Kevin S. Merigian

Prospective evaluation of gastric emptying in the self-poisoned patient

The authors prospectively studied the effect of gastric emptying (GE) and activated charcoal (AC) upon clinical outcome in acutely self-poisoned patients. Presumed overdose patients (n = 808) were treated using an alternate day protocol based on a 10-question cognitive function examination and presenting vital sign parameters. Asymptomatic patients (n = 451) did not receive GE. AC was administered to asymptomatic patients only on even days. GE in the remaining symptomatic patients (n = 357) was performed only on even days. On emptying days, alert patients had ipecac-induced emesis while obtunded patients received gastric lavage. AC therapy followed gastric emptying. On nonemptying days, symptomatic patients were treated only with AC. No clinical deterioration occurred in the asymptomatic patients treated without GE. AC use did not alter outcome measures in asymptomatic patients. GE procedures in symptomatic patients did not significantly alter the length of stay in the emergency department, mean length of time intubated, or mean length of stay in the intensive care unit. Gastric lavage was associated with a higher prevalence of medical intensive care unit admissions (P = .0001) and aspiration pneumonia (P = .0001). The data support the management of selected acute overdose patients without GE and fail to show a benefit from AC in asymptomatic overdose patients.

A comparison of blind nasotracheal and succinylcholine-assisted intubation in the poisoned patient

In the patient obtunded by drug intoxication, the optimal method of airway protection prior to gastric emptying is not clear. We report a prospective randomized trial of two methods of intubation in this patient population. Fifty-two overdose patients with Glascow Coma Scale scores of 12 or less were intubated either orotracheally after succinylcholine administration or nasotracheally. Success rate, time to intubate, difficulty, and complications of intubation were compared for the two groups. We found a success rate of 100% (23 of 23) for succinylcholine assisted intubation (SAI) versus 65% (19 of 29) success with blind nasotracheal intubation (BNI). Mean time to intubate was 64 seconds and 276 seconds in the SAI and BNI groups, respectively. Eighty-six percent (19 of 22) of patients were intubated successfully in less than 120 seconds in the SAI group versus 37% (10 of 27) in the BNI group (P less than .005). In the SAI group, the mean number of attempts was 1.3 per patient, (range, one to three) with 96% (22 of 23) having two or fewer attempts. No complications were identified. In the BNI group, the mean number of attempts was 3.7 per patient, (range, one to 13) with 45% (13 of 29) having two or fewer attempts (P less than .005). Sixty-nine percent of the BNI group experienced epistaxis, 17% had vomiting, and 10% aspirated. We conclude that SAI is a safe and effective method of airway protection in the obtunded poisoned patient. Complications and difficulty in intubation were significantly less with SAI than with blind nasotracheal intubation.

Foreign Body Ingestions in the Emergency Department: Case Reports and Review of Treatment

We report a series of alleged ingestions of razor blades and other metal objects by prisoners presenting to an inner city Emergency Department. Fourteen claims of ingestions of razor blades or other metal objects involving eight prisoners occurred in a 5-week period. The motives behind the ingestions varied. Auditory hallucination was the most common reason given for the ingestions. Other motives included efforts to leave prison, depression, and accidental razor blade swallowing. Attempts were made in all patients to verify ingestions by radiograph. Some ingestions could not be confirmed by radiograph and were considered to be factitious. Only 1 of the 14 incidents resulted in hospital admission. All others were either treated in the Emergency Department or the patient was returned to jail with no treatment. No patient had a poor clinical outcome as a result of the ingestion, indicating that diagnostic radiographs and invasive procedures may not always be necessary. A review of treatment of foreign body ingestions is given as well as a summary of the treatment and outcome of these cases.

Single-dose oral activated charcoal in the treatment of the self-poisoned patient: a prospective, randomized, controlled trial.

Oral activated charcoal (OAC) is a universally accepted treatment of the overdose patient. Although the benefits of OAC have been suggested, there are no conclusive clinical data indicating that OAC affects outcome in overdose patients. This study was a prospective, randomized, controlled trial to determine the effects of OAC treatment in the self-poisoned adult patient. Adult patients presenting to the emergency department (ED) with a history of oral overdose were assigned to treatment with OAC (50 g) or supportive care only on an even-odd day protocol. Patients did not undergo gastric evacuation procedures in the ED. The outcome measures were clinical deterioration, length of stay in the ED or hospital, and complication rate. Over a 24-month period, 1479 patients were entered into the study. There were no significant differences in outcome parameters between the OAC treatment group and controls when comparing the length of intubation time, length of hospital stay, and the complication rates associated with the overdose. There was a higher incidence of vomiting and longer length of ED stay associated with OAC treatment. The results of this study indicated that oral drug overdose patients do not require gastric evacuation or charcoal administration. OAC provided no additional benefit to supportive care alone, was associated with a higher incidence of vomiting and a longer length of ED stay, and did not improve clinical outcome.

Envenomation from the brown recluse spider: review of mechanism and treatment options.

