as prescribed. Following a 10-day admission, he was discharged home on permanent hemodialysis but otherwise at his baseline functional status. Discussion: Initiation of baclofen therapy in CKD patients is a known cause of encephalopathy due to impaired renal drug clearance. This case exhibits a discrepancy between the severity of the patient’s encephalopathy and his ostensibly therapeutic serum baclofen concentration. Our patient exhibited rapid encephalopathy onset following baclofen initiation with no other changes in his home medications and no other reported exposures. Given that baclofen is renally excreted unchanged with minimal hepatic metabolism, specific drug-drug and CYP interactions are not expected. The patient showed no symptomatic improvement and no baclofen clearance until HD was initiated, at which time baclofen concentrations decreased and mentation improved. Although expanded drug screening was not performed, the patient’s history and bloodwork is consistent with baclofen as the causative agent. Interestingly, this patient’s serum baclofen concentration was within the range of previously reported therapeutic concentrations. It is possible that CNS baclofen concentrations exceeded serum baclofen concentrations; however, CNS baclofen concentrations were not obtained. Limitations of this single-patient case report also include the lack of expanded drug screening. Conclusion: Significant baclofen-associated encephalopathy is possible in patients with advanced renal insufficiency even with therapeutic serum baclofen concentrations. 

Excedrin overdose in a 27 year old male – A case of toxic coingestion 

Kyle Zemeir, DO MA, David Jones, MD MBS MCR FACEP 

Aspirin, acetaminophen and caffeine overdoses are well documented in the literature. However, there is a paucity of literature with all three of these drugs as coingestants. We present a 27-year-old male in the ED after intentional overdose of 400 tabs of Excedrin migraine™ (250mg Acetaminophen/250mg Aspirin/65mg Caffeine) and 100 tabs of Melatonin (5mg). Total ingested quantity was 100g Acetaminophen, 100g Aspirin, 26g caffeine and 500mg melatonin. Patient initially presented alert and oriented. Vital signs revealed tachypnea of 25 and tachycardia of 106. Initial ECG showed sinus tachycardia with slight widening of the QRS to 108ms and QTc of 408ms. 1 ampule of 50mEq bicarbonate was given. ICU and Nephrology consults were placed prior to any lab results. Initial VBG showed pH 7.17 (7.35-7.45), CO2 35 (50-60mmHg), HCO3 13 (22-26 mEq/L). Initial Chem-8 showed Na 141 (135-145 mEq/L), K 2.6 (3.5-5.5 mEq/L), Cl 107 (98-108 mEq/L), Glc 307 (70-100 mg/dL) , iCa 1.11 (0.8-2.2 mmol/L). Initial lactate was 11.9 (0.5-2.2 mmol/L) with an anion gap of 26 (4-12mEq/L). IV Bicarbonate infusion at 150mL/hr and K+ repletion through one peripheral IV at 10 mEq/hr were started as more peripheral lines were obtained. The patient was empirically started on Intravenous N-Acetylcysteine. Initial acetaminophen level was 82.7 (<10ug/mL) and salicylate level 44.8 (15-30mg/dL). At this point the Oregon Poison Center was contacted. It was recommended to start the patient on multiple dose activated charcoal (MDAC) every 2 hours for concern of pharmacobeozar. An intermittent dialysis catheter was placed in the right internal jugular vein in anticipation of emergent dialysis. During the procedure, the patient appeared to have widening of his QRS complex on the monitor. Repeat ECG showed sinus tachycardia 120, QRS 141ms, QTc 533ms. Bicarb drip was increased to 600mcg/min and repeat ECG obtained which showed sinus tachycardia 100, QRS 104ms, QTc 578ms. The patient additionally had a fluctuating altered mental status due to the aspirin causing neuroglycopenia. He received 5 blouses of D50 with diminishing returns of his mental status. Intubation was considered but decided against due to concern for worsening acidosis. The patient was managed in the Emergency Department before they received emergent hemodialysis as a definitive treatment. The patient was discharged from the ICU in stable condition two days later. 

Amoxicillin-Clavulanate-Induced Liver Injury with Cholestatic Pattern 

Jeffrey Phillips, MD, Daniel Tirado, MD, Courtney Temple, MD, Caroline Wight, MD

Background Amoxicillin and amoxicillin-clavulanate are among the most widely prescribed antibiotics in the United States. From 2013 to 2016, amoxicillin-clavulanate ranked among the top five most prescribed antibiotics nationwide. Similarly, it accounts for 64% of all antibiotic prescriptions among children in European pediatric emergency departments. Although the overall risk of drug induced liver injury (DILI) from these antibiotics is low, amoxicillin-clavulanate is one of the most implicated agents in reported cases of idiosyncratic DILI in both adults and children. Most cases present with a cholestatic pattern and are self-limited. We present a severe case of adult DILI attributed to amoxicillin-clavulanate. Case Report A 47-year-old previously healthy man presented with three weeks of painless jaundice and acholic stools. Symptoms began four days after completing a twice daily, seven-day course of amoxicillin-clavulanate for otitis media. He denied substance use, concurrent medications, personal or family history of liver disease and malignancy. His exam was notable for marked jaundice with scleral icterus, and skin excoriations from intense pruritus. Laboratory evaluation revealed a total bilirubin of 22.5 mg/dL, direct bilirubin 15 mg/dL, AST/ALT 48 and 55 IU/L respectively, alkaline phosphatase 282 U/L, and INR 1.11. Computed tomography (CT) of the abdomen showed a decompressed gallbladder with no biliary ductal dilation, and otherwise no clinically relevant lesions. No ultrasound was obtained. Hepatology was consulted and the patient was admitted for further management. During his admission, he underwent Magnetic Resonance Cholangiopancreatography (MRCP), which revealed mild intrahepatic pruning and peripheral ductal paucity concerning for a sclerosing process. The patient subsequently underwent liver biopsy confirming DILI, with findings of cholestasis with canalicular bile plugs, minimal portal inflammation, and no significant fibrosis. His total bilirubin peaked at 24.9 mg/dL, AST and ALT at 63 and 80 IU/L respectively, alkaline phosphatase at 268 U/L and INR at 1.42. He was briefly considered for liver transplant evaluation, though ultimately demonstrated clinical improvement. The patient was managed supportively and discharged with improving labs and symptoms after a 15-day admission. Discussions While DILI secondary to amoxicillin has been described, the addition of clavulanic acid increases the risk of liver injury from 3 to 17 per 100,000 exposures. The cholestatic pattern seen in this patient, characterized by jaundice, pruritus, and elevated alkaline phosphatase, is usually self-limiting but may persist due to bile duct injury. In rare cases, liver injury progresses to vanishing bile duct syndrome, liver failure, or necessitate liver transplantation. Most patients recover with supportive care; however, given the estimated 10% mortality patients with DILI, close monitoring for acute liver failure and timely consideration of transplant evaluation is essential. Conclusion Clinicians should maintain a high index of suspicion for DILI in patients presenting with jaundice following antibiotic use. Although often self-limited, amoxicillin-clavulanate induced liver injury can lead to serious complications. Recognition and supportive care are key, along with monitoring for signs of hepatic decompensation. 

