Publications by authors named "Andrew Koons"

15 Publications

  • Page 1 of 1

Syndrome of Inappropriate Antidiuretic Hormone Secretion and Lead Toxicity in a Child With Sickle Cell Disease and Pica.

Cureus 2021 Aug 1;13(8):e16813. Epub 2021 Aug 1.

Division of Medical Toxicology, Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, Allentown, USA.

We describe the presentation and management of a three-year-old child with a history of pica, vitamin D deficiency, and sickle cell disease, who was admitted for pyelonephritis, and found to have elevated blood lead level (BLL) of 103.7 µg/dL, and who subsequently developed altered mental status and syndrome of inappropriate antidiuretic hormone secretion (SIADH). In consultation with Medical Toxicology, the patient was chelated with calcium disodium edetate (EDTA) and British Anti Lewisite (BAL). The patient's hyponatremia was managed with hypertonic saline infusion. The patient's encephalopathy improved throughout her hospital course, and she was discharged on hospital day 8. Following five days of EDTA and three days of BAL injections, her repeat BLL was 15.3 µg/dL. SIADH has been associated with severe lead poisoning and may be more likely to occur in high risk patients such as individuals with sickle cell anemia, particularly where medications are used that may cause iatrogenic hyponatremia.
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http://dx.doi.org/10.7759/cureus.16813DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8425150PMC
August 2021

Reversible Total Vision Loss Caused by Severe Metformin-associated Lactic Acidosis: A Case Report.

Clin Pract Cases Emerg Med 2021 May;5(2):206-209

Lehigh Valley Health Network, Department of Emergency and Hospital Medicine, Allentown, Pennsylvania.

Introduction: Metformin is a biguanide used to treat diabetes mellitus (DM). Metformin-associated lactic acidosis (MALA) carries a high mortality and can occur in patients with renal failure from drug bioaccumulation. Reversible vision loss is a highly unusual, rarely reported complication of MALA. We present a case of a patient whose serum metformin concentration was unusually high and associated with vision loss.

Case Report: A 60-year-old woman presented to an outside hospital emergency department with acute vision loss after being found at home confused, somnolent, and hypoglycemic, having last being seen normal two days prior. She reported vomiting and diarrhea during that time and a recently treated urinary tract infection. The visual loss resolved with continuous renal replacement therapy.

Conclusion: This novel case of a patient with Type II DM prescribed metformin and insulin who developed reversible vision loss while suffering from MALA highlights the potential for vision loss in association with MALA.
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http://dx.doi.org/10.5811/cpcem.2021.3.51141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8143825PMC
May 2021

Influence of Pennsylvania liquor store closures during the COVID-19 pandemic on alcohol withdrawal consultations.

Am J Emerg Med 2021 Jul 31;50:156-159. Epub 2021 Jul 31.

Lehigh Valley Health Network, USF Morsani College of Medicine, Allentown, PA, United States of America.

Introduction: Alcohol withdrawal syndrome (AWS) is a serious consequence of alcohol use disorder (AUD). Due to the current COVID-19 pandemic there was a closure of Pennsylvania (PA) liquor stores on March 17, 2020.

Methods: This is a retrospective, observational study of AWS patients presenting to a tertiary care hospital. We used descriptive statistics for continuous and categorical variables and compared AWS consults placed to the medical toxicology service for six months preceding liquor store closure to those placed between March 17, 2020 and August 31, 2020. We compared this to consults placed to the medical toxicology service placed from October 1, 2019 through March 16, 2020. Charts were identified based on consults placed to the medical toxicology service, and alcohol withdrawal was determined via chart review by a medical toxicologist. This study did not require IRB approval. We evaluated Emergency Department (ED) length of stay (LOS), weekly and monthly consultation rate, rate of admission and ED recidivism, both pre- and post-liquor store closure.

Results: A total of 324 AWS consults were placed during the ten month period. 142 (43.8%) and 182 (56.2%) consults were pre- and post-liquor store closure. The number of consults was not statistically significant comparing these two time frames. There was no significant difference by patient age, gender, or race or by weekly or monthly consultation rate when comparing pre- and post-liquor store periods. The median ED LOS was 7 h (95% Confidence Interval (CI) Larson et al. (2012), Pollard et al. (2020) [5, 11]) and did not significantly differ between pre- and post-liquor store periods (p = 0.78). 92.9% of AWS patients required admission without significant difference between the pre- and post-liquor store closure periods (94.4% vs. 91.8%, p = 0.36). There was a significant increase in the number of AWS patients requiring a return ED visit (Odds Ratio 2.49; 95% CI [1.38, 4.49]) post closure.

