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Plant Poisoning, Alkaloids - Tropane

Richard A Wagner, MD, PhD, FACEP, Staff Physician, St. Joseph's / St. Mary's Hospitals, Tucson; Consultant, Arizona Drug and Poison Information Center
Samuel M Keim, MD, Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine

Updated: Sep 23, 2009

Introduction

Background

Alkaloids are plant metabolites that have a nitrogen-containing chemical ring structure, alkali-like chemical reactivity, and pharmacologic activity. The alkaloids represent a very diverse group of medically significant compounds that include well-known drugs like the opiates.

A subgroup of the alkaloids is the alkaloid amines. The 3 major pharmacologic groups of alkaloid amines are the hallucinogenic alkaloid amines, the stimulant alkaloid amines, and the highly anticholinergic tropane alkaloids (also called the belladonna alkaloids or bicyclic alkaloids).

Plants that contain the tropane alkaloids atropine, scopolamine, and hyoscyamine include the following:

• Datura species (jimson weed, angel's trumpet, thorn apple)
• Hyoscyamus niger (henbane)
• Atropa belladonna (deadly nightshade)
• Mandragora officinarum (mandrake)

All of these plants have long histories of hallucinogenic use and have been connected with sorcery, witchcraft, native medicine, and magico-religious rites dating back to 1500 BC and Homer's Odyssey. (Homer's use of the plant moly as an antidote to Circe's poisonous anticholinergic drugs may have been the first recorded use of an anticholinesterase to reverse central anticholinergic intoxication.)

Chinese herbal medicines containing tropane alkaloids have been used to treat asthma, chronic bronchitis, pain, and flu symptoms. In Mexico, Datura is taken by Yaqui women to lessen pain of childbirth. In Africa, a common use is to smoke leaves from Datura to relieve asthma and pulmonary problems. Many cultures worldwide add plants with tropane alkaloids (particularly Datura species) to alcoholic beverages to increase intoxication.

Recently, Datura has been used as a recreational hallucinogen in the US, resulting in sporadic cases of anticholinergic poisoning and death. Numerous cases of anticholinergic poisoning also have resulted from belladonna alkaloid contaminants in foods, including commercially purchased Paraguay tea (an herbal tea derived from Ilex paraguariensis), hamburger, honey,¹ stiff porridge made from contaminated millet, and homemade "moon flower" wine. Other accidental ingestions include misuse as an edible wild vegetable² and inclusion in homemade toothpaste,³ as well as a large epidemic in New York and the eastern US that resulted from heroin contaminated with scopolamine⁴ .

Although most tropane alkaloids cause an anticholinergic syndrome, a recent report indicates that the tropane alkaloid–containing medicinal herb Erycibe henri Prain ("Ting Kung Teng") contains a tropane alkaloid that may cause a cholinergic syndrome, as well as renal, hepatic, and erythrocyte toxicity.⁵ This is considered atypical for the tropane alkaloids, which are predominantly strongly anticholinergic.

Pathophysiology

Toxicity from plants containing tropane alkaloids manifests as classic anticholinergic poisoning. Symptoms usually occur 30-60 minutes after ingestion and may continue for 24-48 hours because tropane alkaloids delay gastric emptying and absorption.

Scopolamine, acting as an antagonist at both peripheral and central muscarinic receptors, is thought to be the primary compound responsible for the toxic effects of these plants. Tropane alkaloids are found in all parts of the plants, with highest concentrations in roots and seeds.

Atropine is an artifact of purification, produced by racemization of l-hyoscyamine. The proportion of each alkaloid present varies among species, time of year, location, and part of plant. As little as one-half teaspoon of Datura seed, equivalent to 0.1 mg of atropine per seed, has caused death from cardiopulmonary arrest. The usual route of ingestion is as a tea, although ingesting seeds or other plant parts and smoking dried leaves also are common.

Frequency

United States

Incidence is sporadic, with clusters of poisoning cases, mostly among adolescents using plants for their hallucinogenic effects.

According to the American Association of Poison Control Centers' National Poison Data System Annual Report 2007, 938 single exposures to anticholinergic plants were reported, and no deaths were documented.⁶

During 2005, 975 anticholinergic plant poisonings were reported to Poison Control Centers in the United States; 566 of these cases were treated in health care facilities.⁷

During 1998-2004, a total of 188 reported human exposures were identified by Texas Poison Control Centers.⁸ Seventy-six percent of the exposures occurred in June-October, 82% of the cases occurred in males, and 72% of cases occurred in those aged 13-19 years.