Methamphetamine-Induced Serotonin Syndrome in a Polysubstance User: A Case Report 

Keino Robinson, MD

Methamphetamine is well-known for causing sympathomimetic toxicity, including agitation, hyperthermia, and seizures. Serotonin syndrome (SS), a potentially life-threatening condition resulting from excessive serotonergic activity, is rarely associated with methamphetamine use alone. While SS is commonly linked to serotonergic drugs, such as SSRIs or MDMA, methamphetamine has been less frequently identified as a solitary cause. Here, we report a 30-year-old Caucasian male with polysubstance use who developed serotonin syndrome after using methamphetamine, highlighting diagnostic challenges in distinguishing SS from other stimulant-related toxicities in patient with polysubstance use. 

Fournier's Gangrene: Can't Miss Diagnosis, Can't Miss Sonographic Findings 

Alvaro Lewis, MD and Patsy Chenpanas, MD 

Fournier's Gangrene is a critical diagnosis that cannot be missed in Emergency Medicine, and is a clinical diagnosis. We know to immediately consult our surgical colleagues, but what do you do if your colleagues are not immediately convinced? We review a case of Fournier's Gangrene that showed characteristic ultrasound findings that were obtained while Urology and Surgery requested a CT for confirmation of the diagnosis after their evaluations. Knowledge of the sonographic abnormalities in Fournier's Gangrene, as demonstrated in this case report, can empower Emergency Physicians in future discussions with surgical colleagues, expedite diagnosis and definitive care, and improve patient outcomes. 

"La Belle Indifference" 

Myra Khushbakht, MD, Michaela Angelique Go, MD MPH

Necrotizing fasciitis is an emergent diagnosis with a high risk of morbidity and mortality. This case report will be discussing an atypical presentation of necrotizing fasciitis. Although the patient’s clinical presentation looked similar to cellulitis without evidence of subcutaneous gas on imaging, key findings of discerning altered mental status and rapid vital sign changes likely secondary to septic cardiomyopathy increased suspicion of an insidious presentation of necrotizing fasciitis. The diagnosis was ultimately made with a beside fasciotomy that showed “dishwater” drainage. Patient was emergently sent to the operating room for a debridement. After being successfully weaned off vasopressors, the patient was downgraded from the SICU to a general medicine ward for continued care and discussions on reconstructive surgery with skin grafting. Necrotizing fasciitis can be a difficult diagnosis to make. If the diagnosis remains unclear, a bedside surgical exploration can be crucial to aiding a definitive diagnosis. 

Climate Change and GME; A Scoping Review 

Adrian Cois, Sara Kirkpatrick, Rachelle Heron 

Background: Climate change threatens humanity's health and well-being. While climate change topics have been increasingly incorporated into undergraduate medical education, it is unclear to what extent they have been incorporated into graduate medical education (GME) curricula in the United States (US). Objective: To examine how climate change has been incorporated into GME curricula in the US. Methods: We conducted a scoping review of published literature from 2013 through November 2023. PubMed and Scopus were searched with articles assessed by 3 reviewers in a blinded fashion. Resources were included if they described how climate change is incorporated into GME curricula in the US, and if they discussed topics such as disaster medicine, mass casualty events, environmental medicine, public health, health policy, wilderness medicine, quality improvement, and sustainability. Articles were processed using Rayyan, and manuscripts were analyzed using descriptive numerical analysis and qualitative assessment to identify article characteristics and themes. Results: The inclusion criteria generated 17 articles, which examined climate change incorporation into GME curricula and curriculum interventions covering topics for inclusion. The most common type of article (5) identified was surveys of program directors on the inclusion of climate-related topics. Conclusion: Published accounts of climate-related topics in US GME program curricula are few. More content is found in topics related to Emergency Medicine. Curricula frameworks have been proposed for pediatric and internal medicine residency programs, but we know little about their efficacy. These gaps should be filled with future scholarship to educate learners to improve healthcare sustainability and resiliency. 

20-Year Review Pediatric Methamphetamine Exposure 

Christopher L Kennedy, Robert G Hendrickson 

Background: Methamphetamine is the predominant stimulant in the western United States and has been associated with pediatric exploratory ingestions. We sought to describe the exposure locations, clinical presentations, interventions, and outcomes of pediatric exploratory exposures in the United States over the last 20 years. Methods: We searched the National Poison Data System (NPDS) over a 20-year period (1/1/2004-12/31/2023). Cases were included if they were a hospitalized child (<6 years) after an exposure to methamphetamine (substance code 0201127) by ingestion or unknown route. We extracted age, level of healthcare, clinical effect, therapies, exposure sites, and medical outcomes. Results: We included 1,359 subjects. Cases increased by 333% over the 20-year period. The majority of children were <2 years old (988/1359; 73%). There was a near even split between patients admitted to an ICU (662, 49%) and the pediatric floor (697, 51.3%). Most of these exposures occurred at home (1,100, 81%) or another residence (132, 10%). Agitation (1,075, 79%), Tachycardia (872, 64%) and hypertension (249, 18%) were the predominate clinic effects reported. Less commonly reported clinical effects included rhabdomyolysis (129, 9%), hyperthermia (151, 11%), and CNS depression (106, 8%). Medical outcomes included 291 (21%) mild, 831 (61%) moderate, 216 (16%) major, and 3 (0.2%) children died. Treatments included benzodiazepines (943, 69%), intravenous fluids (829, 61%), and intubation (75, 6%). Conclusion: Exposures of young children to methamphetamine continue to increase in the United States and the majority of exposures occur in the child’s home. About half of children admitted for methamphetamine ingestions were admitted to the intensive care unit and the majority had moderate to severe outcomes. Further research should be performed to further characterize this group and prevent future exposures. 

