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Next Up…killer Vegetables

Most toxic mushroom ingestions simply result in abdominal cramping, nausea/vomiting and diarrhea.  But beware of amatoxin-containing mushrooms appropriately termed the “deadly white Amanitas” (i.e. A. phalloides (figure 1), A. bisporigera (Figure 2)).

Suspect amatoxin ingestion in a patient with an appropriate history and (if you’re lucky) the mushroom in question.  Patients with amatoxin ingestion will experience acute gastroenteritis (within 24hrs of ingestion) then will experience temporary symptom resolution (within 24-36hrs of ingestion) and finally, in cases of severe intoxication, will undergo fulminant hepatic and multi-organ failure (within 2-4 days of ingestion).  With confirmed or strongly suspected cases of amatoxin ingestion, you should start treatment immediately and contact your local poison center (with possible referral to an on-call mycologist).  For large ingestions (1-2 mushrooms), consider transferring to a liver transplant center early.

Aside from managing your ABC’s, the following therapies are recommended:

1. Aggressive fluid resuscitation

2. Initial GI decontamination with activated charcoal (only in alert patients)

3. Multiple dose activated charcoal to reduce toxin enterohepatic circulation (only in alert patients)

-       0.5g/kg (max 50g) q4hr for 4 days after ingestion

4. IV silibinin dihemisuccinate to prevent hepatocellular toxin uptake

-       IV loading dose 5 mg/kg followed by IV continuous infusion 20 mg/kg/day x6 days or until recovery

-       Obtain silibinin by calling 1-866-520-4412

-       If silibinin unavailable, administer high dose penicillin G IV continuous infusion 300,000-1,000,000 units/kg/day (max 40,000,000 units)

5. NAC for antioxidant therapy

A. phalloides

Figure 1: A. phalloides


A. bisporigera

Figure 2: A. bisporigera

All images from UpToDate.



Peredy TR. Amatoxin-containing Mushroom Poisoning Including Ingestion of Amanita phalloides. UpToDate. March 2014.

Highlight Reel

Here are the highlights from the 2012 ACEP Clinical Policy regarding Critical Issues in the Initial Evaluation and Management of Patients Presenting to the ED in Early Pregnancy:

The initial quantitative BhCG level does not help to distinguish among unspecified abortion (i.e. threatened abortion), normal intrauterine pregnancy, and ectopic pregnancy.  Therefore, the discriminatory threshold is no longer utilized in clinical decision-making.  Do not let a BhCG level lower than the discriminatory threshold deter you from getting a pelvic US in a symptomatic, unconfirmed early pregnancy.  Ectopic pregnancies can present with low, normal and high BhCG levels; ectopic pregnancy ruptures can occur at any BhCG level.  Do not let a low BhCG level in the setting of an indeterminate pelvic US provide false reassurance that you have ruled out an ectopic pregnancy.

Rhogam is recommended in Rh negative women with completed abortions (level B recommendation).  There is insufficient data to support or refute it’s use in threatened abortions or ectopic pregnancies.

Methotrexate (MTX) is not infallible.  Treatment failure after the first dose of MTX is well documented.  Some patients require multiple doses of MTX for successful resolution of ectopic pregnancies.  Furthermore, patients who have received MTX can still rupture their ectopic pregnancy.  Therefore, for patients with confirmed or suspected ectopic pregnancies s/p MTX arrange timely follow-up if stable or rule out ruptured ectopic if unstable.



Strayer R. Rule Out Ectopic in the Emergency Department. EMUpdates.com

Hahn SA. Lavonas EJ. Mace SE. Napoli AM. Fesmire FM. Clinical Policy: Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy. Ann Emerg Med. 2012;60:381-390.




This may be surprising to many of you, but some of our patients abuse medication.  In addition to Dilaudid, morphine, and Percocet, lets add topical ophthalmic anesthetics such as tetracaine to our “red flag” list.  The most common offenders are young male manual laborers particularly those involved in welding and foundry.

Even when diluted, topical ophthalmic anesthetics can directly injure corneal epithelium, stroma and endothelium; the inflammatory response to the direct injury can further damage delicate ophthalmic structures.  This form of keratitis is often misdiagnosed as acanthamoeba keratitis.

Continue reading “Iabuse” »

Welcome to Elmhurst

Dengue fever (DF) is a viral infection (one of four serotypes) transmitted by mosquitos in endemic regions of the world.  Classic DF is an acute febrile illness associated with HA, retro-orbital pain and muscle/joint pains.  Differential diagnoses include malaria, leptospirosis, and typhoid fever.  Treatment is supportive with adequate hydration and acetaminophen for HA, myalgia, and fever.  Avoid NSAIDs and aspirin for potential bleeding complications.

The most feared manifestation of DF is dengue hemorrhagic fever (DHF) which is hypothesized to be immune-mediated.  To make this diagnosis, the World Health Organization has delineated 4 cardinal features:

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To Bleed or Not to Bleed

Extracranial internal carotid artery dissection can cause ischemic stroke by thrombus formation or thromboembolism and subsequent arterial occlusion.  In fact, it is the 2nd most common etiology of strokes in patients younger than 45 years.  Traditionally, anticoagulant or antiplatelet agents have been administered to prevent ischemic insults, but does increased bleeding risk outweigh the benefits of these agents?

In 2010, the Cochrane Reviews determined there were no randomized controlled trials comparing either anticoagulants or antiplatelets to the control of no therapy.  Therefore there is no evidence supporting the routine use of antithrombotic agents in the treatment of extracranial internal carotid artery dissection.  There were also no randomized controlled trials comparing anticoagulants to antiplatelets, but the studies that did exist showed no significant difference between the two agents.

Currently underway is a large study that will hopefully shed some light on this controversy.

Continue reading “To Bleed or Not to Bleed” »

Zara Mathews