Table ). Only 9 deaths (17.0%) were adjudicated as being preventable, whereas 14 (26.4%) were potentially preventable and 30 (56.6%) were deemed not preventable. After adjustment for preventability, the FTR rate decreased significantly to 13.4% (23 of the 172 patients who experienced a complication after emergency surgery) (Figure).Discussion | Failure to rescue has been used to assess quality of care. Its utility, however, is limited because of imprecise definitions and difficulty in collecting standardized data for comparison. 2 The current definition of FTR may be inadequate and overemphasizes variables beyond a trauma system's control. This definition also classifies most nonpreventable deaths as FTR. This classification system leads to an inflated FTR rate that includes many cases in which no "failure" occurred. Incorporation of preventability into definitions of FTR may allow for more precise assessments of surgical performance.Identifying the characteristics and risk factors in this more specific group may aid in the development of strategies to improve surgical care. In our cohort of all patients who developed a complication after emergency surgery (both preventable and not preventable), we found that 78 patients (45.4%) had a medical complication and 94 (54.6%) had a surgical complication. We have confirmed what others have reported in that lack of insurance is associated with higher rates of FTR. 3 In addition, in our cohort, hypotension on admission to the emergency department and a higher Injury Severity Score were also associated with FTR.Limitations of the study include the retrospective design, a patient cohort from a single institution, and the subjective nature of the determinations of preventability. In addition, some patients who died may have opted to forgo further treatment. Exclusion of those deaths from the preventable group would affect our results.Future efforts to improve patient care should focus on preventable FTRs. This approach is now part of a national movement embraced by the American College of Surgeons, which has set a goal of zero preventable deaths from trauma. 4

Abstract. An 18-month-old male presented to the emergency department (ED) for evaluation of lethargy and apnea. Four hours before presentation, the patient was found with an empty bottle of ibuprofen, an ingestion of as much as 7.2 grams (600 mg/kg). The ED course was remarkable for a 30-second tonic-clonic seizure. Laboratory analysis was notable for metabolic acidosis. Four-hour and 7.5-hour serum ibuprofen levels were 640 and 39 g/mL, respectively. Following treatment, the patient improved and was extubated the next morning. While metabolic acidosis has been frequently described at doses exceeding 400 mg/kg, seizures occurring early in the course of ibuprofen toxicity have been rarely noted. Key words: ibuprofen; poisoning; pediatrics. ACADEMIC EMERGENCY MEDICINE 2000; 7:821-823 Ibuprofen is a commonly used overthe-counter nonsteroidal anti-inflammatory analgesic derived from propionic acid. In general, overdoses of ibuprofen result in mild effects. These effects include abdominal pain, nausea, vomiting, lethargy, headache, tinnitus, and ataxia.1 Serious toxicity, including coma, apnea, metabolic acidosis, hypotension, bradycardia, and renal and hepatic dysfunction, has been observed in ingestions of more than 400 mg/kg. Symptoms usually develop within four hours of ingestion. CASE REPORTAn 18-month-old, 12-kg male with an unremarkable past medical history was brought to the emergency department (ED) for evaluation of lethargy. According to the parents, the patient was found approximately four hours prior to presentation with an empty bottle of ibuprofen, and with pill fragments in his mouth. The patient had two episodes of emesis; one spontaneous and the other manually induced by a grandparent. After a brief period of relatively normal behavior, the parents noted that the patient became limp and was not easily aroused. The patient subsequently became apneic, prompting the parents to bring him to the ED. The patient's past medical history included eczema and otitis media. His parents indicated that he was occasionally given pseudoephedrine but was not given any in the last 24 hours. Further, it was discovered that his grandmother took lisinopril, for which all tablets were accounted.Later investigation indicated a potential ingestion of as much as 7.2 grams of ibuprofen (600 mg/kg).On presentation to the ED, the patient was lethargic. Vital signs were temperature (rectal) 96.8ЊF, respiratory rate 16 breaths/min, heart rate 123 beats/min, and blood pressure 118/48 mm Hg. The patient's vital signs remained in this range throughout his ED course. Physical exam was significant for an intact gag reflex, reactive pupils (3 mm), and withdrawal from painful stimuli. He received, in increments, a total of 600 mL of normal saline and 1 mg of naloxone without response. A short time later the patient sustained a 30-second tonicclonic seizure, which resolved with lorazepam 1 mg IV push. The patient then became apneic, requiring endotracheal intubation. Subsequent lavage with a 12-Fr nasogastric tube and 300 mL of norm...

The enzyme alcohol dehydrogenase metabolizes ingested ethylene glycol (EG) to the toxic compounds glycolic and oxalic acids. Renal failure, acidosis, hypocalcemia, and death may follow. Traditional treatment of EG poisoning may require ethanol, a competitive substrate of alcohol dehydrogenase, and hemodialysis, that removes both EG and its toxic metabolites. A new alcohol dehydrogenase inhibitor, fomepizole (4-methylpyrazole), was approved in 1997 for patients at least 12 years old with suspected or confirmed EG poisoning. Fomepizole has not been studied adequately in the pediatric population. We present a case of an 8-month-old male infant who drank up to 120 mL of EG and developed acidosis and oxalate crystalluria. He was treated with fomepizole and hemodialysis. Even after the completion of hemodialysis, fomepizole appeared to effectively block the production of EG toxic metabolites and to allow the resolution of acidosis; the patient recovered within 48 hours. This is the first report of fomepizole treatment of EG poisoning in an infant.4-methylpyrazole, fomepizole, poisoning, ethylene glycol, hemodialysis, infant, child, pediatrics.

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