Effect of Gastric pH and Duodenal pH on Water Bead Expansion Rates 

Daniel Tirado, Robert G. Hendrickson 

Background: Water bead ingestions in young children are frequently reported to poison centers, with the most serious sequelae resulting in small bowel obstructions. We present a research study evaluating water bead expansion rate in an acidic solution and subsequent placement into a neutral solution to simulate pediatric gastric emptying from the stomach into the duodenum. Hypothesis: We hypothesize that the mean rate of size increase is greater in more neutral solution compared to acidic solution. Methods: This research study used a set of water beads purchased from an online store for which the manufacturer states each bead may expand up to 60 millimeters (mm). Mean gastric emptying time for the population (<5 years old) is 3 hours. Mean pH of gastric fluid is 2 and of duodenal fluid is 6. Seven water beads (same brand) were placed into a hydrochloric acid-based gastric simulant solution with a pH of 2. Each water bead was measured at 0, 1, 2, and 3 hours while in the acidic solution. After three hours (mean gastric emptying time), the beads were transferred into the duodenal simulant solution with a pH of 6. Measurements of each bead were then taken at 4, 6, 8, 10, and 12 hours. All measurements were recorded using calipers. Ordinal variables were compared using the Wilcoxon Signed-Rank test. Results: The largest water bead expanded to 34 mm at 12 hours. The mean rate of increased water bead diameter in the gastric simulant solution (pH=2) and duodenal simulant solution (pH=6) were 0.96 mm/hour and 2.47 mm/hour, respectively (P<0.05, z=-2.3664). Conclusion: The rate of water bead expansion is increased in a duodenal simulant solution with pH 6 compared to a gastric simulant solution with pH 2. This is consistent with the pathophysiology of bowel obstruction cases - beads minimally expand in the stomach, fit through the pylorus, and then expand rapidly in the upper small bowel. These results will be used in future studies to determine the effect of various interventions on water bead expansion rates in neutral environments. The primary limitation of the study is that it is in vitro and may not reflect in vivo conditions. 

Frequency and severity of cannabis toxicity before and after legislative change to increase cannabis edible package size 

Horowitz KM, Cowdery C, Hendrickson RG 

Background: On 1 April 2022, legislation was enacted in Oregon to increase the maximum amount of tetrahydrocannabinol (THC) that could be sold in a single package from 50 to 100 mg. We sought to evaluate if there was any change in the frequency of poison center cases and the severity of symptoms among different age groups before and after the date, the legislation was enacted. Methods: This is a retrospective chart review of the Oregon Poison Center database (Toxicall) for the 3 years around the legislative change (18 months before and after). Patient age, amount ingested (if known), symptomatic manifestations, and treatments were recorded. Cases were excluded if the patient’s age or clinical course was unknown. Data was analyzed by age group (<6 years,6–19 years, 20–65 years, or >65 years) and symptom severity, defined by the following criteria: “severe” if documented seizures, hypotension, respiratory depression, or intubation; "moderate” for documented CNS depression or benzodiazepine administration; “mild” if there was documentation of symptoms that did not receive intervention; and “no effect” if asymptomatic. Cases reporting >50 mg THC ingestions were separately evaluated. Categorical variables were analyzed using chi square and Fisher exact test if data was sparse. Results: 443 cases were included in the study. The number of cases increased from 204 before to 239 after the change in package size, a 17% increase. Most of the increase was in the <6-year-old age group with an increase of 26 cases (an 34.2% increase). In the 20–65 age group, there was an increase in symptom severity after the change in package size (p = .02), particularly an increase in mild/moderate cases. Cases with reported ingestions >50 mg THC (n = 85) increased from 39 before to 46 after the change (18% increase). There was an increase in symptom severity (p = 0.04) in the post-legislative period, most notable for an increase in mild severity cases from 1 to 12. Discussion: Limitations include the retrospective design, the voluntary nature of poison center reporting, the limited number of cases with reported doses, and the possibility of additional fac-tors that increased cannabis exposures in this timeframe. Conclusions: Following the increase in the maximal allowable limit of THC in a single package, total number of cases of THC exposure to the OPC increased, particularly in the <6-year-old population. There was also an increase in symptom severity among adults (20–65-year-old), particularly among mild and moderate severity cases. There was a slight increase in the number and severity in cases involving greater than 50 mg THC. Further attention on the potential effects of legislative change on the frequency of symptomatic exposures is warranted. 

Evaluation of hydroxocobalamin interference on determination of carboxyhemoglobin percentage by co-oximetry 

Horowitz KM, Bierman J, Kazmierczak S, Ran R 

Background: Hydroxocobalamin is a red chromophore with absorption peaks at 274, 351, 500, and 526 nm, raising concerns that it could interfere with spectrophotometric tests. In particular, co-oximetry uses similar absorption spectra to determine carboxyhemoglobin percentage (CO-Hgb%). Case reports of patients treated for presumed carbon monoxide and cyanide exposure suggest hydroxocobalamin caused falsely decreased CO-Hgb%. Animal and spiked blood experiments, however, demonstrate both CO-Hgb% elevations and reductions. These models might not accurately reflect clinically relevant serum concentrations or account for changes with metabolism. This study investigated the effect of hydroxocobalamin administration on CO-Hgb% in human subjects. Methods: Patients who received hydroxocobalamin for hypotension were screened for inclusion. Patients with a blood gas on which a CO-Hgb% could be determined before and within 12 hours after administration of hydroxocobalamin were included. Patients were excluded if they did not have a CO-Hgb% drawn before and after hydroxocobalamin administration, received methylene blue before hydroxocobalamin administration or before collection of the subsequent blood gas, received >6 L of IV fluids over 4 hours during or after hydroxocobalamin infusion, or received >1.5 L of blood products between administration of hydroxocobalamin and collection of the subsequent blood gas. Cases were reviewed retrospectively. No blood testing or interventions were dictated by the IRB-approved study protocol. Samples were measured on one of two Radiometer ABL800 co-oximeters (measuring in the 478-673 nm range). Assignment to a particular instrument was random. Imprecision for each instrument for CO-Hgb%<5% was ±0.3%. CO-Hgb% before and after hydroxocobalamin administration was compared using two-tailed t-test. Results: 21 subjects were screened; 14 were analyzed. CO-Hgb% generally increased after administration of hydroxocobalamin (mean: +0.81% (95%CI 0.22-1.39; p<0.05)) with a range of -1.7 to +2%. Subsequent blood gas was obtained, on average, 4.1 hours (range: 0.6-10.5 hours) after hydroxocobalamin administration. Discussion: Hydroxocobalamin might interfere with CO-Hgb% detection but does not demonstrate a clinically relevant deviation in results when using the Radiometer ABL800. Possible causes might include short distribution half-life of hydroxocobalamin (1-2 hours), metabolism to cyanocobalamin which has a different absorption spectrum (278, 361, and 550 nm), instrument-specific variations, or interference unrelated to wavelength absorption. Limitations include the availability of only one co-oximeter model, low CO-Hgb%, heterogenous population, possible contribution of critical illness, and the retrospective nature of the study. Future investigations of laboratory interference by hydroxocobalamin in human subjects on different instruments might help determine the true incidence, cause, and significance of this effect. 

