Adam K. Rowden

CT pulmonary angiography utilization in the emergency department: diagnostic yield and adherence to current guidelines.

The aim is to investigate the patterns of computed tomography pulmonary angiography (CTPA) use and adherence to current guidelines. Medical records of patients investigated with CTPA for pulmonary embolism (PE) in a single academic hospital from January 2011 until December 2012 were reviewed. Wells scores were calculated retrospectively by researchers blinded to the results of the CTPA. “Avoidable imaging” was defined as imaging performed against current recommendations of the European Society of Cardiology or the PIOPED investigation group. A total of 646 patients underwent testing; 61 cases of PE were diagnosed (9.4%). Potentially avoidable imaging was performed in 49.5% and 71.5% of patients, depending on the criteria used; 11.5% of imaging studies were performed in low-risk patients with negative D-dimer assays. There is evidence of CTPA overuse and D-dimer underuse. Adherence to guidelines and appropriate use of D-dimer assay might reduce avoidable imaging and ionizing radiation exposure.

Incidental Findings on Computed Tomography Angiography in Patients Evaluated for Pulmonary Embolism

RATIONALE To investigate how often computed tomography (CT) pulmonary angiography contributes to establishing a diagnosis in patients presenting to the emergency department and how it performs compared to chest radiograph. OBJECTIVES The objective of this study was to measure the ability to identify a diagnosis and to investigate the prevalence and significance of incidental findings in patients evaluated with computed tomography pulmonary angiography in the emergency department. METHODS All adult patients evaluated with CT angiography over a 2-year period (January 1, 2011 to December 31, 2012) were included in the analysis. A total of 641 records were identified. Chest radiographs and CT angiography reports were reviewed to determine whether they could provide a diagnosis in patients without pulmonary embolism (PE). Studies negative for PE were stratified into three categories according to significance: type I prompted immediate action, type II required follow up, and type III had findings of limited significance. MEASUREMENTS AND MAIN RESULTS CT angiography identified a diagnosis in 22.46% of the patient population and in 14.31% of patients without PE. In patients who had CT angiography with chest radiograph, diagnoses were provided in 14.01 and 9.86% of patients, respectively. When analysis was isolated to patients with low probability for PE, CT angiography provided a diagnosis in 20% and chest radiography in 10.23% of patients. The majority of missed cases represented infiltrates too small to be detected by radiography and were believed to represent lung infections by the interpreting radiologist. Among studies negative for PE, 15% were type I, 17.07% were type II, 48.1% were type III, and the rest were normal. CONCLUSIONS CT angiography is superior to chest radiography at providing a diagnosis in patients investigated for PE, even when no PE is present. However, in patients at low risk for PE, the clinical benefit of the additional diagnoses is questionable.

Pediatric Ziprasidone Overdose

We describe the first ziprasidone overdose with quantitative serum levels of a pediatric patient in coma and with pinpoint pupils. This case is an important contribution to the pediatric ziprasidone literature because it illustrates that ingestion of just 1 pill may result to profound mental status and respiratory depression in a child. H.C., a 30-month-old girl, presented to the emergency department approximately 30 minutes after an accidental ingestion of an adult family members medication. The child was found on the floor surrounded by numerous pills and was witnessed to have ingested at least 1 tablet by a caregiver. After finding the child with the pills, the family observed the child for a brief period but transported her to the hospital after she became lethargic and unresponsive. The child received 2 doses of 0.4 mg of intravenous naloxone without change in her neurologic status. The child then underwent a rapid sequence intubation for airway protection and subsequently received gastrointestinal decontamination with 15 g of activated charcoal via the orogastric tube. Ziprasidone is an atypical antipsychotic drug that was approved by the Food and Drug Administration in February 2001 for the general treatment of schizophrenia in adults. Previously reported pediatric ziprasidone overdoses describe a syndrome of sedation, tachycardia, hypotonia, and coma consistent with that of the patient described in this paper. In pediatric ziprasidone overdose, QTc prolongation and hypotension have also been illustrated, but seizures have not been reported. An interesting aspect of this case is the development of pinpoint pupils unresponsive to naloxone. This phenomenon has been reported before with overdose of olanzapine, a similar atypical antipsychotic. The mechanism of miosis associated with overdose of atypical antipsychotics is unclear but is likely related to interference with central innervation of the pupil. Pupil size is maintained by a balance between sympathetic and parasympathetic neurohumeral tones. We propose that an overdose of an alpha-1 receptor blocking agent, such as ziprasidone, results in unopposed parasympathetic stimulation resulting in miosis.

Case Series of Overdosed Patients Managed in an Observation Unit

Background: Observation units (OU) are an increasing aspect of hospitals in the United States. OU provide more efficient use of resources in an increasingly taxed healthcare system. The majority of poisoned patients’ medical issues resolve within 24 hours, making them ideal candidates for an OU. The purpose of this study was to examine the types and safety of overdoses placed in our OU at Einstein Medical Center Philadelphia, an urban, level one trauma center with 100,000 emergency department (ED) visits annually in Philadelphia, Pennsylvania. We hypothesized that the majority of patients admitted to the OU do not require further medical intervention or upgrading to a higher level of care. Methods: The study is a retrospective chart review of patients with ICD-9 codes associated with overdose or poisoning admitted to our OU between 7/1/10 and 12/31/12. A total of 137 patients were identified, 112 were included. Exclusions were: admission to the hospital prior to transfer to OU (17); transfer to psychiatry (4); miscoded (2); and seen at another site (2). Research associates, reviewed medical charts using a structured data collection form to record disposition, age, gender, etnicity, ingested substances, mental status, medical interventions and any upgrades in disposition. Results: Between 7/1/10 and 12/31/12 there were 112 patients admitted to the OU. Patient’s age ranged from 17 to 76 years old (mean 38), with 46 males (41%) and 66 females (59%). Ethnicity was mostly African American 73 (65%). A total of 230 different substances were recorded with 61 (26.5%) patients taking more than one intoxicant. The most common overdoses were sedative- hypnotics 66 (28.7%) and antipsychotics 22 (9.6%). Initial OU mental status recorded was: alert and oriented to person, place and time 60 (54%); 46 (41%) sedated, and 6 (5%) confused. The most common medical interventions in the ED were sedatives 18 (16%) and naloxone 12 (10.7%). The most common medical interventions in the OU were: sedatives 24 (21.4%); oxygen 10 (8.9%); and naloxone 5 (4.5%). No intubations or cardiac arrests occurred in the ED or OU. No patients were upgraded to a higher level of care. Seven patients were transferred to psychiatry. Conclusions: The disposition of stable patients to an OU who present to the ED after overdoses appears to be safe. Understanding the types of overdoses that are safe to be managed in an OU can assist in disposition, patient flow, use of resources, and provide appropriate level of care.

