Acute poisoning through consumption of plants picked from the wild is not uncommon in Hong Kong. Gelsemium elegans Benth. is one of the most poisonous native plants which can cause toxicities ranging from dizziness to respiratory depression and muscle paralysis after ingestion. We report three cases of gelsemium poisoning in a family after consumption of a homemade herbal soup made of a plant believed to be Cassytha filiformis Linn. collected in the countryside. All of them presented with dizziness, nausea and generalised weakness and bilateral ptosis about 1 hour post-ingestion. C. filiformis is generally regarded as non-toxic and it does not contain gelsemium alkaloids. The exact origin of the gelsemium was not known in this case. This case highlighted the potential public health threat posed by the practice of picking and consumption of wild plants. Emergency physicians should also be aware that the plant species reported by the patients may not always be the ones causing clinical toxicities. (Hong Kong j.emerg.med. 2015;22:60-63)

Introduction: Non-prescription slimming products are popular and can be easily purchased from the Internet. However, adulteration of these products with undeclared substances including prescription drugs is not uncommon. We report a case of serotonin syndrome after an overdose of a non-prescription product containing sibutramine. Case report: A 21-year-old woman presented with somnolence, sinus tachycardia, generalised increase in tone, hyper-reflexia and clonus more prominent in the lower limbs after an intentional overdose of a non-prescription slimming product obtained from the Internet. The product was later found to contain sibutramine and other substances such as animal thyroid tissues, caffeine and phenolphthalein. Quantitative analysis of patient's serum on presentation revealed a sibutramine concentration of 112 ng/mL, which far exceeded the reported peak serum concentration after a single oral dose of 15 mg (the maximum daily recommended dose). No other culpable agent was identified. The overall clinical presentation was compatible with serotonin syndrome associated with sibutramine overdose. The patient made a full recovery after supportive management. Discussion and conclusion: This case highlighted the health threat posed by non-prescription slimming products sold over the Internet. Sibutramine overdose can result in serotonin syndrome, as in overdose of other serotonergic agents. Early recognition and timely supportive treatment are essential to ensure a good clinical outcome.

Objectives (1) to characterise the clinical features of acute epiglottitis in adults in Hong Kong; (2) to identify predictors for airway intervention and uneventful recovery without intensive care unit (ICU) admission. Modified Early Warning Score (MEWS) was also applied in risk stratification. Methods A retrospective cohort study of 122 consecutive laryngoscopically confirmed cases admitted to Pamela Youde Nethersole Eastern Hospital from 1998 to 2007. Results The mean patient age was 51 years (range 18–84 years) and the male-to-female ratio was 1.9 to 1. Sore throat, dysphagia and odynophagia were the commonest symptoms and the median MEWS on presentation was 1 (range 0–10). Nine patients (7.4%) required airway intervention (5 orotracheal intubations, 2 nasotracheal intubations and 2 tracheostomies) and one patient died. Univariate analysis showed that recurrent attack (OR 35.0, 95% CI 2.77–442.69, p=0.013), dyspnoea (OR 17.41, 95%CI 2.09–144.79, p=0.001), stridor (OR 30.0, 95%CI 2.42–372.65, p=0.016) and MEWS equal to or greater than 4 (OR 5.81. 95%CI 1.16–29.17, p=0.049) were significantly associated with airway intervention. Only stridor remained a reliable predictor in multivariate analysis (OR 88.46, 95%CI 5.48–1427.45, p=0.001). Performance of MEWS in prediction for airway intervention was evaluated with the Receiver Operating Characteristic (ROC) curve. The area under curve (AUC) was 0.71 (95%CI 0.503–0.909). Forty-five patients did not require ICU admission (36.9%). Multiple logistic regression showed that absence of hoarseness (OR 3.10, 95%CI 1.10–8.79, p=0.033), absence of fever (OR 3.2, 95%CI 1.25–8.16, p=0.015) and MEWS <1 (OR 7.07, 95%CI 1.31–38.07, p=0.023) were predictors of uneventful recovery without ICU care. Conclusion A selective approach should be adopted in airway management but those with stridor on presentation should have their airway secured without delay. MEWS cannot replace clinical judgement but a low MEWS on presentation may help in identifying low risk patients who can be managed safely without ICU admission.

Cocaine abuse has become more affordable and popular amongst drug abusers locally in recent years. Spontaneous pneumomediastinum is an uncommon but a well-reported complication after smoking "crack" cocaine in the West. We report a case of spontaneous pneumomediastinum after smoking cocaine. The patient was managed conservatively and he recovered uneventfully. A review of literature on the mechanism, clinical presentation and management is presented.

Starting from the 1st July 2009, poisoned patients who fulfilled the emergency medicine ward (EMW) admission criteria were transferred to the EMW for subsequent care after intensive care unit (ICU) management. This study was undertaken to review the impact of such a strategy on the length of stay (ALOS). Study design: This was a retrospective study on consecutive poisoned patients discharged from the ICU from the 1st July 2009 to 31st December 2010. Poisoned patients from the 1st January 2008 to 30th June 2009, who were discharged to the general medical ward or to other specialty wards were used as historical controls for comparison. Method: Medical records of eligible cases were reviewed and data were collected using a standardized data collection form. Disease severity during the ICU stay was assessed using the Acute Physiology and Chronic Health Evaluation II (APACHE II) score. The median ALOS and APACHE II scores of the 2 groups were compared. Results: A total of 32 poisoned patients were transferred from the ICU to EMW during the study period, in which 28 patients were included as the study group. For the historical control group, 19 patients were identified for comparison. The study group had a significantly shorter median length of stay in the ICU (21.3 h vs. 36.0 h, p=0.013) and a significantly shorter median ALOS (28.8 h vs. 52.5 h, p=0.002) compared to the historical control group. All patients discharged to the EMW survived with no ICU re-admission. Conclusion: The strategy of using the EMW as a stepdown unit for selected poisoning cases after ICU discharge is feasible, safe and effective.