The brown recluse spider is commonly found throughout the midsouth region of the United States. Bites from the brown recluse occur when the spider is trapped in clothing or its nest is otherwise disturbed. The bite may be undetected by the patient until hours or days later when a characteristic lesion develops. Mild reactions to envenomation are usually limited to a lesion only. In some cases, a severe reaction results which can be life-threatening. Although there have been case reports of various pharmacological agents used for the treatment of brown recluse bites, none have been shown to be consistently effective. Therapy for brown recluse bites remains centered around aggressive wound care. Early surgical excision has not been shown to be of benefit and in most cases delays healing. This review focuses on the physiological mechanisms of the brown recluse venom and current treatment options.

Plasma Catecholamine Levels In Cyclic Antidepressant Overdose

Cyclic antidepressant overdose is a major cause of morbidity and mortality in self-poisoned patients. The major cause of mortality with cyclic antidepressant overdose is cardiotoxicity. We determined plasma catecholamine levels in 41 symptomatic acute overdose patients to identify interactions between QRS duration (a marker for cardiotoxicity) and a presumed hyper-adrenergic state. Using a linear multivariable regression analysis, QRS duration correlated with the presence of cyclic antidepressant, plasma norepinephrine levels, the ratio of norepinephrine to epinephrine level, and pulse rate (p less than 0.001, r2 = 0.42). Commensurate physiologic changes were not found in the presence of elevated catecholamine levels in the cyclic antidepressant overdose group. One possible explanation for the blunted systemic response to the elevated catecholamine levels is adrenergic desensitization. Investigation of serial catecholamine levels during cyclic antidepressant overdose may lead to modification of our current theories of cardiotoxicity and therapy.

Clinical Pharmacology Of Lysergic Acid Diethylamide: Case Reports And Review Of The Treatment Of Intoxication

Intoxication and overdose are common presenting complaints to the emergency department. Acute intoxication with lysergic acid diethylamide (LSD) has become a relatively rare event, especially when compared with the incidence of ethanol and cocaine intoxication. We recently had an outbreak of presumed LSD intoxications occurring over one weekend. All patients had attended a performance by the musical group The Grateful Dead. At present, LSD intoxication or overdose can only be suspected based on clinical findings because there are no readily available rapid laboratory tests for detecting either the parent compound or the metabolites of the drug. The clinical findings and outcomes of five patients with suspected LSD intoxication are presented. The pharmacological effects of LSD and treatment modalities of intoxication are reviewed. All patients were treated conservatively based on clinical signs and symptoms. Only one patient required hospital admission for combative behavior that was initially refractory to pharmacological restraint.

Diagnosis and management of the drug overdose patient.

The manifestations of drug overdose can be complex and result in a variety of physiological effects. Drug overdose situations involving multiple agents further confuse the clinical picture. The clinician must be able to diagnose and treat the patient to prevent unnecessary morbidity or mortality. Often the risk of treating drug overdose with an additional pharmacological agent outweighs the potential benefit. In these cases, the best treatment may involve observation alone. This review describes the current diagnostic and management techniques for the drug overdose patient. Specific drug groups that are commonly used for overdose are discussed with emphasis on physiological manifestations of intoxication and poisoning and the potential for delayed effects. Treatment options for various groups are also discussed. It appears that invasive procedures such as gastric lavage and whole-bowel irrigation are not appropriate for the majority of overdose situations. The use of oral activated charcoal may also be of limited value. As specific antidotes for drug overdose are not widely available, supportive treatment must be based on the individual patient.

Hyperthermia, hypertension, hypertonia, and coma in a massive thioridazine overdose

This report characterizes an atypical presentation of a thioridazine overdose. Clinical manifestations included wide Q.R.S. complex, hyperthermia, hypertension, hypertonia, and coma. Plasma catecholamine levels were markedly elevated. The patient was treated with dantrolene sodium and supportive care. The patients condition improved over time, with questionable response to dantrolene sodium. Supportive care was the mainstay of treatment.

The Pharmacology of Alcohol Withdrawal Syndrome Treatment Reviewed: Efficacy, Cost, and Safety.

Alcohol continues to be one of the most common drugs of abuse. The morbidity and mortality associated with alcohol withdrawal has decreased significantly with the advent of pharmacologic intervention. However, the best method for the treatment of alcohol withdrawal syndrome remains controversial. With chronic use, alcohol can disturb the function and balance of several neurotransmitter systems such as excitatory amino acids, GABA, serotonin, and acetylcholine. Compensatory mechanisms in these pathways appear to predominate during chronic use but may become pathologic during withdrawal. As the understanding of alcohol-induced cellular changes increases, treatment of chronic abuse and withdrawal can be refined. Several groups of drugs are efficacious as either primary or adjunct agents in the treatment of alcohol withdrawal. This review describes the current theories on the etiology and treatment of alcohol withdrawal syndrome with emphasis on efficacy, cost, pharmacokinetic parameters, and safety considerations. A proposed withdrawal regimen is also described. Benzodiazepines appear to be the safest and most efficacious choice. With a wide variety of pharmacokinetic parameters and low cost of treatment, they remain the drugs of choice for withdrawal. Ethanol, barbiturates, antiseizure medications, and sympatholytic and sympathomimetic drugs are also reviewed. Newer agents that may have a future role in withdrawal are discussed as well.