Unrecognized Hypoxia and Respiratory Depression in Emergency Department Patients Sedated For Psychomotor Agitation: Pilot Study

Introduction The incidence of respiratory depression in patients who are chemically sedated in the emergency department (ED) is not well understood. As the drugs used for chemical restraint are respiratory depressants, improving respiratory monitoring practice in the ED may be warranted. The objective of this study is to describe the incidence of respiratory depression in patients chemically sedated for violent behavior and psychomotor agitation in the ED. Methods Adult patients who met eligibility criteria with psychomotor agitation and violent behavior who were chemically sedated were eligible. SpO2 and ETCO2 (end-tidal CO2) was recorded and saved every 5 seconds. Demographic data, history of drug or alcohol abuse, medical and psychiatric history, HR and BP every 5 minutes, any physician intervention for hypoxia or respiratory depression, or adverse events were also recorded. We defined respiratory depression as an ETCO2 of ≥50 mmHg, a change of 10% above or below baseline, or a loss of waveform for ≥15 seconds. Hypoxia was defined as a SpO2 of ≤93% for ≥15 seconds. Results We enrolled 59 patients, and excluded 9 because of ≥35% data loss. Twenty-eight (28/50) patients developed respiratory depression at least once during their chemical restraint (56%, 95% CI 42–69%); the median number of events was 2 (range 1–6). Twenty-one (21/50) patients had at least one hypoxic event during their chemical restraint (42%, 95% CI 29–55%); the median number of events was 2 (range 1–5). Nineteen (19/21) (90%, 95% CI 71–97%) of the patients that developed hypoxia had a corresponding ETCO2 change. Fifteen (15/19) (79%, 95% CI 56–91%) patients who became hypoxic met criteria for respiratory depression before the onset of hypoxia. The sensitivity of ETCO2 to predict the onset of a hypoxic event was 90.48% (95% CI: 68–98%) and specificity 69% (95% CI: 49–84%). Five patients received respiratory interventions from the healthcare team to improve respiration [Airway repositioning: (2), Verbal stimulation: (3)]. Thirty-seven patients had a history of concurrent drug or alcohol abuse and 24 had a concurrent psychiatric history. None of these patients had a major adverse event. Conclusion About half of the patients in this study exhibited respiratory depression. Many of these patients went on to have a hypoxic event, and most of the incidences of hypoxia were preceded by respiratory depression. Few of these events were recognized by their treating physicians.

Successful treatment of repaglinide-induced hypoglycemia with octreotide

We present a case of an 82-year-old African American male who presented to the ED with rapaglinide-induced hypoglycemia who was successfully treated with the administration of subcutaneous octreotide. Repaglinide is an oral agent for the treatment of type 2 diabetes. It is a representative of meglitinide class of medications—a relatively new therapeutic option for physicians to treat type 2 diabetes of which only Prandin repaglinide and Starlix natglinide are available in the United States. Numerous case reports and a recently published prospective trial have demonstrated the clinical benefit of octreotide for the treatment of hypoglycemia from both acute and chronic sulfonylurea toxicity. Meglitinides and sulfonylureas have a similar mechanism of action; therefore, octreotide has been advocated as a potential treatment of meglitinide-associated hypoglycemia and has been used after natglinide-associated hypoglycemia. To our knowledge, we report the first use of octreotide in repaglinide-associated hypoglycemia. JG is an 82-year-old African American male who presented to the emergency department (ED) via emergency medical services with a chief complaint of dizziness and confusion for 20-minute duration before his arrival. Emergency medical services reported bedside glucose determination of 56 mg/dL, which was subsequently treated with 1 ampule of 50% intravenous dextrose with complete resolution of his symptoms. Presenting vital signs were as follows: blood pressure, 142/80; heart rate, 80/min; respiratory rate, 16/min; and temperature, 37.4°C. The patients physical examination was unremarkable. He had a normal mental status and a nonfocal neurologic examination. He denied recent alcohol or illicit drug use and claimed to be taking all of his medications as prescribed by his primary care physician. He had no change in his meal habits, denied fever or vomiting, and intentional ingestion. The remainder of the review of systems was negative. The patients medications were confirmed via the patents pharmacy, and a consultation was made with the staff medical toxicologist at our institution and with time it was 0735-6757/

Radiopacity of ingested transdermal medicinal patches: a simulated human model.

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Emergency management of oral hypoglycemic drug toxicity.

Division of Medical Toxicology, Department of Emergency Medicine, Albert Einstein Medical Center, Philadelphia, PA 19141, USA Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine & University of Virginia Health System, Charlottesville, VA 22908, USA Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC 27834, USA