Anthony M. Burda

Cocaine: History, Social Implications, and Toxicity—A Review

The amount of positive cocaine results in an urban emergency department are staggering. The ages of use are becoming more common in older age groups. Most of these patients have underlying medical conditions, including end-stage renal disease (on hemodialysis) and heart and lung disease. Most of their visits to the emergency department are for cocaine exacerbation of underlying chronic condition, adding exponentially to health care dollars. This article describes the history and pharmacology of illicit cocaine use.

Use of subcutaneous terbutaline to reverse peripheral ischemia

Four cases are presented, one involving extravasation of a dopamine and dobutamine solution in the arm and three involving accidental digital injection of epinephrine into the thumb. In three cases, local infiltration of terbutaline resulted in dramatic reversal of vasospasm and ischemia. In the remaining case the use of terbutaline resulted in minor clinical improvement. These are the first reported cases involving the successful treatment of peripheral ischemia with subcutaneous terbutaline. This experience suggests that terbutaline may be an effective alternative for treatment of peripheral ischemia when phentolamine is not available.

Methylene chloride: Report of five exposures and two deaths

Five patients presented to the emergency department (ED) following exposure in an enclosed space to methylene chloride (dichloromethane), used for removing paint. Two workers and three rescuers were involved. Two rescuers complained only of dizziness and mild nausea, and were subsequently discharged from the ED. One rescuer was asymptomatic. Worker no. 1 arrived in cardiac arrest and eventually died in the ED despite resuscitation efforts. Worker no. 2 also presented to the ED in cardiac arrest, and was successfully resuscitated to pulse and blood pressure. However, he never regained consciousness or spontaneous respirations, and died on the fourth day. Of interest is that worker no. 2s carboxyhemoglobin level increased from 2% to 8% over the 9 hours following admission, despite administration of 40% to 50% oxygen by endotracheal tube. Among the conclusions that can be drawn are (1) the cause of death in these patients was not carbon monoxide poisoning, but solvent-induced narcosis; (2) carboxyhemoglobin levels may continue to rise following cessation of exposure, despite administration of high flow oxygen; (3) rescuers can easily become victims if proper protective clothing and respirators are not worn.

Street Drugs Possibly Tainted With Clenbuterol

A30-year-old man presented to a suburban emergency department with complaints of tachycardia, tachypnea, palpitations, and anxiety. He stated he may have “gotten some bad heroin.” That evening he admitted to abusing heroin and cocaine with his family. Immediately after exposure they all felt that something was wrong. The patient did not have any respiratory depression and did not require naloxone. The patient was awake, alert, and afebrile. His vital signs were: heart rate, 113 beats per minute; blood pressure, 100/60 mmHg; and oxygen saturation, 98% on room air. The initial blood glucose level was 300 mg/dL. Reported chemistries were: sodium, 141 mEq/L; potassium, 2.9 mEq/L; chloride, 107 mEq/L; bicarbonate, 23 mEq/L; blood urea nitrogen, 17 mg/dL; serum creatinine, 1.1 mg/dL; blood glucose, 165 mg/dL; and anion gap, 13. His arterial blood gas values were: pH, 7.39; PCO2, 37 mmHg; and PO2, 81 mmHg. His troponin level was 0.44 ng/mL. The Illinois Poison Center has received at least 7 calls regarding patients treated in the emergency department who had reportedly abused heroin who did not exhibit typical signs and symptoms consistent with an opiate intoxication. These patients presented with atypical symptoms of tachycardia, palpitations, and hypokalemia, and they did not demonstrate classic opiate symptoms such as central nervous system and respiratory depression, miosis, or bradycardia. Additionally, none of these patients required the use of naloxone (Narcan), a specific antagonist for opiate toxicity. The causative agent in 2 cases was identified as clenbuterol through specialized urine drug tests. The other patients who fit the toxidrome profile did not have confirmatory tests performed.

Pharmacy Preparedness for Incidents Involving Nuclear, Biological, or Chemical Weapons

Recent worldwide terrorist attacks and hoaxes have heightened awareness that more incidents involving weapons of mass destruction (WMD) may occur in the United States. With federal funding assistance, local domestic preparedness programs have been initiated to train and equip emergency services and emergency department personnel in the management of large numbers of casualties exposed to nuclear, biological, or chemical (NBC) agents. Hospital pharmacies will be required to provide antidotes, antibiotics, antitoxins, and other pharmaceuticals in large amounts and/or have the capability for prompt procurement. Pharmacists should become knowledgeable in drug therapy of NBC threats with respect to nerve agents, cyanide, pulmonary irritants, radio-nucleotides, anthrax, botulism, and other possible WMD.

Silibinin for cyclopeptide mushroom poisonings

Much has been published in emergency medicine and clinical toxicology literature regarding mushroom poisoning management. However, few articles in pharmacy publications have addressed the management of such emergencies. Interestingly, a recently published comprehensive practical review of 37

Discontinuation of 5% alcohol in 5% dextrose injection: Implications for antidote stocking

In 2005, The Illinois Poison Center reported the lack of availability of 10% alcohol in 5% dextrose injection.[1][1] The center wishes to inform health-system pharmacists of the discontinuation of 5% alcohol in 5% dextrose injection. The only manufacturer of this product (Hospira) stopped producing

Pharmacy Preparedness for Incidents Involving Weapons of Mass Destruction

Recent worldwide terrorist acts and hoaxes have heightened awareness that incidents involving weapons of mass destruction (WMD) may occur in the United States. With federal funding assistance, local domestic preparedness programs have been initiated to train and equip emergency services and emergency department personnel in the management of large numbers of casualties exposed to nuclear, biological, or chemical (NBC) agents. Hospital pharmacies will be required to provide antidotes, antibiotics, antitoxins, and other pharmaceuticals in large amounts and/or have the capability for prompt procurement. Pharmacists should become knowledgeable in drug therapy of NBC threats with respect to nerve agents, cyanide, pulmonary irritants, radionucleotides, anthrax, botulism, and other possible WMD.

Taking a Stand against Accidental Childhood Poisoning: The Founding of the Nation's First Poison Control Center in Chicago

Prior to the 1950s, there existed no formal system for poison prevention or treatment in the United States. Estimates place the number of pediatric poisoning fatalities at over 400 per year at that time. After World War II, urbanization and modern technological methods brought forth over 250,000 different brand name products on the market. Health care professionals presented with cases of acute poisoning usually had little knowledge of what ingredients were contained in these new products making it difficult, if not impossible, to treat these patients. In the 1930s, decades before the creation of the Chicago Poisoning Control Program, pharmacist Louis Gdalman had already established a poison information service at St. Lukes Hospital. Because of Mr. Gdalmans training in pharmacy and chemistry, physicians throughout the city of Chicago and from around the United States called on him around the clock in search of his assistance. In the late 1940s, Mr. Gdalman began recording information on small cards and developed a standard data collection form. By the 1950s he had established an extensive library on the management of acute and chronic poisoning. The first poison control center in Chicago was described as nothing more than a desk, chair, and a telephone located in the inpatient pharmacy. Reluctance by hospital administrators to designate space, resources, and funds were problems confronted by the first poison control center. Poison centers of the 1990s still experience these same difficulties.