Widespread access to information on hallucinogenic plants through the Internet may lead to a further increase in the incidence.

International

Worldwide incidence is unknown. However, cases have been reported in Germany, Italy, Greece, Saudi Arabia, Tanzania, Australia, Brazil, Hong Kong, Taiwan, Mexico, Chile, and Venezuela, attesting to broad geographic distribution of Datura species.

Mortality/Morbidity

Nonfatal cases are likely underreported.

• Of the 975 anticholinergic plant poisonings reported to the American Association of Poison Control Centers in 2005, there were no fatalities.⁷
• In 1993, 318 cases of Datura poisoning were reported to the American Association of Poison Control Centers; the Centers for Disease Control and Prevention (CDC) reported 2 deaths.
• In 1994, the CDC reported 7 cases of anticholinergic poisoning in 3 families who consumed contaminated commercial Paraguay tea.⁹
• Reports of sporadic cases or clusters of cases involving intentional use as a hallucinogen are frequent; most patients recover uneventfully, although fatalities do occur.
• Related deaths from drowning, exposure, and lack of supportive care have been reported.

Sex

Males are more frequently involved in cases of intentional exposure.

Age

No age predilection exists, although Datura use as a recreational drug is more common among adolescents. Accidental ingestion and resultant toxicity in children has been reported.

Clinical

History

• As in any patient presenting with an acute change in mental status or suspected poisoning, attempt to obtain the following information:
  • Complete past medical history
  • Medication history
  • Precise description or sample of suspected toxicant(s)
  • Route of administration, amount ingested, time since ingestion, and reason for ingestion
  • Co-ingestants and use of alcohol or other street drugs
• Initial signs and symptoms may include the following:
  • Dry mucous membranes and skin
  • Dysphagia and dysarthria
  • Photophobia
  • Blurred vision
  • Tachycardia
  • Urinary retention
• Initial signs and symptoms may be followed by hyperthermia, confusion, agitation, combativeness, seizures, coma, and death.
• Amnesia regarding events following ingestion of tropane alkaloids is common.
• Identification of ingested plants can be diagnostic of tropane alkaloid poisoning.
  • Datura species, the most commonly encountered plants containing tropane alkaloids, are 3-5 foot annuals with coarse-toothed leaves.
  • Trumpet-shaped flowers are 3-5 inches in length, with white-pale-violet colored petals (see Media files 1-2).
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    Datura stramonium (jimson weed). Note 4-5 inch long white flowers.© 2000 Richard Wagner

    
    
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    Datura stramonium flower. Note the trumpetlike shape.© 2000 Richard Wagner

    
    
  • Most important for taxonomic identification are spiny, round, chambered seed pods (see Media file 3).
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    Datura stramonium (close-up of unripe seed pods). Note spiny appearance of pods.© 2000 Richard Wagner

    
    

Physical

The mnemonic "red as a beet, dry as a bone, blind as a bat, mad as a hatter, and hot as a hare" is useful to remember the anticholinergic toxidrome.

• Vital signs
  • Tachycardia and tachypnea
  • Hyperpyrexia (in about 20% of cases)
  • Inconsistent hypertension and hypotension, respiratory depression (rare)
  • Warm dry skin (may be flushed)
• Head, ears, eyes, nose, and throat
  • Mydriasis and cycloplegia (almost always occur and may persist for days)
  • Dry mucous membranes
• Abdomen
  • Diminished bowel sounds
  • Distention of urinary bladder
• Neurologic
  • Agitation, confusion, and hallucinations
  • Seizures, decreased muscle coordination, paralysis, respiratory depression, and coma (rare)

Differential Diagnoses

Workup

Laboratory Studies

• No specific diagnostic studies for tropane alkaloid poisonings exist.
• Tropane alkaloids are not included in standard drugs of abuse or comprehensive toxicology panels; serum drug concentrations are neither helpful nor readily available to aid in initial management.
• Since acetaminophen and salicylate are common co-ingestants in many poisonings, consider assays for acetaminophen and salicylate levels.
• In febrile patients, consider blood and urine cultures.
• Serum electrolyte levels may provide insight into other intoxicating agents and co-ingestants.
• Consider a pregnancy test for all patients capable of bearing children.

Imaging Studies

• Consider CT scan of the head for patients with altered mental status that is inadequately explained by toxicity from ingested agent or is unresponsive to appropriate intervention.

