Results: A total of 120 subjects were enrolled in the study, resulting in 57 subjectsenrolled into each group, and six subjects who were treatment failures. Baselinecharacteristics did not differ (p � 0.05) between children in the study and placebogroups. However, one interesting difference that approached significance was thatchildren in the study group had experienced more venipuncture needlesticks in thepast two years (M � 6.8, SD � 15.0) than the placebo group (M � 2.8, SD � 3.7,t(63) � �1.97, p � 0.054). The relative risk of a painful venipuncture stick was 1.2,or 20% greater (95% confidence interval 0.77 to 1.90) in the placebo group than thestudy group. There were no significant differences in mean levels of patient, parent orobserver ratings of procedural anxiety, or patient pulse rate or the patient’s meanrating of venipuncture pain between the study and placebo groups (p � 0.05). Therewere no significant differences in mean pain ratings (p � 0.05) when data weregrouped by patient age ranges (� 7 years, 7–11 years, 12–18 years).

Conclusion: Application of liposomal lidocaine prior to venipuncture did show asmall reduction in relative risk of patient perceived venipuncture pain, but did notreduce the mean level of patient perceived pain during venipuncture. No differencesin mean levels of procedural anxiety rating, patient pulse rate, or mean venipuncturepain rating was observed between study groups.

361 Medication Errors Occurring in FomepizoleAdministration

Wong S, King R, Molai S, Fleishman J, Commons B, Labat M, Kleinschmidt K/University of Texas Southwestern Medical Center, Dallas, TX; Medical Center ofLewisville, Lewisville, TX

Study Objective: Fomepizole (4MP) is an antidote for methanol and ethyleneglycol toxicities. The first dose of 4MP is 15 mg/kg; the maintenance dose isdecreased 33% to 10 mg/kg every 12 hours (h) for 4 doses (2nd to 5th doses).Starting with the 6th dose, 4MP is returned to 15 mg/kg every 12 h. Duringhemodialysis (HD), 4MP is given every 4 h. If the most recent 4MP dosing is � 6 hago, then a dose should be given before starting HD. At the end of HD, if the mostrecent dose of 4MP is � 3 h ago, another full dose of 4MP should be given; if themost recent dose of 4MP is � 3 h ago, a 1⁄2 dose of 4MP should be given. Thepurpose of this study is to investigate the frequency and types of medication errors(ME) that occur during 4MP administration and the impact of these errors onpersistent or worsening acidosis.

Methods: We searched 2 hospital pharmacy databases on patients who received4MP between 1-1-98 and 7-31-08. All patients who received 4MP in our studyperiod were included. There were no other inclusion or exclusion criteria. A chartreview was performed and a case report form was used for data collection. We define4MP ME as any of the following conditions: 1) 4MP was given � 13 h apart; 2) the2nd, 3rd, 4th or 5th dose is � 30% or � 35% decrease from the first dose; 3) the 6th

dose is not the same as the first dose; or 4) incorrect frequency and/or dosage whilethe patient is on HD. The data were extracted by three data abstractors who wereblinded to the purpose of the study and trained in data abstraction.

Results: Of the 83 patients whose charts were examined; a total of 149 4MP doseswere given; 25 patients received � 2 doses (totaling 66 doses in those patients). Of the 25patients, 11 (44%) received 4MP � 13 h apart at least once, and 13 (52%) receivedimproper dosage at least once. Of the 66 doses, 53 (80%) had timing errors (TE) and 20(30%) had dosing errors (DE). Of the 20 DE, 17 (85%) received excessive 4MP. Of the83 patients, 15 received HD and a total of 43 4MP doses. Of the 15 patients, 14 (93%)had at least one ME, representing 29 (67%) of the 43 dosings. No patient developedpersistent or worsening acidosis secondary to 4MP ME.

Conclusion: Limitations in our study include data abstraction errors and lack ofpatient’s weight preventing accurate weight-based dosing calculations. Our studysuggests that in patients who received � 2 doses of 4MP, TE is the most commonME. Of the smaller portion of ME due to DE, most involved excessive 4MP dosing.The errors were not associated with worsening acidosis.

362 Coagulopathy in Pediatric Copperhead SnakebitesAnderson BW, Horwitz DA, Mullins ME/Washington

University School of Medicine, St. Louis, MO; St. Louis University School ofMedicine, St. Louis, MO

Study Objectives: The evaluation and management of known copperhead,Agkistrodon contortrix, snakebites remains somewhat controversial despite more recentliterature asserting the lack of significant systemic and coagulopathic effects. It is quitecommon to see multiple, serial coagulation studies followed on these patients. In thisstudy we determine the incidence of coagulopathy in pediatric copperhead snakebites.

