Double-blind, randomized study of nalmefene and naloxone in emergency department patients with suspected narcotic overdose.

STUDY OBJECTIVES: To compare the efficacy, safety, and withdrawal symptoms in emergency department patients with suspected narcotic overdose treated with nalmefene, an opioid antagonist with a 4- to 10-hour duration of action, with those treated with naloxone. METHODS: Adults in 9 centers who would otherwise receive naloxone for altered consciousness levels were randomly assigned to receive intravenous study drug (1 mg nalmefene, or 2 mg nalmefene or 2 mg naloxone, double-blinded) every 5 minutes as needed for up to 4 doses in a 4-hour study. Outcomes were 20-minute and 4-hour posttreatment changes in respiratory rates, Neurobehavioral Assessment Scale scores, Opioid Withdrawal Scale scores, and incidences of adverse events. RESULTS: Opioid positivity was recorded for 30 of 63 (1-mg nalmefene), 23 of 55 (2-mg nalmefene), and 24 of 58 (naloxone) cases, 75% of whom also had nonopioid central nervous system depressants. Most patients received only 1 dose of study drug. Similar, clinically meaningful improvements in respiratory rates and Neurobehavioral Assessment Scale scores were seen with all treatments. No statistical differences in efficacy or withdrawal outcomes were seen between treatment groups, and no significant overall time-treatment interactions occurred, in either the entire patient group or among opioid-positive cases (P >.21, all comparisons). Adverse events occurred in 30.9% (2 mg nalmefene), 15.9% (1 mg nalmefene), and 15.5% (naloxone) of patients (P >.08); none were associated with morbidity. CONCLUSION: In this study of patients with varied potential causes of altered consciousness, nalmefene (1 mg and 2 mg) and naloxone (2 mg) appeared to be efficacious, safe, and to yield similar clinical outcomes.

Hypothermia: an easy-to-miss, dangerous disorder in winter weather.

A variety of age-related physiologic factors and disease states predispose older patients to hypothermia. These include a decreased ability to produce heat, malnutrition, medications, infections, and social factors such as isolation and poverty. The subtle clinical signs and symptoms of mild hypothermia may mimic cognitive decline, cerebral vascular accident, hypothyroidism, or myxedema coma. The challenge for the physician is to clinically recognize hypothermia and provide prompt diagnosis and treatment. Medical management of the older patient with moderate to severe hypothermia requires in-hospital intensive care, as life-threatening conditions may arise during stabilization and resuscitation.

Predictors of coronary artery disease in patients with cocaine-associated myocardial infarction. Cocaine-Associated Myocardial Infarction (CAMI) Study Group.

PURPOSE: To identify clinical criteria predictive of underlying coronary artery disease in patients with cocaine-associated myocardial infarction. PATIENTS AND METHODS: Using a retrospective cross-sectional study design at 29 acute care hospitals, we identified 70 patients with cocaine-associated myocardial infarction who had a determination of the presence or absence of coronary artery disease. Clinical characteristics of patients with coronary artery disease (> 50% stenosis on cardiac catheterization or reversible ischemia on stress test) were compared with patients without coronary artery disease (< 50% stenosis on cardiac catheterization). RESULTS: Compared with patients without coronary artery disease (n = 21), patients with coronary artery disease (n = 49) were older (42 versus 31 years; P < 0.001), had more traditional cardiac risk factors (2.3 versus 1.5; P < 0.001), more frequent history of hypertension (odds ratio [OR], 5.3; 95% confidence interval [CI], 1.4 to 20.4); more frequent family history of myocardial infarction (OR, 4.4; 95% CI, 1.3 to 15.1), more bradydysrhythmias (OR, 8.0; 95% CI, 1.0 to 65.5), and more likely to have an inferior infarct location (P = 0.04). CONCLUSION: Age, number of cardiac risk factors, location of myocardial infarction, and bradydysrhythmias predict underlying coronary artery disease in patients with cocaine-associated myocardial infarction. If validated, this knowledge may be used to develop a medically appropriate, cost-effective evaluation strategy for patients following cocaine-associated myocardial infarction.

The effect of the menstrual cycle on asthma presentations in the emergency department.

