BackgroundMetformin toxicity is well known to cause lactic acidosis. Multiple cases of hypoglycemia due to isolated metformin overdose have been reported. Increased glucose consumption secondary to anaerobic metabolism has been reported as a possible explanation.Case presentationA 23-year-old Arabic woman took 30 g of metformin. In the emergency department, 4 hours after of the event, she was fatigued but vitally stable. During her hospitalization, she had severe lactic acidosis, hypotension corrected with fluid boluses and vasopressors, and multiple episodes of hypoglycemia (6.3 mg/dL, 38 mg/dL, and 42 mg/dL), requiring multiple 50% dextrose-water boluses. The three hypoglycemic episodes occurred coincident with severe lactic acidosis. She improved after 24 hours of continuous renal replacement therapy.ConclusionsHypoglycemia can be induced by metformin toxicity in the absence of co-ingestants. A possible explanation of metformin-induced hypoglycemia is increased glucose consumption due to anaerobic metabolism, decreased oral intake, decreased liver glucose production, and decreased glucose absorption.

BACKGROUND Trainees ought to master specific procedural skills throughout the course of the emergency residency programme they are enrolled in. AIMS We aim to assess the level of exposure to procedures, the confidence towards performing such procedures during each level of training, and an estimate of the minimum number of procedures required to influence trainee confidence and knowledge. METHODS The authors constructed a survey that was distributed using a snowball sampling method, targeting a sample of emergency trainees at nine training hospitals in Riyadh, Saudi Arabia. Participants were asked to answer multiple questions related to 6 different emergency procedures, including the amount of times the procedure had previously been performed and a personal assessment of confidence level related to each procedure using a five-point scale. The mean levels of knowledge and confidence were calculated and used as parameters to reflect on the training of participants. RESULTS The survey was completed by a total of 104 participants and revealed that the most common overall procedure performed was endotracheal intubation with the least common being vaginal delivery. A significant difference was noted between senior trainees and trainees at junior levels in the mean knowledge score for procedures [F(3,100)= 6.03, p= 0.001]. A positive correlation was found between the number of procedures performed and the confidence level. The minimum number of procedures according to the survey revealed the need for more than 15 intubation attempts, 6-10 central line insertions, 1-5 chest tube placements, 1-5 shoulder reductions and 6-10 lumbar punctures to build confidence in trainees. CONCLUSION Procedures that are less frequently performed in specific settings should be noted and attempts should be made to broaden exposure through simulations or rotations at other centres with higher procedural exposure rates.

Objectives: To evaluate the Saudi campers’ knowledge and the applied safety practices regarding carbon monoxide poisoning during camping activities. Method: The cross-sectional questionnaire-based study was conducted from December 1, 2018, to February 1, 2019, in Riyadh, Saudi Arabia, and comprised young male campers from recreational camps in the northern parts of the city. Data was collected from the participants regarding socio-demographic characteristics, knowledge regarding carbon monoxide poisoning, the applied safety measures to prevent carbon monoxide poisoning and the dealing with carbon monoxide poisoning during camping activities. Data was analysed using SPSS 22. Results: There were 235 male subjects with mean age 24.47±1.139 years (range: 21-32 years). Of the total, 50(21.3%) participants had received civil defence education or training. Overall, 137(58.3%) participants had a good mean knowledge score, and 157(66.8%) participants had a good mean practice score for applying healthy measures in preventing and managing carbon monoxide poisoning. As a preventive measure against carbon monoxide poisoning, the use of carbon monoxide detectors was valued by 107(45.5%) participants. Having civil defence training, having a monthly income >10,000 Saudi Riyals, and having a good knowledge score were the elements that had significant association with the choice related to carbon monoxide detector usage. Conclusion: The campers had relatively high knowledge regarding carbon monoxide poisoning, but this knowledge was not fully translated into good health practice. Key Words: Environmental toxin, Camping, Carbon monoxide poisoning, Knowledge, Practice.