Opiate content in poppy seed tea brewed using real-world quantities and methods 

Horowitz KM, Hoang D, Kazmierczak S, Castelli R 

Introduction: People have attempted to extract opiates from the surface of unwashed Papaver somniferum seeds by brewing poppy seed tea for recreational consumption. Various extraction methods are available online as are reports of the intoxicating effects after consuming these teas. However, the quantities of opiates extracted is unclear. Previously published laboratory-based small quantity extractions have demonstrated these extractions can yield variable quantities of morphine (0.0024-3.81 mg in 18 mL) and codeine (0.041-0.58 mg in 18 mL)1, but this used small volumes and laboratory-grade equipment and techniques. We sought to quantify the opiates extracted when brewing poppy seed tea using commonly recommended proportions of ingredients and commonly available equipment. Methods: Using data from a prior study (unpublished data from a prior ACMT abstract), we selected the brewing technique that demonstrated the greatest extraction of morphine and codeine. To best replicate real-world practices, we searched online forums for commonly referenced equipment and quantities/ratios of ingredients. We then chose three poppy seed brands found on common online marketplaces whose labeling indicated the seeds were unwashed or had minimal processing. Three samples (A-C) of each brand (#1-3) were made. Liquid chromatography/mass spectrometry was performed on each sample determine the concentrations of codeine and morphine in each. Testing for other opiates, such as thebaine or noscapine, was not available. Results: Morphine content ranged from 1837.0 ng/mL to 19482.5 ng/mL. Codeine content ranged from 295.5 ng/mL to 20124.9 ng/mL. Brand 2 consistently demonstrated a greater opiate content than the other brands with an average of 18389.5 ng/mL morphine and 18576.0 ng/mL codeine (or 18.4 mg and 18.6 mg per liter, respectively). Discussion: Our study was designed to replicate real-world extractions of morphine and codeine when brewing poppy seed teas using commonly referenced proportions, techniques, and tools. The morphine and codeine content of these teas vary widely and could result in clinically relevant oral doses. Limitations of this study include the small sample size and lack of quantification of other opiates. Despite these limitations, our data suggests that even individuals using widely available equipment to brew their own poppy seed tea may be at risk for opioid toxicity depending on their tolerance, amount of tea consumed, and amount of opiates extracted. 

Clinical features of Paralytic Shellfish Poisoning cases from the 2024 Oregon outbreak 

Horowitz KM, Cowdery C, Hendrickson RG 

Background: Paralytic shellfish poisoning (PSP) occurs after consuming bivalves (e.g. mussels) that accumulate saxitoxin, a voltage-gated sodium channel antagonist that causes paresthesia and paralysis. Toxicology resources state that consuming a greater number of affected shellfish results in more severe symptoms and that symptoms occur within 30 minutes. Research Question: Do all PSP symptoms begin within 30 minutes of exposure? Do the number of shellfish that are consumed correlate with symptom severity? Methods: This retrospective chart review of Poison Center cases was approved by the Oregon Health and Science University IRB. We included cases with the substance code “paralytic shellfish poisoning” and excluded cases if data was insufficient. Results: Eighteen cases were identified; one was excluded. Time to symptom onset was variable; 13/17 (76.5%) < 30 minutes, 4/17 (23.5%) > 30 minutes, including one with onset at 4.5 hours. Clinical symptoms included: 9/17 (52.9%) hand/feet numbness, 14/17 (82.4%) oral/perioral numbness, 3/17 (17.7%) ataxia, 2/17 (11.8%) proximal extremity numbness, and 1/17 (5.9%) paralysis with respiratory failure. No patient died. Nine cases had progression of symptoms after presentation. All severe symptom progression (e.g. intubation, new-onset ataxia) occurred within six hours of ingestion and all minor progression (e.g. increase in area of paresthesia) occurred within nine hours. The most severe manifestations occurred in a patient with orofacial numbness within one hour after ingesting 20 mussels who presented with bilateral lower extremity weakness three-four hours after ingestion and progressed to respiratory failure and intubation six-seven hours after ingestion. The number of mussels ingested was documented in 13 cases. Four patients ingested >10 mussels; symptom onset ranged from “immediate” to 4.5 hours, the latest progression of symptoms was 8.5 hours after ingestion, all were admitted, and two were admitted to the ICU. Seven patients ate <5 mussels; all had symptom onset within minutes, symptom progression as late as seven hours after ingestion, symptom resolution within 13 hours, and three were admitted. Conclusion: In this population, symptom onset following ingestion of shellfish containing saxitoxin was variable with one-quarter developing symptoms beyond 30 minutes of ingestion and one as late as 4.5 hours after ingestion. All symptom progression occurred within nine hours. The number of mussels ingested did not correlate with time-to-symptom-onset but did correlate with severity. Limitations include small sample size, few severe cases, and potential recall bias. 

Fentanyl Toxicity in Children Under Six: A Retrospective Analysis of Clinical Presentation and Outcomes 

Courtney Temple, MD Robert G. Hendrickson, MD 

Background: The widespread presence of illicit fentanyl in the United States has led to a concerning increase in unintentional exposures among young children. There is currently limited data describing the characteristics of these exposures. Research Question: What are the clinical characteristics, interventions, and outcomes in young children following unintentional illicit fentanyl exposure? Methods: This is a retrospective analysis of illicit fentanyl exposures in children under six years reported to the National Poison Center Database (NPDS) from 2013-2023 (substance codes 3185166/8057336). Cases of adverse drug reactions, withdrawal, multiple drug ingestions (>2 substances), non-exposures and those with substance/product codes with pharmaceutical product names were omitted. Results: A total of 1,466 cases were identified. Most exposures occurred in children aged 1-2 years (n=757, 55.9%) or ≤1 year (n=481, 35.5%). The gender distribution was balanced, with 48.9% female (n=663) and 51.1% male (n=788). Major symptoms included CNS depression and respiratory compromise, with severe CNS depression (unresponsive to stimuli) in 32% of cases (n=469), moderate depression in 24% (n=346), and mild depression in 10% (n=151). A total of 694 cases (47%) involved either respiratory depression or arrest; 573 cases of respiratory depression (39%) and 170 cases of respiratory arrest (12%). A minority of patients developed acidosis (113, 7.7%), bradycardia (61, 4.2%), or hypoxic brain injury (24, 1.6%). Naloxone was administered in 62% of cases (n=916), 9.7% (n=142) had cardiopulmonary resuscitation, 9.4% (n=139) were intubated, and 3.0% (n=44) required vasopressors. About half (45%, n=653) were admitted to an ICU, 20% (n=300) had non-ICU admission, and 27% (n=393) were managed in the emergency department. In those with known duration of symptoms (n=1047), symptoms resolved after ≤8 hours in 247 (24%), 8-≤24 hours in 500 (48%), and 1-7days in 277 (26%). Outcomes were significant, with 43% (n=624) experiencing major effects, 28% (n=413) moderate effects, and a 3.5% (n=51) mortality rate. The majority of fentanyl exposures occurred in the child’s own residence (82%, n=1,202). Other locations included other residences (6.1%, n=89), public places (3.5%, n=52), schools (0.1%, n=2), and unspecified locations (2.2%, n=32). Conclusion: Illicit fentanyl exposures in children frequently result in severe CNS and respiratory depression, high rates of ICU admission, and substantial morbidity and mortality. These data highlight the critical need for targeted public health outreach, including education on safe storage practices and fentanyl exposure prevention. 