BACKGROUND: Seventy-five percent of all adult hospital admissions for asthma are women. OBJECTIVE: To determine whether a relationship exists between phases of the menstrual cycle and asthma exacerbations in adult females. METHODS: Data were analyzed from 182 nonpregnant, adult females with asthma aged 13 years to menopause. Date of presentation, patient age, duration of asthma attack, date of last menstrual period, regular interval between menses, presenting peak expiratory flow rate, and admission and discharge decision were recorded prospectively. Treatment interventions abstracted retrospectively from patient charts included use of oxygen, xanthines, beta-adrenergic agonists, corticosteroids, and magnesium sulfate. The menstrual cycle was divided into 4 phases based on fluctuations in serum estradiol levels. The 4 intervals were preovulatory (days 5-11), periovulatory (days 12-18), postovulatory (days 19-25), and perimenstrual (days 26-4). RESULTS: Data were analyzed with a goodness-of-fit chi 2. Between June 1991 and May 1992, 182 females (mean +/- SD age, 28.5 +/- 8.0 years) were surveyed. No significant differences were noted for use of oxygen, beta-adrenergic agonists, xanthines, or magnesium among members of the 4 menstrual groups. Intervention with corticosteroids was least in the postovulatory interval (y:n) 0.5:1 and greatest in the preovulatory interval 3.0:1 (alpha = .03) Presentations by menstrual interval were as follows: preovulatory, 36 (20%); periovulatory, 43 (24%); postovulatory, 18 (10%); and perimenstrual, 85 (46%) (alpha < .01). CONCLUSIONS: Asthma presentations are least frequent when serum estradiol levels are at a sustained peak. We observed a 4-fold variation in asthma presentations during the perimenstrual interval, when serum estradiol levels decrease sharply after that prolonged peak. These findings suggest that monthly variations in serum estradiol levels may influence the severity of asthma in adult females.

The use of ondansetron in the treatment of nausea and vomiting associated with acetaminophen poisoning.

BACKGROUND: Nausea and vomiting associated with poisoning can complicate treatment and in some cases delay potential antidote administration. Side effect such as lowering the seizure threshold may at times discourage the use of traditional phenothiazine and butyrophenone antiemetics. METHODS: We performed a prospective, single arm, observational study examining the effectiveness of the 5HT3 receptor antagonist ondansetron in the management if nausea and vomiting associated with acetaminophen poisoning. Patients with a history or laboratory evidence of acetaminophen poisoning were eligible for inclusion in the study. Exclusion criteria included age less than 18 or greater than 65, use of other antiemetic therapy within the previous 12 hours, history of preexisting hepatic or hematologic disease, pregnancy, or significant ingestion of other substances. Upon meeting entry criteria, patients were administered 8 mg of intravenous ondansetron. Nausea was graded on a 100 mm scale with number of emetic episodes recorded before and after treatment. RESULTS: Six patients were entered in the study. All patients had nausea and at least one emetic episode prior to ondansetron and prior to administration of N-acetylcysteine. All patients reported relief of nausea after ondansetron. The degree of nausea decreased by an average of 52% at 30 min and 88% at 60 min following ondansetron administration. No significant vital sign changes were recorded in any patient, and there were no complications related to therapy. Three patients were administered N-acetylcysteine, and all tolerated this therapy without vomiting after ondansetron. CONCLUSIONS: Ondansetron appears to be a potentially useful adjunct in the management of nausea and vomiting associated with acetaminophen poisoning.

Intravenous magnesium in the treatment of hydrofluoric acid burns in rats.