Conclusion: There were nearly 2.5 times greater odds of ED recidivism among post-liquor store closure AWS patients compared with pre-closure AWS patients.
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http://dx.doi.org/10.1016/j.ajem.2021.07.058DOI Listing
July 2021

Old and Cold: A Novel Case of Combined Secobarbital and Pentobarbital Poisoning in an Elderly Woman.

Cureus 2021 Jan 3;13(1):e12446. Epub 2021 Jan 3.

Emergency Medicine, University of South Florida Morsani College of Medicine / Lehigh Valley Health Network, Allentown, USA.

A 94-year-old woman was found unresponsive in her room at an independent living facility. Upon paramedic arrival, the patient had a Glasgow Coma Scale of 3, and she was transported to the emergency department (ED). In the ED, she was unresponsive but spontaneously breathing, bradycardia, and hypothermia. Serum concentrations of both secobarbital (3.3µg/mL; therapeutic 1.0-2.0µg/mL) and pentobarbital (9.5µg/mL; therapeutic < 5.0µg/mL) were detected and elevated. This type of poisoning is quite rare and should be considered in patients presenting with hypothermia and coma, even in patients showing brain death signs. The use of hemodialysis for refractory pentobarbital poisoning may be helpful.
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http://dx.doi.org/10.7759/cureus.12446DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7854340PMC
January 2021

Altered Mental Status and Cyanosis in a Pediatric Patient with Methemoglobinemia.

Case Rep Pediatr 2020 20;2020:8896754. Epub 2020 Nov 20.

Lehigh Valley Health Network, Department of Emergency and Hospital Medicine, Division of Pediatric Emergency Medicine, USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown 18103, PA, USA.

Methemoglobinemia results from increased amounts of oxidized hemoglobin in the blood with an ensuing change in oxygen dissociation curve and lack of oxygen delivery to tissue. A previously well, male toddler was brought to the Pediatric Emergency Department (PED) by Emergency Medical Services (EMS) with abrupt onset of altered mental status and cyanosis after a suspected ingestion of "Rush" nail polish remover. He was quickly diagnosed with methemoglobinemia by both clinical presentation and chocolate-colored blood appearance. He emergently received intravenous (IV) methylene blue (MB) with immediate and sustained improvement requiring no further doses. Though inhalation of nitrites and subsequent methemoglobinemia is frequently reported in adolescents, we were unable to find any cases in the literature detailing ingestion of this product and the resulting clinical manifestations. Our objective with this report is to describe a rare case of a toddler with an accidental ingestion of "Rush" nail polish remover, a nitrite compound. Our patient presented to the PED with abrupt onset of altered level of consciousness, hypotension, and cyanosis resulting from acquired methemoglobinemia. This case report demonstrates the importance of emergency clinicians being able to make clinical judgements and decisions based on the history and physical exam when methemoglobinemia is suspected.
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http://dx.doi.org/10.1155/2020/8896754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7695503PMC
November 2020

Sex Differences in Substance Use and Misuse: A Toxicology Investigators' Consortium (ToxIC) Registry Analysis.

Subst Abuse Rehabil 2020 29;11:23-31. Epub 2020 Sep 29.

Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, PA 18103, USA.

Background: Variations between male and female populations are previously reported in classes of harmfully used/misused drugs, severity of substance use disorder and risk of relapse. The aim of this study was to provide a review of bedside medical toxicologist managed, sex-specific poisonings in adults that present with harmful drug use/misuse.

Methods: ToxIC Registry cases ≥19 and ≤65 years old, with harmful drug use or misuse during the timeframe June 2010-December 2016, were studied. Demographics, primary agents of toxic exposure, administration route and complications were analyzed. Descriptive methods were used in the analysis.

Results: The database included 51,440 cases. Of these, 3426 cases were analyzed in which the primary reason for the encounter was harmful substance use/misuse. Females were found to harmfully use/misuse pharmaceutical drugs (N=806, 65.6%) more than nonpharmaceutical drugs (N=423, 34.4%). Males more frequently used nonpharmaceutical drugs (N=1189, 54.1%) than pharmaceutical drugs (1008, 45.9%). Analgesics were used by females (N= 215, 18.2%) and males (N=137, 6.6%). Sedative hypnotics were used by females (N=165, 14%) and males (N=160, 7.8%). Psychoactive agents were used by males (N=325, 15.8%) and females (N=67, 5.7%). Sympathomimetics were used by males (N=381, 18.5%) and females (N=151, 12.8%). The majority of both male and female participants, 1712 (57.9%), utilized an oral route of administration. However, 312 (16.5%) of males utilized inhalation vs 73 (6.8%) of females inhaled their substance.

Conclusion: There were sex-specific differences among patients evaluated for harmful substance use/misuse by toxicologists. Considering these differences in regards to management and preventive approaches may be indicated.
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http://dx.doi.org/10.2147/SAR.S263165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532888PMC
September 2020

Mobitz Type II Atrioventricular Heart Block After Candlenut Ingestion.

