Edward A. Ramoska

A one-year evaluation of calcium channel blocker overdoses: Toxicity and treatment

STUDY OBJECTIVE To examine the cardiovascular toxicity of calcium channel blockers and the efficacy of various treatments. DESIGN Case series collected prospectively over one year. SETTING Three regional poison control centers. TYPE OF PARTICIPANTS One hundred thirty-nine hospitalized patients who had ingested a calcium channel blocker. INTERVENTIONS Calcium, dopamine, atropine, isoproterenol, glucagon, and pacemakers. MAIN RESULTS Hypotension, sinus node suppression, and dysrhythmias often occur with calcium channel blocker overdoses, but atrioventricular nodal block occurs more often with verapamil (chi 2 test, P < .025). Calcium was administered to 23 patients and was efficacious in reversing depression of cardiac conduction and increasing blood pressure. Dopamine was administered to ten patients and was efficacious in increasing blood pressure. Atropine was administered to eight patients, but only two had a positive response. CONCLUSION Atrioventricular nodal depression is more common with verapamil overdoses. Calcium and dopamine are useful in treating toxicity from calcium channel blocker overdose, whereas atropine is sometimes useful.

Bupropion overdose : a 3-year multi-center retrospective analysis

Bupropion (Wellbutrin; Burroughs Welcome Co, Research Triangle Park, NC) is a unique monocyclic antidepressant about which there is limited overdose information. A retrospective analysis of all bupropion ingestions reported to five regional poison control centers from 1989 through 1991 was conducted. There were 58 cases of bupropion ingestion and nine cases of combined bupropion and benzodiazepine ingestion. Sinus tachycardia was the only toxic cardiovascular effect noted, except for one case of hypotension in the bupropioin and benzodiazepine group. Neurological toxicity was commonly encountered and included lethargy, tremors, and seizures. Both benzodiazepines and phenytoin were efficacious in controlling seizures. Five cases of pure bupropion overdose had electrolytes reported. Serum potassium ranged from 2.6 to 4.2 mEq/L (mean, 3.3 mEq/L). In overdose, bupropion seems to lack major cardiovascular toxicity; however, it does manifest significant neurological toxicity.

Propranolol-induced hypertension in treatment of cocaine intoxication

The case of a patient with apparent cocaine toxicity and drug-mediated hypertension and tachycardia is presented. IV propranolol was used as the initial treatment for his hyperadrenergic state, resulting in a decrease in heart rate but a paroxsymal increase in blood pressure. The patient required nitroprusside for control of elevated blood pressure. A mechanism of unopposed alpha stimulation as a result of beta-2 receptor blockade is proposed, and a cautious approach to the use of propranolol in these patients is suggested.

Effect of ED management on ICU use in acute pulmonary edema

Acute pulmonary edema (APE) is a common Emergency Department (ED) presentation requiring admission to an intensive care unit (ICU). This study was undertaken to examine the effect of ED management on the need for ICU admission in patients with APE. ED records of APE patients were abstracted for patient age, prehospital and ED pharmacological treatment, diagnoses, airway interventions, and ICU length of stay (LOS). Statistical analysis was through multiple regression, logistic regression, chi-square, and ANOVA. One hundred eighty-one patients composed the study group. Pharmacological treatment included nitroglycerin (NTG), 147 patients (81%); morphine sulfate (MS), 88 (49%); loop diuretics (LD), 133 (73%); and captopril sublingual (CSL), 47 (26%). Use of CSL and MS were associated with opposing needs for ICU admission. MS use was associated with increased ICU admissions (odds ratio, 3.08; P = .002), whereas CSL use was associated with decreased ICU admissions (odds ratio, 0.29; P = .002). Morphine sulfate use also demonstrated an increased need for endotracheal intubation (ETI) (odds ratio, 5.04; P = .001), whereas CSL demonstrated a decreased need for ETI (odds ratio, 0.16; P = .008). Ninety-three patients required some form of respiratory support. Forty received noninvasive pressure support ventilation (NPSV) from a bilevel positive airway pressure system (BiPAP), and 60 received endotracheal intubation. Some patients received more than 1 form of respiratory support; all other patients received supplemental oxygen only. The ICU-LOS associated with different airway interventions were supplemental oxygen, 0.72 days; BiPAP, 1.48 days; and ETI, 3.70 days (P < .001). Specific ED pharmacological interventions are associated with a decreased need for ICU admission and endotracheal intubation in acute pulmonary edema patients, whereas use of noninvasive pressure support ventilation correlates with a reduction in the ICU length of stay for patients who do require critical care admission.