STUDY OBJECTIVE: To gather preliminary data on the safety and efficacy of IV magnesium in a rat model of hydrofluoric acid burns. MODEL: Forty-seven anesthetized male rats (200 to 300 g) received a standardized burn with 52% hydrofluoric acid. INTERVENTIONS: Animals were anesthetized with 30 to 50 mg/kg ketamine IM and 1 to 3 mg/kg xylazine IM. A standardized chemical burn was created by topical application of 52% hydrofluoric acid. The rats were divided into four treatment groups: group 1 received no treatment; group 2 received intradermal injection of 10% calcium gluconate; group 3 received 80 mg/kg MgSO4 IV; and group 4 received 160 mg/kg MgSO4 IV. After the rats were killed, the burn lesions were excised and examined by a pathologist to determine the grade of burn (which was equal to the clinical degree of burn). MEASUREMENTS AND MAIN RESULTS: Microscopic examination of the burns revealed differences among the four groups. Five of 13 group 1 rats (37%) died within 24 hours of burn initiation. Of group 1 survivors, 50% had grade 2 burns, and the other 50% had grade 3 burns. In group 2, eight of 11 rats (73%) had grade 3 burns. Twenty-five percent of group 3 rats (three of 12) had grade 3 burns, and only 9% of group 4 rats (one of 11) had grade 3 burns. Only the difference in the rates of grade 3 burns for groups 2 and 4 was statistically significant. Although not statistically significant, burns in groups 3 and 4 tended to be smaller in diameter than burns in groups 1 and 2. CONCLUSION: High-dose IV magnesium sulfate reduces the severity of hydrofluoric acid burn compared with conventional intradermal calcium gluconate therapy. Early deaths appeared to be prevented by both calcium and magnesium therapies.

Acute thermoregulatory disorders.

Symptoms and signs of impaired thermal homeostasis are protean. Clinical encounters with the geriatric patient, whether acute or chronic, are often marked by imprecise historical detail, ambiguous physical findings, differing laboratory values, and unexpected responses to therapeutic modalities. In addition, geriatric patients presenting with disorders of thermoregulation have a greater morbidity and mortality than other groups. This article briefly reviews thermoregulation as well as some of the causes and treatments for both hypothermia and hyperthermia.

Anaphylactoid reaction following ketorolac tromethamine administration.

OBJECTIVE: To report a case of an anaphylactoid reaction to injectable ketorolac tromethamine in a patient with no prior history of allergies or risk factors associated with nonsteroidal anti-inflammatory drug-induced hypersensitivity reactions. CASE SUMMARY: A 37-year-old man without a significant medical history presented to an emergency department with vague, dull, left-sided chest pain. Myocardial infarction was ruled out based on an unremarkable electrocardiogram, chest X-ray, and laboratory data that were within normal limits. Sublingual nitroglycerin 0.4 mg, magnesium/aluminum hydroxide gel 30 mL, and intravenous ranitidine 50 mg were administered without resolution of symptoms. Ketorolac tromethamine 60 mg was administered intramuscularly with resolution of symptoms. The patient was discharged; however, within 30 minutes, he returned to the emergency department with facial swelling, shortness of breath, and chest tightness. Multiple doses of aerosolized albuterol and intravenous methylprednisolone and diphenhydramine were administered, resulting in a slight improvement of symptoms. The patient was admitted for a complete cardiac evaluation that proved negative. The allergic symptoms resolved and the patient was discharged without medication after a three-day hospitalization. DISCUSSION: Ketorolac tromethamine is the first injectable nonsteroidal antiinflammatory drug approved for short-term pain management. A review of the literature revealed no similar cases of anaphylactoid reaction. CONCLUSIONS: Healthcare professionals must be aware of the potential risks of anaphylactoid reactions, especially in light of the increased use of injectable ketorolac in the ambulatory setting and availability of the oral formulation.

Container residue after activated charcoal administration in the emergency department.

We hypothesized that sources of activated charcoal (AC) used as a form of gut decontamination in the treatment of drug overdose may deliver significantly less charcoal than expected because of retained charcoal and sorbitol (ACS) from the treatment of 50 consecutive overdose patients were collected. Health care personnel delivering the dose were unaware of the study hypothesis. A total of 82 containers were obtained in this manner. Each container was labelled to contain 25 g AC and 48 g sorbitol. Five unused containers of ACS were obtained as controls. Each container was thoroughly cleaned, and the contents vacuum filtered and washed with 1 L of tap water. The tared filter paper and charcoal was dried for 24 h and weighed. The average amount of charcoal retained in each used container (retained) was 0.549 g (range 0.318-1.637 g). This accounts for 2.2% of the 25 g dose expected to be delivered. The average amount of charcoal found in each unused container (actual) was 25.892 g. The delivered dose (actual minus retained) may be calculated as 101.4% of the expected 25 g dose. When using this formulation of ACS there is no significant difference between the amount of charcoal given to an overdose patient and the amount ordered for gut decontamination. Despite the poor suspension of charcoal in sorbitol and the less than ideal conditions under which it is given, the patient receives an adequate dosage of AC if it is ordered.