J Am Osteopath Assoc 2020 Dec;120(12):839-843

The candlenut is a highly accessible seed marketed as a natural weight-loss supplement. However, there is little known about the exact mechanism of action for weight loss nor for the many adverse symptoms it causes, such as nausea, vomiting, fatigue, cardiac dysrhythmias, and even death. In this case report, the authors present a 44-year-old woman who developed a second-degree, Mobitz type II atrioventricular block after consumption of a candlenut supplement. She presented to the emergency department with syncope and her cardiac rhythm indicated a second-degree heart block soon after ingesting candlenuts recommended by her treating physician. Interestingly, a detectable digoxin concentration obtained on hospital day 2 was measured but of unclear significance given no obvious exposure to a cardioactive glycoside. The patient's rhythm normalized on hospital day 2 and she was discharged uneventfully.
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http://dx.doi.org/10.7556/jaoa.2020.136DOI Listing
December 2020

Opioid-Induced Sickle Cell Crisis With Multiple, Life-threatening Complications.

J Am Osteopath Assoc 2020 Nov;120(11):770-773

The risk of opioid use disorder among patients with sickle cell disease who are treated with chronic opioids remains unclear, but the complications associated with opioid use and overdose can be accentuated in those with sickle cell disease. In this case report, we describe a 13-year-old girl with sickle cell disease who presented to the emergency department after a morphine overdose causing renal infarction, acute kidney injury, acute respiratory distress syndrome, and posterior reversible encephalopathy syndrome.
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http://dx.doi.org/10.7556/jaoa.2020.125DOI Listing
November 2020

Characteristics of Transgender Patient Cases Managed by a Toxicologist: an Analysis of the Toxicology Investigator's Consortium (ToxIC) Registry: January 2017-June 2019.

J Med Toxicol 2021 01 17;17(1):16-26. Epub 2020 Jun 17.

Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, 1909 Earls Court, Allentown, PA, 18103, USA.

Introduction: The Toxicology Investigators Consortium (ToxIC) database, created in 2010 by the American College of Medical Toxicology (ACMT), compiles data recorded by medical toxicologists. In January 2017, the data field for transgender (and if transgender, male-to-female or female-to-male) was added to the ToxIC form. Little is known regarding trends in poisonings among transgender patients. We sought to review consultations managed by a bedside toxicologist and provide descriptive data in trends among types of exposures within the transgender demographic.

Methods: A retrospective ToxIC database evaluation of cases in which the patient identified as transgender were reviewed from January 2017-June 2019 and descriptive demographics reported.

Results: The registry contained 113 cases that involved transgender patients. Of those with complete data, 41 (36.6%) were male-to-female, 68 (60.7%) were female-to-male, and 3 (2.7%) identified as gender non-conforming. Of those with complete data, the most common reason for encounter was intentional use of a pharmaceutical drug (N = 97, 85.8%), of which 85 (87.6%) were classified as intentional pharmaceutical use intended for self-harm. Analgesics were the most common class of drugs used out of those reported (N = 24, 22%). Forty-six (90.2%) patients aged 13-18 with complete data were identified as encounters due to self-harm. Attempt at self-harm was the most common reason for intentional pharmaceutical encounter among the sample of transgender patients with complete data (N = 85, 87.6%); with female-to-male patients having an N = 53 (77.9%).

Conclusion: Among transgender patients in the ToxIC registry, the most common primary reason for the encounter was intentional use of a pharmaceutical drug intended for self-harm. In this small cohort, there were some age and transition differences in prevalence. These findings may inform poisoning prevention practices as well as sex- and gender-based management of patients in this vulnerable population.
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http://dx.doi.org/10.1007/s13181-020-00789-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7785623PMC
January 2021

HOUR Prediction Rule.

Acad Emerg Med 2019 10 23;26(10):1201-1202. Epub 2019 May 23.

Emergency Medicine and Medical Toxicology, Lehigh Valley Health Network, Bethlehem, PA.

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http://dx.doi.org/10.1111/acem.13769DOI Listing
October 2019

Emergency Medicine Resident Self-assessment of Clinical Teaching Compared to Student Evaluation Using a Previously Validated Rubric.

Clin Ther 2018 08 29;40(8):1375-1383. Epub 2018 Jul 29.

Department of Emergency and Hospital Medicine, Lehigh Valley Health Network; Faculty at University of South Florida, Morsani College of Medicine, Tampa, Florida. Electronic address:

Purpose: The quality of clinical teaching in the emergency department from the students' perspective has not been previously described in the literature. Our goals were to assess senior residents' teaching ability from the resident/teacher and student/learner viewpoints for any correlation, and to explore any gender association. The secondary goal was to evaluate the possible impact of gender on the resident/student dyad, an interaction that has previously been studied only in the faculty/student pairing.

