Haloperidol, a Novel Treatment for Cannabinoid Hyperemesis Syndrome.

Cannabinoid hyperemesis syndrome (CHS) is typically unresponsive to conventional pharmacologic antiemetics, and patients often require excessive laboratory and radiographic testing and hospital admission. We report 4 cases of CHS that failed standard emergency department therapy but improved significantly after treatment with haloperidol. Although the exact mechanism for CHS remains unclear, dysregulation at cannabinoid type 1 seems to play a role. Recent animal data demonstrate complex interactions between dopamine and cannabinoid type 1 signaling, a potential mechanism for haloperidol success in patients with CHS. Our success with haloperidol in these 4 patients warrants further investigation of haloperidol as an emergency department treatment for CHS.

Old drug new trick: levamisole-adulterated cocaine causing acute kidney injury.

Levamisole is an agent previously used in humans and later withdrawn from the US drug market due to concerns of agranulocytosis.It is currently used as an adulterating agent in cocaine, bringing to light toxicities typically manifested by vasculitis and skin necrosis.We report a case of a 36-year-old crack cocaine user who presented with a purpuric rash on her face and limbs. Levamisole-induced vasculitis was suspected, and she therefore underwent an extensive work-up. In addition to these findings, she also presented with acute kidney injury of unknown etiology, which was later attributed to levamisoleadulterated cocaine.

Haloperidol for treatment of cannabinoid hyperemesis syndrome.

Cannabinoid hyperemesis syndrome (CHS) is a condition characterized by cyclical vomiting without other identifiable cause in patients with chronic cannabis use. Patients with CHS report that compulsive bathing and hot showers are the only reliable treatments to improve symptoms. Cannabinoid hyperemesis syndrome is usually unresponsive to conventional pharmacologic antiemetics, and patients often require hospital admission. We report a case of CHS that improved significantly after treatment with haloperidol in the emergency department.

Single-dose ziprasidone associated with QT interval prolongation.

Ziprasidone has been rarely associated with QT prolongation especially in patients (1) with no underlying cardiac or metabolic disorders, (2) who are receiving no concomitant medications known to prolong the QT interval, and (3) whom therapy is being initiated at a low dose. We report a 47-year-old patient who was agitated with suicidal ideation. He had a history of cocaine use, the last time being 72 hours before emergency department (ED) presentation. His electrocardiogram (ECG) on arrival in the ED showed a QT of 484 milliseconds and a QTc of 475 milliseconds with a pulse of 58 beats per minute. The patient was given 20 mg intramuscular (IM) ziprasidone for agitation. He reported feeling palpitations and weakness 45 minutes after receiving ziprasidone. His QT interval was prolonged on ECG and returned to baseline after 72 hours. Clinicians should consider obtaining an ECG before ziprasidone administration.

Strategies for implementing emergency department pharmacy services: results from the 2007 ASHP Patient Care Impact Program.

PURPOSE: Strategies proposed during a patient care impact program for implementing emergency department (ED) pharmacy services are described. SUMMARY: In June 2007, the American Society of Health-System Pharmacists developed a patient care impact program entitled "Introducing an Emergency Department Pharmacist into Your Institution" to provide experiential training to practicing pharmacists seeking to establish ED services in their institutions. Under the guidance of four mentors, 19 pharmacists from a variety of practice settings, including community-based hospitals and academic and tertiary-care-based institutions, were selected for participation the six-month program. Participants were divided into two groups, and each group was assigned two mentors. During their initial meeting, participants identified anticipated challenges to implementation of pharmacy services in the ED and began to define strategies with their mentors for effectively managing the anticipated challenges. Each group participated in one-hour monthly teleconferences with their mentors. In addition to monthly teleconferences, participants regularly contacted their mentors for additional assistance and several visited their mentors' institutions. Participants developed job descriptions for an ED pharmacist, developed a rationale and justification for implementing pharmacy services in the ED, obtained approval and support from appropriate parties for the ED pharmacist's role, developed plans for introducing a pharmacist to the ED, and developed quality-assurance methods to monitor the effectiveness of the pharmacist's role. CONCLUSION: Despite the diversity in practice settings, participants of the program faced similar challenges in implementing ED pharmacy services at their institutions. Various strategies toward solutions to these challenges were shared among participants and mentors.

Computerized physician order entry- based hyperglycemia inpatient protocol and glycemic outcomes: The CPOE-HIP study.

OBJECTIVE: To evaluate the impact of implementing a computerized physician order entry (CPOE)-based hyperglycemia inpatient protocol (HIP) on glycemic outcomes. METHODS: This retrospective, cross-sectional study compared blood glucose values, hemoglobin A(1c) values, diabetes medication profles, and demographic data of diabetic patients admitted to medicine services between March 15, 2006, and April 11, 2006 (before CPOE-HIP protocol was adopted), with data of diabetic patients admitted between October 3, 2007, and October 30, 2007 (1 year after CPOE-HIP protocol was implemented). RESULTS: A total of 241 diabetic patients comprised the pre-CPOE-HIP group and 197 patients comprised the post-CPOE-HIP group. After the protocol was adopted, there was a decrease of 10.8 mg/dL in the mean glucose concentration per patient-day (175.5 +/- 81.2 mg/dL vs 164.7 +/- 82 mg/dL, P<.001). Additional glycemic control improvements included a 5% increase in patient-days with serum glucose concentrations between 70 and 150 mg/dL (41.1% vs 46.1%, P = .008) and a 3.1% decrease in patient-days with glucose concentrations above 299 mg/dL (16.9% vs 13.8%, P = .023). The percentage of patient-days with glucose concentrations less than or equal to 50 mg/dL was not significantly different (0.95% vs 1.27%,P = .15). Compliance with the American Diabetes Association recommendation for hemoglobin A1c inpatient testing frequency increased from 37.3% to 64.5% (P<.001). The length of stay did not differ between the groups. CONCLUSIONS: Implementation of a hospital-wide, CPOE-based, hyperglycemia management protocol had a favorable impact on glucose targets, decreasing excessively high glucose levels without increasing clinically meaningful hypoglycemic events. Compliance with hemoglobin A(1c) testing recommendations also improved.