Other Tests

• Obtain an electrocardiogram (ECG) at presentation for all patients with suspected toxic ingestions.

Procedures

• Consider lumbar puncture (LP) for patients with fever and altered mental status.
• Consider invasive monitoring for hemodynamically unstable patients.

Treatment

Prehospital Care

Transport patient to nearest emergency facility with capabilities for advanced life support (ALS), at minimum. Primary assessment should focus on airway and respiratory, circulatory, and neurologic systems.

• Unless patient is extremely agitated, obtain IV access and monitor vital signs frequently.
• Consider administration of naloxone and thiamine.
• Do not use ipecac and defer administration of activated charcoal, unless a prolonged transport time is anticipated.
• Assess for hypoglycemia and other causes of altered mental status. Manage seizures with benzodiazepines.
• Physostigmine is not recommended in prehospital setting.

Emergency Department Care

As in all cases of suspected poisoning, follow the ABCDEs of emergency medicine (airway, breathing, circulation, disability, exposure), then the ABCDEs of toxicology (antidotes, basics, change absorption, change distribution, change elimination).

• Provide oxygen and intubate if significant CNS or respiratory depression exists and no gag reflex is present. Assess circulation and initiate cardiac and pulse oximetry monitoring. Obtain a 12-lead ECG and evaluate for QRS prolongation, ischemia, and evidence of arrhythmia.
  • Sinus tachycardia is common and does not require treatment for a stable patient. Obtain blood for laboratory analysis and bedside glucose measurement while obtaining IV access. Inspection after full-body exposure should be performed to assess signs of trauma or seizure.
  • Agitated or hallucinating patients often respond to reassurance and a darkened room. If chemical restraint is required, benzodiazepines are the drugs of choice. Early consultation with a poison control center is frequently helpful.
• Consider GI decontamination foremost. Ipecac is contraindicated because of the potential for seizures. Gastric lavage is controversial; while it is commonly performed, no reliable data on outcomes exist to support its use, and the risk of aspiration and other complications is increased. Administer activated charcoal (1-2 g/kg) orally or per nasogastric or orogastric tube. One or 2 additional doses may be given at 1- or 2-hour intervals to ensure adequate gut decontamination.
  • An ileus without distension is not a contraindication to a single dose of charcoal, and charcoal given alone may be as effective or more effective than emesis and lavage procedures. Use of cathartics to hasten elimination from GI tract remains controversial. Sorbitol may be used with first dose of charcoal; further use may cause serious fluid shifts to the intestine, diarrhea, dehydration, and hypernatremia.
  • Tropane alkaloids are lipophilic and cross the blood-brain barrier; hemodialysis and hemoperfusion are generally ineffective. No effective methods of changing distribution or elimination of tropane alkaloids exist.
• Specific antidote for tropane alkaloid toxicity is physostigmine salicylate, a reversible acetylcholinesterase inhibitor capable of directly antagonizing CNS manifestations of anticholinergic toxicity.
  • Physostigmine (at doses lower than those producing peripheral side effects of salivation, lacrimation, urination, defecation, emesis) can reverse central effects of the following conditions:
    • Coma
    • Seizures
    • Hallucinations
    • Agitation
    • Severe dyskinesias
    • Respiratory depression
  • However, unless relative certainty can be established that the toxicity present is due to tropane alkaloid poisoning and not to co-ingestants or other substances, confirmatory peripheral manifestations of anticholinergic toxicity should coexist prior to administration of physostigmine.
  • Physostigmine has been used as a diagnostic tool for tropane alkaloid poisoning, but this use is controversial.
  • Physostigmine can induce a life-threatening cholinergic crisis (eg, seizures, respiratory depression, asystole). Since most patients can be safely treated without this antidote, physostigmine preferably should be used in consultation with a poison control center and generally should be used only for patients in the following states:
    • Unresponsive to supportive measures
    • Tachydysrhythmias and subsequent hemodynamic compromise
    • Intractable seizures unresponsive to benzodiazepines
    • Extremely severe agitation or psychosis
  • Physostigmine is contraindicated in patients receiving tricyclic antidepressants, disopyramide, quinidine, procainamide, cocaine, or other agents producing cardiac conduction abnormalities. Relative contraindications include reactive airway disease, intestinal obstruction, and administration of depolarizing paralytic agents.
• Following GI decontamination, most patients rarely require more than physiologic monitoring and psychologic support.
  • Patients experiencing agitation and hallucinations usually respond to reassurance and benzodiazepines.
  • Most phenothiazines are contraindicated because of their anticholinergic properties.
  • If signs or symptoms of urinary retention exist, Foley catheterization should be performed for bladder decompression.