Toxicology screening of the trauma patient: a changing profile.

STUDY OBJECTIVES: To determine the current ingestants found in the multiply injured trauma patient and to determine if this select group of ingestants affected the resuscitation, evaluation, or convalescent management of these patients. DESIGN: A one-year retrospective analysis was performed on all patients who were admitted to an urban trauma center with a discharge diagnosis of multiple trauma and who received a comprehensive toxicology screening test. MAIN RESULTS: One hundred twenty-seven of the 177 patients (72%) who fulfilled the criteria had positive toxicology screens. Ethyl alcohol was the only drug present in 26 of these patients (20%); 57 (45%) were positive for drugs other than ethyl alcohol. A combination of ethyl alcohol and at least one other drug was quantified in 44 patients (35%). The most often encountered substances were ethyl alcohol (55%), marijuana (24%), and cocaine (21%). Twelve drug screens (9%) demonstrated pharmaceuticals (eg, acetylsalicylic acid, acetaminophen, or cyclic antidepressants) that may require specific antidotal treatment. CONCLUSION: The ingestant profile found in this subgroup of trauma patients differed from those of previous studies. Although a select group of these ingestants requires specific treatment or affects the physical assessment of the patient, none of these trauma patients received more than supportive care.

China White epidemic: an eastern United States emergency department experience.

STUDY OBJECTIVE: The purpose of this study was to isolate significant clinical or demographic findings concerning overdose patients treated during a China White (3-methyl fentanyl) epidemic and compare them with data for all unintentional narcotic overdose patients during a 24-month period. DESIGN: We reviewed charts from 85,246 patient visits to our emergency department during the 24-month period of January 1987 through December 1988 to study this narcotic epidemic. Data from the Allegheny County Coroner's Office pertaining to unintentional drug overdose deaths that occurred during this same period also were reviewed. SETTING: The first outbreak of narcotic overdoses in the eastern United States involving China White occurred in Allegheny County, Pennsylvania, in 1988. TYPE OF PARTICIPANTS: Patients were included if they met the criteria of a suspected unintentional narcotic overdose, but excluded if they were not given naloxone. INTERVENTIONS: Emergency physicians became suspicious of China White use after an unusual increase in narcotic overdoses presenting to the ED coupled with "routine drug of abuse" screens negative for opiates despite dramatic patient responses to naloxone. In most of the cases in which specific testing was done, there were positive indicators of fentanyl derivatives. Investigations found China White present in street drugs and paraphernalia. MEASUREMENTS AND MAIN RESULTS: A cluster was defined as a time period with a statistically significant increase in overdoses over the expected number for an interval of equal length. Although there were no significant clinical differences in case presentation during the 24-month period, there was a statistically significant 13-fold increase in overdoses during the September through November 1988 cluster (mean, 13 vs 0.95 per month, P less than .001 by Wilcoxon rank-sum test). A dramatic increase in unintentional drug overdose deaths occurred in the county during this cluster. A total of 18 fentanyl-positive unintentional drug overdose deaths, predominantly male (89%) and black (56%), with an age range of 19 to 44 years (mean, 34.9 years), were reported by the county coroner (13 during the cluster). Narcotic overdoses and unintentional drug overdose deaths declined sharply with confiscation of a clandestine China White laboratory. CONCLUSIONS: China White was responsible for a dramatic rise in unintentional drug overdose deaths in Allegheny County in 1988. There were no significant clinical differences between China White overdose survivors and other unintentional narcotic overdose victims. Overdoses responsive to naloxone with inconsistent routine toxicologic screens may be due to a fentanyl analogue.

Flumazenil for the reversal of refractory benzodiazepine-induced shock.

Benzodiazepines are known to cause central nervous system and centrally mediated cardiovascular depression. The benzodiazepine antagonist flumazenil has been shown to antagonize benzodiazepine-induced central nervous system depression. We report a case in which cardiovascular depression secondary to benzodiazepine use was reversed by this agent.