Reliability of patient history in determining the possibility of pregnancy

In an effort to assess the reliability of patient history in excluding pregnancy, we studied the correlation between specific historical factors and the presence of a positive qualitative serum beta-human chorionic gonadotropin assay. Two hundred eight patients were studied, and information was collected prospectively on a variety of historical criteria. Three historical variables were statistically less likely to be associated with pregnancy: last menstrual period that was on time, the patient thinking she was not pregnant, and the patient stating there was no chance she could be pregnant (P less than .001). There was, however, still at least a 10% chance of the patient being pregnant. Combinations of historical criteria were likewise unsuccessful at totally excluding pregnancy. These data support the contention that patient history is an unreliable method of excluding pregnancy in emergency department patients and supports the liberal use of pregnancy tests.

Midazolam use in the emergency department

Midazolam is a new imidazobenzodiazepine derivative that is two to three times as potent as diazepam, is water-soluble, has a rapid onset and short duration of action, and produces a profound amnestic effect. These properties make it an extremely useful drug for outpatient sedation. We performed retrospective review of midazolam use in a general emergency department over a one-year period. Midazolam was used in 120 patients, 71 men and 49 women, with an average age of 46 years. The average dose given was 3.4 mg, with a range of 1 to 10 mg. In 69 of the cases (57%) other drugs were administered, most commonly an opiate. There were only four adverse reactions. One patient developed urinary retention, one patient vomited, and two patients were somnolent for a prolonged period of time. There were no serious cardiovascular or respiratory problems. We conclude that midazolam is a safe drug to use in the emergency department. Close monitoring of the patient and the availability of airway support equipment are mandatory.

Propranolol treatment of albuterol poisoning in two asthmatic patients

The cases of two asthmatic adolescents who overdosed on albuterol are presented. Both patients were tremulous, tachycardic, and hypokalemic. Both were treated successfully with IV propranolol. Neither patient developed bronchospasm. The toxicity of albuterol overdoses and its treatment are discussed.

Credentialing of emergency physicians: Support for delineation of privileges in invasive procedures

The American College of Emergency Physicians states in its “Guidelines for Delineation of Clinical Privileges in Emergency Medicine” that a qualified emergency physician “performs such definitive treatment as falls within the physician’s competence.“’ The exact definition as to what treatments or procedures an emergency physician is competent to perform, though, remains nebulous. The resuscitation and stabilization of critical patients is one of the hallmarks of the emergency physician; yet in many institutions emergency physicians are granted very restricted clinical privileges. New emergency physicians or even entire groups of physicians may meet severe resistance from the hospital staff when requesting privileges for invasive procedures. Personal experience has shown this problem of credentialing to be most evident in institutions in which the style of emergency medicine changes abruptly from passive to active with the introduction of newer career emergency physicians. Why emergency physicians should undergo a different credentialing process from the remainder of the medical staff is unclear. Other generalists or specialists need only cite their completion of a residency or special course to be granted specific privileges, whereas emergency physicians may have to petition specific department chairmen for permission to perform invasive procedures. In other situations emer-

Acute digoxin overdose: Use of digoxin-specific antibody fragments

An acute ingestion of 6 to 7 mg digoxin as a suicidal gesture in a 76-year-old man with chronic heart disease is presented. The patient arrived in the emergency department approximately 5 hours after ingestion with a normal serum potassium and increasing numbers of multifocal premature ventricular contractions. Digoxin-specific antibody fragments were administered. The patient developed ventricular tachycardia and ventricular fibrillation and was eventually stabilized 35 minutes after the Fab fragments were infused. A review of the pharmacology and indications for use of digoxin-immune Fab fragments is also presented.

Initial management of adolescent overdoses

A retrospective study of pediatric patients presenting to a community hospital emergency department with acute intentional toxidromes was conducted. The characteristics of these patients and their initial medical management were reviewed. Forty-six patients were included in this study with 35 recreational overdoses and 11 suicide attempts or gestures. The mean age of these patients was 15.8 (range 10 to 18 years). The most commonly abused substance was ethanol, followed in frequency by benzodiazepines and barbiturates. Initial management centered on active airway management, gastrointestinal decontamination, and extended observation. Ten patients were intubated, lavaged, extubated, and subsequently discharged from the emergency department. Only one patient required hospital admission. The value of toxicologic screens, emergency department endotracheal intubations, gastric lavage, and charcoal/cathartic therapy is discussed