Increased psilocybin-related exposures reported to a regional Poison Center after legalization. 

Robert G. Hendrickson, Courtney Temple 

Background: On October 20, 2020, Oregon voters approved the Oregon Psilocybin Services Act (Measure 109) which legalized the “manufacture, delivery, administration of psilocybin at supervised, licensed facilities”. After a two-year rules development process, Oregon began accepting applications for licensure on January 2, 2023. Research question: Did the legalization of manufacture, delivery, and administration of psilocybin change the rate or severity of psilocybin-related adverse effects reported to the Oregon Poison Center? Methods: We searched the Oregon Poison Center database for human, exposure, ingestions, within Oregon, with Generic codes for psilocybin (0058000, 0310161), from 2015-2024. We divided the time periods into pre-legalization (2015-2020), pre-licensure (2020-2022), and post-licensure (2023-2024). Annual case counts were predicted for 2024 by extending the rate of 2024 cases prior to 11/12/24 to 365 days. Counts of psilocybin-related cases were compared using Student t-test. Clinical outcomes were compared using Chi-square. Results: A total of 366 cases were identified over the 10-year period. Cases increased from 15 in 2015 to 68 cases in 2023 and 70 predicted cases in 2024. Patients were largely young adults: age 13-19y (125; 34%), age 20-29y (84, 23%), age 30-39y (56, 15%), age 40-49y (26, 7%), with few children (<13y, 7%) or adults >50y (9%). The majority had moderate (43%) or minor (20%) outcomes, with 5% major outcome and 1 death (0.3%). The majority of exposures occurred in the patient’s own (68%) or another (5%) residence, 18% were unknown location, and only one was reported from a healthcare facility (0.3%). The majority of cases were intentional abuse (233, 64%). Adverse drug reaction (6, 2%) and unintentional therapeutic error (1, 0.3%) were rare. Cases significantly increased from 24/year in the pre-legislation period to 40/year in the pre-licensure period (p=0.047) and to 64/year in the post-licensure period (p=0.046). The proportion of cases that were severe (moderate or major toxicity or death) were not different in the three periods (58% vs. 75% vs. 60%, p=NS). Discussion: We found a significant increase in cases of psilocybin toxicity after the legalization vote and then after the licensure period. We did not find an increase in clinical severity. The vast majority of cases occurred in residences and were intentional abuse and we found no cases associated with licensed facilities. Our data suggests that acceptance of psilocybin and adverse events from psilocybin increased once the law was passed and further increased after licensure, but that cases are unrelated to licensed facilities. Limitations include a lack of generalizability due to the specifics of this one state’s laws. 

Opioid Overdose Among People Who Intend to Only Use Illicit Stimulants 

Smith, Jeffrey; Hendrickson, Robert 

Background: Patients who develop opioid toxicity despite intending to use stimulants are a poorly described group that may have unique clinical characteristics. Research Question: Are there differences in clinical outcomes for those who intended to use only stimulants versus those who intended to use only opioids when presenting to an emergency department with an opioid overdose? Methods: The Toxicology Investigators Consortium (ToxIC) Drug Overdose Toxico-Surveillance Reporting Program (DOTS) was an observational study of patients presenting to emergency departments at 17 medical centers for an opioid, stimulant or undifferentiated overdose (2022-2024). Blood was obtained within 24 hours of their arrival and analyzed for over 1200 illicit drugs. Clinical information was recorded from subject interviews and chart review. Subjects were included if they had an opioid overdose and excluded if they intended to use multiple drugs or did not complete the interview. Subjects were then divided into two groups; those intending to use only an opioid or only a stimulant. Categorical data were compared using Chi square and Fisher exact test when cell counts were <5, and Wilcoxon rank sum tests were computed for continuous variables. All patients provided written informed consent and central and site IRBs approved this study. Results: Three-hundred thirty-two subjects met inclusion criteria and 150 were excluded (131 `use of drug combinations; 19 incomplete interview), leaving 182 subjects. Of these 182, 51 (28%) intended to use only stimulants and 131 (72%) intended to only use opioids. The median serum fentanyl concentration was lower in those that intended to use stimulants compared to those who intended to use opioids (3.8 ng/mL, IQR: 1.5,6.2 vs. 5.0 ng/mL, IQR 2.9,11.0; p = 0.02). Subjects who intended to use stimulants received lower total doses of naloxone (2.0mg vs 4.0mg, p = 0.04) than those who intended to use opioids. Subjects who intended to use stimulants did not have higher rates of naloxone administration by EMS (80% vs. 64%, p=NS), admission (33% vs. 31%, p=NS), naloxone infusion (7.8% vs. 5.0%, p=0.NS), or intubation (2.0% vs. 3.1%, p=NS). Conclusions: Patients who intended to use stimulants made up a notable proportion of opioid overdoses treated in emergency departments in our study. This group had lower serum fentanyl concentrations and were administered lower doses of naloxone which may reflect a lower tolerance in opioid naïve stimulant users. Novel approaches to decrease harm amongst this group are warranted, including prescription of naloxone to people who use stimulants. 

Calcium precipitation in bedside calcium gel mixing for dermal hydrofluoric acid exposure treatment 

Colleen Cowdery, Steven Kazmierczak, John Thompson 

Background Commercially-produced calcium gels for the treatment of hydrofluoric acid (HF) exposure are infrequently stocked by hospitals. A common Poison Center recommendation is to mix a calcium salt with a water-soluble gel to produce 2.5% calcium gel. Hypothesis Does mixing 10% calcium chloride or gluconate solutions with different brands of water-based gels result in calcium precipitation and reduced calcium concentrations in resulting solutions? Methods This is a basic science experiment. After conducting a survey of AAPCC Poison Center HF treatment guidelines, a ratio of 10 mL of 10% calcium salt (calcium chloride or calcium gluconate) to 30 mL of gel was mixed (six brands of water-based gel, one brand petroleum-based) by hand for 15-20 seconds to create 2.5% solutions. The resulting mixtures were photographed and assessed visually for precipitation and for viscosity, and the solutions (excluding the precipitate) were analyzed for total calcium concentration using a Beckman AU700 chemistry analyzer. Results After mixing, the majority of samples showed rapid precipitation and loss of gel-like viscosity. Calcium concentrations in the mixes were lower than the expected 2.5% for both calcium gluconate (43-76% lower) and calcium chloride (10-29% lower) indicating that calcium precipitated out of solution. Viscosity rapidly decreased from > 1000 centiPoise (cP) (e.g. gel) to <100 cP (e.g. water) in four of six solutions, and remained > 1000 cP for the remaining two. Limitations: Calcium concentration was not measured in the solid precipitate and not all available healthcare gels were analyzed. Conclusions We found that the common practice of mixing calcium-containing solutions with commonly available gels resulted in immediate precipitation, loss of gel-viscosity, and a reduction in dissolved calcium concentration. The common recommendation to mix a calcium gel at bedside may result in reduced calcium content and an unreliable product for treatment of dermal HF exposures. 