Consultations

• Early consultation with a toxicologist or poison control center is frequently useful for toxic exposures or ingestions to help in decision-making with regard to decontamination and therapeutic interventions; this is particularly true with the use of physostigmine in cases of tropane alkaloid poisoning.
• Psychiatric consultation is important for all intentional ingestions.
• Contact with primary care provider is optimal for all hospital admissions or cases of serious illness.

Medication

Activated charcoal is indicated for all tropane alkaloid poisonings, within an hour of ingestion, with the possible exception of poisoning from smoking leaves. Benzodiazepines are first-line agents for agitation and seizures. Physostigmine should be used only for life-threatening complications.

GI decontaminant

Activated charcoal is used after a drug or plant ingestion to limit adsorption of toxins. Traditionally given after the stomach has been emptied by emesis or lavage, recent evidence indicates that it may be used alone, without lavage.

Activated charcoal (Liqui-Char)

Emergency treatment in poisoning caused by drugs and chemicals. Network of pores present in activated charcoal adsorbs 100-1000 mg of drug per gram of charcoal. An extremely important component of tropane alkaloid poisoning. May decrease severity and duration of poisoning. Does not dissolve in water.
For maximum effect, administer within 30 min after ingesting poison.

Dosing

Adult

1 g/kg PO or by gastric tube; repeat dose of 0.25-0.5 g/kg may be given in 2 h; first dose may be given with cathartic (eg, sorbitol)

Pediatric

<2 years: Not recommended
>2 years: 0.5-1 g/kg PO or by gastric tube

Interactions

Effectiveness of other medications decrease with coadministration; do not mix charcoal with sherbet, milk, or ice cream (decreases adsorptive properties of activated charcoal)

Contraindications

Documented hypersensitivity; poisoning or overdosage of mineral acids and alkalies; GI obstruction

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Protect airway in patients with absent gag reflex; not very effective in poisonings of ethanol, methanol, and iron salts; induce emesis before giving activated charcoal; after emesis with ipecac, patient may not tolerate activated charcoal for 1-2 h; can administer in early stages of gastric lavage; without sorbitol, gastric lavage returns are black

Benzodiazepines

First-line agents for treatment of tropane-alkaloid-induced seizures. Lorazepam is thought to be most effective and has a longer seizure half-life than diazepam.

Lorazepam (Ativan)

Sedative hypnotic with short onset of effects and relatively long half-life. DOC if IV access is available.
Increasing the action of gamma-aminobutyric acid (GABA), which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation.
Monitoring patient's blood pressure after administering dose is important. Adjust prn.

Dosing

Adult

0.1 mg/kg IV; rate of 2 mg/min; commonly administered 1-4 mg initially, with doses up to 10 mg prn

Pediatric

0.1 mg/kg IV initial dose (0.15-0.2 mg/kg PR)

Interactions

Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs

Contraindications

Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution with renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease

Midazolam (Versed)

Used as alternative in termination of refractory status epilepticus. Because midazolam is water soluble, it takes approximately 3 times longer than diazepam to peak EEG effects. Thus clinician must wait 2-3 min to fully evaluate sedative effects before initiating procedure or repeating dose. Published reports of IM and anecdotal reports of nasal use exist (when IV access is not possible).

Dosing

Adult

10 mg IM (when IV/PR is impossible)
Refractory status: 0.2 mg/kg IV then infusion 0.1-0.4 mg/kg/h; intubation and pressor support are necessary

Pediatric

0.2 mg/kg IM, then obtain IV access

Interactions

Sedative effects of midazolam may be antagonized by theophyllines; narcotics and erythromycin may accentuate sedative effects of midazolam because of decreased clearance

Contraindications

Documented hypersensitivity; preexisting hypotension; narrow-angle glaucoma; sensitivity to propylene glycol (the diluent)

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution with congestive heart failure, pulmonary disease, renal impairment, and hepatic failure

Diazepam (Valium)

Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA. Frequently used in prehospital systems since refrigeration is not required.