Methods: We performed an institutional review board-approved, retrospectivechart review of all pediatric venomous snakebites over the past fifteen years presentingto St. Louis Children’s Hospital, a large, urban tertiary care facility. Cases wereidentified by querying billing data using ICD-9 codes for venomous snakebites andlizards E905.0, nonvenomous snakebites E906.2, and toxic effects of venom 989.5.From this list of cases, nonvenomous snakebites and bites or stings from otheranimals were excluded. The remaining individual charts were then reviewed notingthe following: patient demographics including age, sex, zip code; whether the type ofsnake was identified with certainty, presumptively identified, or unknown; location ofbite on patient; laboratory assessment of coagulation parameters; presence of clinicalbleeding complications.

Results: Our search yielded 428 patient records of which 338 were excluded. Wereviewed the 89 remaining charts coded as venomous reptile bites. Of these 89 charts,we excluded 11 charts including 3 re-admissions for secondary closure afterfasciotomy, 1 dry bite, 1 iguana bite, 1 miscoded chart, 1 admission for delayedwound complications after initial admission elsewhere, 3 charts which wereinaccessible due to microfilm malfunction, and 1 definite rattlesnake bite. The finaldata set included 78 venomous snakebites, of which 18 were positively identified ascopperheads, 36 were presumptively identified as copperheads, and 24 wereunknown. In no case did clinically apparent bleeding complications develop. Meanand median values for most abnormal coagulation studies for each patient by degreeof certainty were: positively identified copperheads PT 12.9/13, PTT 30.6/30.3, INR1.08/1.06, Plt’s 265/259, fibrinogen 226/229; presumptively identified copperheadsPT 13.7/14.1, PTT 29.6/29.2, INR 1.09/1.09, Plt’s 270/252 fibrinogen 263/258,and c) unknown PT 14.2/14.4, PTT 30/30, INR 1.1/1.1, Plt’s 291/275, fibrinogen293/289. One outlier in the “unknown” category had INR �8, PT �65, PTT�150, Plt’s 187 but no clinical bleeding complications. This patient was bitten by anunknown “black snake” believed by the toxicology consultant to be a rattlesnake andwas excluded from the above data analysis.

Conclusion: In snakebites known with certainty to be from copperheads, it is safeto forego coagulation testing thereby saving significant money and patient discomfort.

363 Obese Dosing Adjustments for SelectedAntimicrobials in the Emergency Department

Fuentes JM, Mullins ME/Washington University School of Medicine in St. Louis,St. Louis, MO; Washington University in St. Louis, St. Louis, MO

Study Objective: The Centers for Disease Control and Prevention have reporteda dramatic increase in obesity over the past 20 years in the United States, makingobesity a public health crisis. Emergency physicians should be aware ofpharmacokinetic and pharmacodynamic changes in the obese population. Weevaluated whether our institution’s emergency physicians are adhering to doseadjustment for selected antibiotics based on guidelines from our antibiotic utilizationreview (AUR) committee.

Methods: From January to March 2008, we performed a retrospective review ofpatients at an urban level I trauma center. All patients studied had a weight �100 kg;a body mass index �40 kg/m2; and received cefazolin, cefepime, or ciprofloxacin inthe emergency department. Based on AUR guidelines, the initial dose regardless ofcreatinine clearance should be 2 g IV for cefazolin or cefepime and 800 mg IV or 750mg PO for ciprofloxacin. If patients did not receive the prior dosing for theseantibiotics, the dose was considered to not adhere to the guidelines.

Results: A total of 1,072 patients met the study criteria, and 30 received morethan one antibiotic. A total of 503, 293, and 306 doses of cefepime, cefazolin, andciprofloxacin were given, respectively. The guidelines for cefepime, cefazolin, andciprofloxacin were not adhered to for 455 (90.5%), 281 (95.9%), and 302 (98.7%)doses, respectively, while the guidelines were adhered to for 48 (9.5%), 12 (4.1%)and 4 (1.3%) doses, respectively.

Conclusions: Antimicrobial dose adjustment in the severely obese populationrarely occurs in the emergency department. Failure to dose-adjust antibiotics in thispopulation can lead to inadequate treatment and also may promote resistance toantimicrobials.

364 Acid Base Status as a Predictor of Severity inSalicylate Toxicity

Levine M, Gresham C, Brooks DE, Lansburg J, Kania R, Thomas SH/BannerGood Samaritan Medical Center, Phoenix, AZ; University of Oklahoma, Tulsa, OK

Study Objectives: We sought to determine if the acid base status on presentationto the emergency department (ED) could be used as a marker of severity of salicylate

Research Forum Abstracts

S114 Annals of Emergency Medicine Volume , . : September