Clinical Decision Support Tool Impact on Emergency Department Returns in Low-Income Atrial Fibrillation Patients 

Maja Strusinska-Thayer, BS, Miriam Elman, MPH MS, Bradley Hopkins, MS, Thuan Nguyen, MD MS PhD, Bory Kea, MD MCR 

Study Objectives: Atrial fibrillation (AF) is associated with higher rates of Emergency Department (ED) return among patients of lower socioeconomic status (SES). Clinical decision support (CDS) tools are known to improve patient engagement. We sought to assess whether CDS tools decrease rates of ED return among patients of lower SES with AF using insurance class as a proxy. Methods: Retrospective chart review was performed on electronic medical records (EMR) of patients diagnosed with AF at 3 EDs (1 academic, 2 community) in the Portland Metropolitan area from January 2020 to October 2023 as part of an ongoing step-wedged cluster-randomized trial implementing an AF CDS tool. Records from phases P0 (pre-implementation) and P1 (when ED providers were educated about the CDS tool and a link to the tool was made available in the EMR) were grouped based on insurance class (private, Medicare, Medicaid, and self-pay). Records were reviewed to determine the proportion of patients with AF-related ED return (including recurrent AF, atrial flutter, stroke, etc.) within 1 year of the index visit and the proportion with cardiology and primary care (PCP) follow-up within 14 days of the index visit. Patients were excluded due to specified comorbidities, current anticoagulant use, lack of available insurance information, or index visits < 1 year before chart review. Comparisons were assessed for categorical variables using Fisher’s exact test. Results: Of 4983 study-eligible patients, 402 in P0 and 223 in P1 met inclusion criteria (median age 66 [IQR: 55-76], 43.8% female, 85.0% white, and 85.8% non-Hispanic). Overall, 110 (27.4%) patients in P0 and 57 (25.6%) in P1 returned to the ED. In P0, return rates ranged from 23.8% (Medicare; 95% confidence interval [CI]: 18.6-30.0%) to 37.5% (self-pay; 95% Cl: 13.7-69.4%) by insurance class, but the differences were not statistically significant (p=0.33). In P1, self-pay and Medicaid patients had the highest return rates at 44.4% (95% Cl: 18.9-73.3%) and 40.6% (95% Cl: 25.5-57.7%), respectively, with lower ED returns reported in Medicare (23.7%; 95% Cl: 17.0-32.2%) and privately (18.8%; 95% Cl: 11.1-30.0%) insured patients with their difference of borderline significance (p=0.06). Rates varied significantly for cardiology (p< 0.01) and PCP (p=0.02) follow-up in P0; no difference was seen in P1. Conclusion: The percentage of patients with ED return within 1 year of their index visit varied by insurance class, but differences were not significant in either phase. Cardiology and PCP follow-up differed by insurance status in P0 but not P1. Comparisons between phases will be further explored via modeling. 

The Impact of an Emergency Department Call Back Program on Return Visit Rates 

Zachary Brannan, MD, Walker Andrews, MD, Lauren Ready, MD, Erin Morrow, MD, Morgan Black, MD, Miriam Elman, MPH MS, John Marshall, MD 

Background. Reducing Emergency Department (ED) return visits, which are costly and contribute to crowding, is of increased importance with ED volumes rising nationwide. A previous nonrandomized trial found that an automated callback reduced return visits, but evidence from other callback studies is limited. We hypothesized that a randomized pragmatic clinical trial of a callback program aimed at clarifying discharge instructions and follow-up plans would reduce ED return visits. Methods. The prospective study was conducted in early 2024 at the 博彩网站 Adult ED to assess if callbacks reduce ED returns. Discharged patients were randomized 1:1 to receive a callback within 2 days or not. Logistic regression assessed 7-day ED returns in intention-to-treat (ITT) and as-treated analyses. Estimates of the proportion returning to the ED in 7 days with 95% confidence intervals were reported for each group. Results. Of the 6934 ED visits during the study period, 3436 (49.6 %) met criteria with 1731 randomized to be called and 1705 receiving no call. Patient characteristics were balanced across arms (standard mean difference (SMD) ≤0.6 except race, SMD=0.12); patients had median age of 43.7 years and were predominantly female (56.5%), white (79%), and non-Hispanic (78.5%). Return rates were lower in the called group, with ITT unadjusted (intervention arm: 6.5, 95% CI: 5.5, 7.8; control arm: 7.5, 95% CI: 6.3, 8.9) and adjusted (intervention arm: 7.7, 95% CI: 4.4, 13.2; control arm: 8.4, 95% CI: 4.8, 13.3) models. A total of 923 (53.3%) patients in the intervention arm were successfully contacted. Our “as treated” analyses found a lower rate of return in the contacted group, with unadjusted (contacted: 5.9%; no contact: 7.4%) or adjusted (contacted: 7.1%; no contact: 8.3%) analyses. Conclusion. To our knowledge, this is the first randomized controlled trial to evaluate the impact of an ED callback program on return rates. While there was no statistical difference in return rates between the intervention and control groups, we do feel that the decreased return rate in the contacted group represents clinical significance. 

Impact of Expanded Emergency Department Observation Inclusion Criteria on Hospital Length of Stay 

John Marshall; Valerie Sweitzer; Shana Kusin 

Background: With Emergency Department (ED) crowding and boarding now commonplace nationwide, ED Observation Units with defined protocols can serve as an outlet. There is a dearth of literature related to liberalization of ED Observation protocols and the subsequent impact on quality measures. We sought to relax the ED Observation exclusion criteria for patients with asymptomatic hyponatremia, with our hypothesis being that hospital length of stay would remain stable or improve. Methods: Study investigators revised the hyponatremia exclusion criteria for the ED Observation unit at a single academic, quaternary care center. Previously, patients with a sodium < 130 mmol/L, who do not meet safe ED discharge parameters, mandated inpatient admission. In August 2023, ED Observation Unit criteria were expanded to allow patients with asymptomatic hyponatremia (sodium ≥126 mmol/L) who did not require inpatient-level admission for other reasons. Patients in the year prior to intervention and five months post intervention with sodium levels 126-129 mmol/L were reviewed retrospectively for possible inclusion. In the pre-intervention period these patients were admitted to an inpatient service while all patients in the post-intervention cohort were admitted to ED Observation. Patient length of stay pre and post-intervention was compared, using absolute difference. Results: 25 total patients with asymptomatic hyponatremia met inclusion criteria. Average length of stay in the post intervention group (n=13) was 86.4 hours as compared to 158.6 hours in the pre-intervention group (n=12). This is an absolute difference of 72.2 hours per patient and a 45.6% reduction in length of stay. Over half of the post-intervention group discharged directly from ED Observation, saving a significant number of inpatient beds. Conclusion: Liberalizing ED Observation Unit criteria for asymptomatic hyponatremia can reduce inpatient bed use while decreasing hospital length of stay. Results are generalizable to any ED with an observation unit. With this being a small pilot study, we were limited in our ability to assess health measures including adverse outcomes (although with decreasing length of stay, the presence of significant adverse outcomes in our intervention group is not likely). Future controlled trials would be of benefit. 