Methods: After approval by an institutional review board, a 1-year, grant-funded, single-site, prospective study was implemented at a regional medical campus that sponsors a 4-year dually approved emergency medicine residency. The residency hosts both medical school students (MSs) and physician's assistant students (PAs). Each student and senior resident working concurrently completed a previously validated ER Scale, which measured residents' teaching performance in 4 categories: Didactic, Clinical, Approachable, and Helpful. Students evaluated residents' teaching, while residents self-assessed their performance. The participants' demographic characteristics gathered included prior knowledge of or exposure to clinical teaching models. Gender was self-reported by participants. The analysis accounted for multiple observations by comparing participants' mean scores.

Findings: Ninety-nine subjects were enrolled; none withdrew consent. Thirty-seven residents (11 women) and 62 students (39 women) from 25 MSs and 6 PA schools were enrolled, completing 517 teaching assessments. Students evaluated residents more favorably in all ER Scale categories than did residents on self-assessments (P < 0.0001). This difference was significant in all subgroup comparisons (types of school versus postgraduate years [PGYs]). Residents' evaluations by type of student (MS vs PA) did not show a significant difference. PGY 3 residents assessed themselves higher in all categories than did PGY 4 residents, with Approachability reaching significance (P = 0.0105). Male residents self-assessed their teaching consistently higher than did female residents, significantly so on Clinical (P = 0.0300). Students' evaluations of the residents' teaching skills by residents' gender did not reveal gender differences.

Implications: MS and PA students evaluated teaching by EM senior residents statistically significantly higher than did EM residents on self-evaluation when using the ER Scale. Students did not evaluate residents' teaching with any difference by gender, although male residents routinely self-assessed their teaching abilities more positively than did female residents. These findings suggest that, if residency programs utilize resident self-evaluation for programmatic evaluation, the gender of the resident may impact self-scoring. This cohort may inform future study of resident teaching in the emergency department, such as the design of future resident-as-teacher curricula.
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http://dx.doi.org/10.1016/j.clinthera.2018.06.013DOI Listing
August 2018

Successful Utilization of Mechanical Thrombectomy in a Presentation of Pediatric Acute Ischemic Stroke.

Case Rep Pediatr 2018 15;2018:5378247. Epub 2018 Apr 15.

Diagnostic Radiology, Section of Neuroradiology, Lehigh Valley Health Network/USF MCOM, CC & I-78, Allentown, PA 18103, USA.

Guidelines regarding the management of acute ischemic stroke (AIS) in the pediatric population using mechanical recanalization procedures are lacking. We present a case of a 14-year-old male diagnosed in the Emergency Department with an acute onset stroke who underwent successful mechanical clot removal by interventional radiology.
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http://dx.doi.org/10.1155/2018/5378247DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5925102PMC
April 2018

Women and the Experience of Pain and Opioid Use Disorder: A Literature-based Commentary.

Clin Ther 2018 02 10;40(2):190-196. Epub 2018 Jan 10.

Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, Allentown, Pennsylvania; Section of Medical Toxicology, Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, Allentown, Pennsylvania. Electronic address:

It is generally understood that pain experience and opioid abuse have relied on male-dominated models. However, sex and gender play a role in both pain experience and opioid use disorder. Using the previously validated Texas Tech University Health Sciences Center Sex and Gender Specific Health PubMed Advanced Search Tool, the authors used pertinent literature to develop this literature-based commentary on sex and gender differences in pain experience and opioid use disorder. Women report their experience of pain more frequently, have increased rates of diagnoses related to pain, have increased pain sensitivity, and have a variable response to pain and analgesia. This variable response is due to anatomic, physiologic, hormonal, psychological, and social factors that differ by sex and gender. Women have been found to be at greater risk for opioid abuse in all age groups. This may be due to the differences in pain experience, as well as sex and gender differences in prescribing patterns, cultural norms, and the increased likelihood to experience dependency and withdrawal. Approaches to the treatment of opioid use disorder are also subject to sex and gender differences-an area in need of further investigation.
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http://dx.doi.org/10.1016/j.clinthera.2017.12.016DOI Listing
February 2018

The Aortomesenteric Angle as an Aid in Diagnosing Superior Mesenteric Artery Syndrome.

Clin Pract Cases Emerg Med 2017 May 16;1(2):140-141. Epub 2017 Mar 16.

Lehigh Valley Hospital-Muhlenberg, Department of Emergency Medicine, Allentown, Pennsylvania.

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http://dx.doi.org/10.5811/cpcem.2016.12.30676DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965416PMC
May 2017
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