Treated vs reported toxic exposures: discrepancies between a poison control center and a member hospital.

Statistics accumulated by Poison Control Centers (PCC) are routinely used on the local, regional and national levels by governmental agencies to set policy and direct funding. Incomplete reporting by member hospitals is recognized by PCC as a factor contributing to discrepancies in epidemiological estimates; however little emphasis is classically placed by the PCC on expanding reporting from member hospitals. A 1y retrospective review of patients with toxic exposure presenting to an urban Emergency Medicine Department (EMD) was performed to quantify the lack of concordance between treated and reported toxic exposures. 470 toxic exposures presented over the study period, of which only 123 (26%) were relayed to the regional PCC. Inhalation exposures were least likely to be referred for PCC consultation (3%); whereas PCC consultation was obtained for 33% venomous snake bite cases, and 95% of the cyclic antidepressant ingestions. Clusters of similar exposures resulted in fewer PCC consultations. Understanding each hospital's "profile" for handling toxic exposures, and individualized advertisement by the PCC to their member hospital may increase their data reporting. The statistical significance of their epidemiological studies as well as their revenue may increase.

Poison center utilization in nosocomial toxicologic exposures: a prospective study.

Accidental toxicologic exposures that occur within health care facilities (HCFs) have the potential to increase morbidity and mortality as well as enhance medicolegal liability. By contacting the poison center immediately on recognition of these events, health care providers may ultimately lessen eventual toxic effects through appropriate intervention. Exposures of this nature reported to the poison center over a 12-month period were collected and tabulated for specific occurrences. Six categories of therapeutic mis-adventure were delineated: 1. Right patient/wrong medication (18%); 2. Right patient, right medication/wrong dose or route (16%); 3. Lack of patient education (2%); 4. Proximity of potentially harmful substances to confused persons (54%); 5. Incorrect equipment management (6%); and 6. Pharmacologic treatment based on lab error (4%). This study seeks to increase awareness of poison center ability to assist in management of the "therapeutic misadventure".

Emergency department sonography by emergency physicians.

A retrospective study was conducted to examine whether emergency physicians can perform accurate ultrasonography that influences the diagnosis and treatment of selected disorders in the emergency department (ED). The physicians acquired a moderate level of expertise in sonography using a series of practical demonstrations and lectures. Patients with symptoms suggestive of cardiac, gynecologic, biliary tract, and abdominal vascular disease periodically underwent ED sonography. The initial interpretation was used as a diagnostic adjunct to subsequent therapy. The accuracy of positive sonographic findings was assessed by confirmatory testing, formal review, or confirmatory clinical course. Emergency physicians were able to diagnose correctly (1) the presence and approximate size of pericardial effusions, (2) the presence or absence of organized cardiac activity in patient with clinical electrical mechanical dissociation, (3) the presence or absence of intrauterine pregnancy in pregnant patients with lower abdominal/pelvic complaints, (4) the position of intrauterine devices in patients with suspected uterine perforation, (5) the presence of gallstones in patients with suspected biliary tract disease, and (6) the presence and size of abdominal aortic aneurysms in patients with pulsatile masses or unexplained abdominal pain. It was concluded that reliable sonography which influences diagnosis and therapy can be performed by emergency physicians and that sonography should become a standard procedure in EDs.

Poison center utilization in nosocomial toxicologic exposures: a prospective study.

Accidental toxicologic exposures that occur within health care facilities (HCF's) have the potential to increase morbidity and mortality, as well as enhance medicolegal liability. By contacting the poison center immediately on recognition of these events, health care providers may ultimately lessen eventual toxic effects through appropriate intervention. Exposures of this nature reported to the poison center over a twelve month period were collected and tabulated for specific occurrences. Six categories of therapeutic misadventure were delineated: Right patient/wrong medication (18%); Right patient, right medication/wrong dose or route (16%); Lack of patient education (2%); Proximity of potentially harmful substances to confused persons (54%); and Incorrect equipment management (4%). This study seeks to increase awareness of poison center ability to assist in management of the "therapeutic misadventure."