The Impact of an Assigned Primary Care Physician on Return Visits to the Emergency Department 

John Marshall, MD; Lexy Newberry, MS4; Miriam Elman, MPH MS 

Objectives: As Emergency Department (ED) visits rise nationwide and boarding remains a crisis, it is of increasing importance to prevent unnecessary ED return visits and maximize care that can be delivered safely in the primary care setting. Previous studies suggest that patients with an assigned Primary Care Physician (PCP) often do not visit that provider before returning to the ED, citing convenience and expedience of care in the ED as reasons to come back or struggling to get into their PCP (over 60% unable to get a visit within one week). However, these studies were conducted at a single site or with narrow patient populations. Thus, we aimed to compare the proportion of returns within 7 days for all discharged ED patients for those with and without an assigned PCP over a multi-state catchment area. Methods: This retrospective study took place at an urban quaternary care center, leveraging a pre-existing dataset of over 3000 patients. This dataset was obtained during a separate study evaluating the rate of ED return visits among patients receiving a phone call after initial ED discharge from March to May 2024. Return visits to EDs in Oregon and Washington were captured. Utilizing this dataset, we assessed the return rate at one week among those with an assigned PCP along with 95% confidence intervals (CI). All adults discharged from the ED during this three-month period were included. Results: Patients with an assigned PCP at the time of their initial ED visit had a one week return rate to the same ED of 7.9% (189/2383; 95% CI: 6.9, 9.1), while those without an assigned PCP had a return rate of 4.9% (52/1052; 95% CI: 3.8, 6.4). When looking more broadly at return rates to any outside hospital, these differences resolved: those with a PCP returned at a rate of 13.5% (322/2383; 95% CI: 12.2, 14.9) and those without a PCP returned at a rate of 10.6% (112/1052; 95% CI: 8.9, 12.7). There was also no difference between PCP assignment and return visit rates in those patients receiving a call back after discharge (6.5% [95% CI: 4.9, 8.6] with assigned PCP vs 4.1% [95% CI: 2.2, 7.3] with no PCP), which would have directed them to follow-up with their assigned PCP in most cases. Conclusion: PCP assignment was not associated with lower ED return rates after discharge from initial ED visit for patients in our study and there was no difference in rates when more complete ascertainment of returns was assessed. This finding challenges a common belief in Emergency Medicine that patients with assigned PCPs will be more compliant with follow-up visit instructions and less likely to return to the ED. While our study did not determine reasons for this finding or adjust for possible confounders in analyses, we postulate that this is potentially due to difficulty accessing PCP appointments in a timely manner after discharge from the ED, and may indicate a need for more resources to be devoted to the primary care system. 

Exploring Impact of Secure Chat Implementation on Emergency Department Communication 

Michaela Go, MD MPH, Hasan Alshamrani, MBBS SBEM ArBEM, Obert Xu, MBBS BSN, Steven Mcgaughey, MD MCI 

Background: Effective communication in hospital setting is essential in delivering high-quality patient care. In October 2024, Oregon Health and Science University Hospital implemented an EHR-integrated instant messaging system called Secure Chat. Prior to implementation, modes of communication in the emergency department were via paging system, face-to-face interaction, and phone. Our goal was to evaluate secure chat use in the Emergency Department in regard to ease of use, efficiency, timeliness of information, clarity of information, overall satisfaction, and interruption burden. Methods: Two surveys were sent to physicians working at the 博彩网站 Emergency Department at time of secure chat go-live and three months post-implementation. Both surveys evaluated perceptions of communication with ED nursing staff and specialty consultants via phone, face-to-face interaction, paging, and secure chat. A Mann-Whitney U test was used to evaluate for significant differences in ordinal ratings. Results: Comparing secure chat to phone for communication with ED nursing, secure chat was rated higher for ease of use (U = 231.5, P=0.00003), efficiency (U = 308.0, P=0.0015), and overall satisfaction (U = 293.0, P = 0.0007). There was no difference in clarity or timeliness of information. Comparing secure chat to face-to-face communication, secure chat was rated higher for ease of use. There was no difference in efficiency, timeliness, or overall satisfaction. Face-to-face communication was rated higher for clarity of information. When asked how often physicians were interrupted by different communication modalities, physicians reported a median frequency of “3 – sometimes” for all modalities. However, the distributions of responses differed significantly between secure chat and phone (P = 0.03), and between secure chat and face-to-face interactions (P = 0.007). In terms of perceived burden, phone interruptions were rated as most disruptive with an average score of “3 – very disruptive,” whereas secure chat was rated as “2 – somewhat disruptive” (U = 850.5, P = 0.000002). While both secure chat and face-to-face interruptions were rated similarly on average (“2 – somewhat disruptive”), their response distributions still differed significantly (U = 701.5, P = 0.007). Discussion: Overall, physicians were satisfied with the ease of use and efficiency of using secure chat. Across the five measured domains – easiness, efficiency, timeliness, clarity, and overall satisfaction – satisfaction with secure chat was the same or better in all except clarity, in which face-to-face communication prevailed. The frequency of interruptions was similar across modalities, however physicians generally found secure chat interruptions to be less disruptive than phone interruptions. These findings suggest that secure chat is a promising tool for enhancing hospital communication. Moving forward, we will incorporate user feedback to optimize secure chat usage, with a focus on improving communication and minimizing alert fatigue. Additionally, we plan to further explore secure chat’s role in communication with specialty consultants. 

Addressing the Gap in Pediatric Mental Health Crisis Management: A Novel Multidisciplinary Training for Pediatric and Emergency Medicine Residents 