Dosing

Adult

0.15 mg/kg IV; not to exceed 20 mg

Pediatric

Administer as in adults IV; 0.3-0.5 mg/kg PR

Interactions

Increases toxicity of benzodiazepines in CNS with coadministration of phenothiazines, barbiturates, alcohols, and MAOIs

Contraindications

Documented hypersensitivity; narrow-angle glaucoma

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution with other CNS depressants, low albumin levels, or hepatic disease (may increase toxicity)

Cholinergic agents

Physostigmine is indicated only for reversal of life-threatening complications of tropane alkaloid poisoning (eg, tachydysrhythmias with hemodynamic compromise, seizures refractory to other therapeutic interventions, and severe agitation or hallucinations unresponsive to other therapy). The decision to use physostigmine ideally should be made in consultation with a toxicologist or poison control center.

Physostigmine (Antilirium)

Reversible anticholinesterase inhibitor that increases the concentration of acetylcholine at cholinergic synapses. The only reversible anticholinesterase inhibitor that readily crosses the blood-brain barrier to produce the desired CNS effects. Some recommend repeated slow IV pushes of 0.1-0.3 mg q3min to a maximum of 2 mg to decrease potential for life-threatening cardiovascular adverse effects.

Dosing

Adult

2 mg slow IVP; may be repeated as indicated; clinical effects last 20-60 min

Pediatric

0.02-0.06 mg IVP; not to exceed 0.5 mg/min or 2 mg as a single dose; clinical effects last 20-60 min; may repeat prn

Interactions

May inhibit or reverse effects of nondepolarizing neuromuscular blockers (eg, vecuronium or pancuronium)

Contraindications

Documented hypersensitivity; asthma; cardiovascular disease; diabetes; gangrene; intestinal obstruction; urogenital obstruction; patients receiving choline esters or depolarizing neuromuscular blockers

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Patients should be on a cardiac monitor; may precipitate a cholinergic crisis (eg, seizures, respiratory depression, asystole); atropine should be at bedside; may precipitate bronchorrhea and bronchospasm; may induce fasciculations and muscle weakness; administer 0.5 mg of atropine IV/mg of physostigmine to reverse cholinergic crisis induced by physostigmine

Follow-up

Further Inpatient Care

• Base admission decisions on patient's signs and symptoms.
  • Asymptomatic patients without signs of anticholinergic toxicity or altered mental status may be discharged after 6 hours of observation.
  • Admit symptomatic patients to an ICU setting for monitoring and treatment. They may be discharged after a symptom-free period of 6 hours without use of supportive therapy or antidotes and after appropriate consultations and follow-up have been arranged.

Patient Education

• For excellent patient education resources, visit eMedicine's Poisoning Center and Poisoning - First Aid and Emergency Center. Also, see eMedicine's patient education articles Poisoning and Activated Charcoal.

Miscellaneous

Medicolegal Pitfalls

• Failure to make the diagnosis
• Failure to obtain a toxicology consultation in a critically ill patient with polysubstance toxicity

Multimedia

Media file 1: Datura stramonium (jimson weed). Note 4-5 inch long white flowers.© 2000 Richard Wagner

Media file 2: Datura stramonium flower. Note the trumpetlike shape.© 2000 Richard Wagner

Media file 3: Datura stramonium (close-up of unripe seed pods). Note spiny appearance of pods.© 2000 Richard Wagner

Media file 4: Datura stramonium is the plant shown. © 2000 Richard Wagner

Media file 5: The plant shown is foxglove (Digitalis purpura), which contains cardiac glycosides, not tropane alkaloids. © 2000 Richard Wagner

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Keywords

tropane, belladonna, belladonna alkaloids, jimson weed, loco weed, sacred datura, angel's trumpet, mandrake, henbane, moonflower, moonflower seeds, scopolamine, anticholinergic toxicity, anticholinergic syndrome, hallucinogen, hallucinogenic, alkaloid amines, alkaloid plant poisoning, atropine, hyoscyamine, alkaloid tropane, thorn apple, deadly nightshade

Contributor Information and Disclosures

Author

Richard A Wagner, MD, PhD, FACEP, Staff Physician, St. Joseph's / St. Mary's Hospitals, Tucson; Consultant, Arizona Drug and Poison Information Center
Richard A Wagner, MD, PhD, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Samuel M Keim, MD, Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine
Samuel M Keim, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Summa Health System
Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Michael Hodgman, MD, Assistant Clinical Professor of Medicine, Department of Emergency Medicine, Bassett Healthcare
Michael Hodgman, MD is a member of the following medical societies: American College of Medical Toxicology, American College of Physicians, Medical Society of the State of New York, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

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