Abiezer Disla, Keith Cross, Mariah Racicot, Jessica Bailey 

Introduction: Pediatric mental health emergencies have surged post-COVID-19, with emergency department (ED) visits for these cases increasing. A 2023 needs assessment at Oregon Health & Science University identified skill gaps among residents in verbal de-escalation, restraint use, and pharmacological interventions. To address these gaps, we developed a curriculum integrating online modules and high-fidelity simulations, providing hands-on training in pediatric mental health crisis management. Methods: Using Kern’s 6-step curriculum development model, we created a program that included five online modules and a 4-hour simulation workshop led by a multidisciplinary team of child psychiatrists, pediatric emergency nurses, social workers, ED pharmacists, and pediatric emergency medicine attendings. The workshop featured high-fidelity scenarios, flipped classroom sessions, and small-group discussions. Resident progress was tracked with unique identifiers, and pre- and post-surveys measured changes in knowledge, confidence, and curriculum feedback. Paired t-tests (p < 0.05) were used for data analysis. The study received an IRB waiver. Results: Of 31 residents, 20 (15 EM, 5 pediatrics) completed all surveys. Knowledge scores increased modestly from 73.93% to 75.71%, though not statistically significant (p = 0.322). Residents with lower baseline scores showed marked improvement. Confidence significantly increased (p < 0.05) in verbal de-escalation, pharmacological treatment, restraint use, and overdose management. Participants also reported enhanced preparedness in team-based decision-making and communication during high-pressure situations. Feedback was overwhelmingly positive, with 95% of participants rating the experience as valuable for professional development. Conclusion: This innovative, multidisciplinary training significantly improved residents’ confidence and practical skills in managing pediatric mental health emergencies. Combining high-fidelity simulations and interdisciplinary instruction, this curriculum offers a comprehensive framework for training in high-risk pediatric scenarios. As the first program of its kind at our institution, it has the potential to inform similar initiatives nationwide, addressing the urgent need for pediatric mental health training in EDs. Future studies with larger cohorts are needed to assess long-term impacts on knowledge retention and patient care outcomes. 

Nine Years of Academic Medical Center Experience with a Rural Emergency Medicine Rotation 

Regina Mysliwiec, David Jones, Mary Tanski 

Rural emergency departments care for millions of Americans every year, however most emergency medicine residency programs are based in urban areas, providing trainees with relatively little exposure to the practice of emergency medicine in more austere settings. In partnership with a rural site dedicated to improving the care delivered to a growing patient population, we developed a rural emergency medicine rotation for second year residents. The rotation is now in its ninth year. 95 individuals have completed 101 total rotations. Applications for attending positions at the rural site increased substantially compared to the years before the rotation was developed. Of 13 current emergency physicians, seven rotated through the department as residents. Our experience highlights the value of academic medical centers partnering with rural emergency departments to strengthen rural emergency medicine training and recruitment to the rural workforce. 

PEM PULSE: A Fellow-Led Innovation in Disseminating Pediatric Emergency Medicine Education 

Abiezer Disla, MD, FAAP.- PEM Fellow 

Background: Sharing knowledge is a powerful opportunity to foster learning across teams in dynamic clinical environments. Pediatric emergency departments (EDs) are often high-volume, high-acuity settings. Even clinicians who care for children daily encounter “zebras” that challenge clinical reasoning and demand nuanced differential diagnosis skills. For providers who see pediatric patients less frequently or outside of emergency settings, ongoing exposure to pediatric concepts can be limited. Recognizing this gap, PEM PULSE—Pediatric Updated Learning Scenarios Explored—was created to disseminate high-yield, case-based pediatric emergency medicine (PEM) education in an engaging and accessible format. Theoretical Framework: This initiative is grounded in principles of adult learning theory (Knowles’ Andragogy), emphasizing self-directed, experience-based, and problem-centered learning. It also aligns with constructivist approaches, where learners build knowledge through contextual, meaningful exposure to clinical content. By combining narrative cases, visual stimuli, and interdisciplinary pearls, PEM PULSE promotes retention and reflection across a spectrum of learners. Targeted Learners: The newsletter is designed for a multidisciplinary audience including emergency medicine physicians, pediatric and EM residents, advanced practice providers, nurses, and PEM fellows. It serves both regular pediatric providers and those with more limited exposure to pediatric cases. Innovation Design: Launched in July 2025 and led by a PEM fellow, PEM PULSE is a monthly digital newsletter distributed via email and QR code access. It features: • Case of the Month • Picture of the Month (HIPAA-compliant) • Side-by-Side comparisons of similar conditions • Rare but Real pediatric presentations of adult illnesses • Pharmacy Pearls • Subspecialty Insights • Question of the Month Each edition highlights real patient learning opportunities and promotes interdisciplinary engagement. Engagement & Feedback: The newsletter reaches over 500 recipients across the ED team. Feedback, gathered via embedded QR codes and informal correspondence, has been overwhelmingly positive. Readers describe it as “relevant,” “engaging visual design,” and “great way to refresh pediatric cases monthly” . Challenges & Opportunities: Tracking exact readership and engagement remains a challenge due to current dissemination methods. Content development requires sustained effort and time. However, the program presents opportunities to expand regionally, develop analytic capabilities (e.g., open rates, quiz responses), and involve residents in content creation for sustainability and academic credit. Conclusions: PEM PULSE exemplifies a low-cost, high-yield, fellow-led educational innovation that builds PEM competency, fosters community, and encourages shared learning across diverse ED roles. As clinical teams continue to navigate busy and varied pediatric cases, initiatives like PEM PULSE help reinforce excellence in care through accessible education. References: 1. Knowles, M. (1980). The Modern Practice of Adult Education: From Pedagogy to Andragogy. 2. Gordon, J. A., & Borkan, J. M. (2014). Medical education in the digital age. Academic Medicine, 89(9), 1203–1204. 3. Sherbino, J., Frank, J. R., & Snell, L. S. (2014). Defining roles of clinician–educator. Medical Teacher, 36(9), 787–792. 

Cyberattack Preparedness: A Tabletop Simulation of Unexpected Electronic Health Record Downtime 

Briana Miller, Obert Xu, Kenneth DeVane, Lindsay Strother, David Jones, Joshua Kornegay 

Background Electronic Health Records (EHRs) are essential to modern clinical practice, but unexpected downtime due to technical failures, system updates, or cyberattacks can disrupt care and increase patient safety risks. Despite these threats, formal training on downtime procedures is limited. Simulation-based training can offer a structured, hands-on approach to improving preparedness. This study aimed to develop and implement a tabletop simulation to enhance resident knowledge and confidence in managing EHR downtime. Objectives This study aimed to develop and implement an educational intervention to enhance medical students and emergency medicine residents' knowledge of EHR downtime procedures. Methods A needs assessment was conducted with emergency department leadership to identify gaps in EHR downtime preparedness. A tabletop simulation was developed to replicate an unexpected EHR downtime scenario, requiring participants to apply institutional downtime procedures. A structured debriefing session immediately followed the simulation, where learners received feedback on their performance. Participants completed pre- and post-simulation surveys assessing their perceived preparedness for EHR downtime and a knowledge assessment of downtime protocols. Results A total of 29 learners (medical students and residents) participated in the simulation. Following the simulation, learners reported increased confidence in obtaining the required paperwork, communicating with nursing staff, and placing orders for labs, imaging, and medications. Learners also reported feeling overall more prepared for an EHR downtime and felt the session was valuable for understanding potential patient safety threats during a downtime. Performance on a knowledge based assessment regarding EHR downtime protocols also improved following the scenario. Conclusion This study is the first to evaluate the education outcomes involving a tabletop simulation for EHR downtime in emergency medicine learners. We believe our findings could benefit other institutions in deploying our approach as a mechanism to improve resident knowledge and confidence in managing downtime events.