Nathan D. Mah

Successful Treatment of a Massive Metoprolol Overdose Using Intravenous Lipid Emulsion and Hyperinsulinemia/Euglycemia Therapy

Adrenergic β‐antagonists, commonly known as β‐blockers, are prescribed for many indications including hypertension, heart failure, arrhythmias, and migraines. Metoprolol is a moderately lipophilic β‐blocker that in overdose causes direct myocardial depression leading to bradycardia, hypotension, and the potential for cardiovascular collapse. We describe the case of a 59‐year‐old man who intentionally ingested ~7.5 g of metoprolol tartrate. Initial treatment of bradycardia and hypotension included glucagon, atropine, dopamine, and norepinephrine. Despite these treatment modalities, the patient developed cardiac arrest. Intravenous lipid emulsion (ILE) and hyperinsulinemia/euglycemia (HIE) therapies were initiated during advanced cardiac life support and were immediately followed by return of spontaneous circulation. Further treatment included gastric lavage, activated charcoal, continued vasopressor therapy, and a repeat bolus of ILE. The patient was weaned off vasoactive infusions and was extubated within 24 hours. HIE therapy was continued for 36 hours after metoprolol ingestion. A urine β‐blocker panel using mass spectrometry revealed a metoprolol concentration of 120 ng/ml and the absence of other β‐blocking agents. To date, no clear treatment guidelines are available for β‐blocker overdose, and the response to toxic concentrations is highly variable. In this case of a life‐threatening single‐agent metoprolol overdose, the patient was successfully treated with HIE and ILE therapy. Due to the increasing frequency with which ILE and HIE are being used for the treatment of β‐blocker overdose, clinicians should be aware of their dosing strategies and indications.

Achieving ventricular rate control using metoprolol in β-blocker–naive patients vs patients on chronic β-blocker therapy

STUDY OBJECTIVE The objective of the study is to evaluate the difference in ventricular rate control using an intravenous (IV) metoprolol regimen commonly used in clinical practice in patients receiving chronic β-blocker therapy compared to patients considered β-blocker naive admitted to the emergency department (ED) for atrial fibrillation (AF) with rapid ventricular rate. METHODS A single-center retrospective cohort study of adult ED patients who were admitted with a rapid ventricular rate of 120 beats per minute (bpm) or greater and treated with IV metoprolol was performed. Rate control was defined as either a decrease in ventricular rate to less than 100 bpm or a 20% decrease in heart rate to less than 120 bpm after metoprolol administration. Patient demographics, differences in length of stay, and adverse events were recorded. RESULTS A total of 398 patients were included in the study, with 79.4% (n=316) receiving chronic β-blocker therapy. Patients considered to be β-blocker naive were more likely to achieve successful rate control with IV metoprolol compared to patients on chronic β-blocker therapy (56.1% vs 42.4%; P=.03). β-Blocker-naive status was associated with a shorter length of stay in comparison to patients receiving chronic β-blocker therapy (1.79 vs 2.64 days; P<.01). CONCLUSION Intravenous metoprolol for the treatment of atrial fibrillation with rapid ventricular rate was associated with a higher treatment response in patients considered β-blocker naive compared to patients receiving chronic β-blocker therapy.

Accuracy of Prefilled “Code Cart” Epinephrine Syringes for Direct Administration of Small Doses

nerability for patients with errant weights is small. However, weight entry errors still pose a significant risk to efforts aimed at reducing medication errors, especially in pediatrics, where medications are frequently written based on weight. Urgent and emergent settings appear to be at highest risk for weight entry errors, although the inpatient population is at highest risk for medication errors secondary to errant weight entries owing to the frequency of medication ordering in the inpatient setting.

Sexually Transmitted Infection Review for the Acute Care Pharmacist

Purpose: Review selected sexually transmitted infections (STIs) and treatment recommendations for pharmacists and providers practicing in the acute care setting. Summary: In 2015, the Centers for Disease Control and Prevention (CDC) published an updated guideline on the treatment of STIs with an emphasis on prevention and new diagnostic strategies to combat the growing problem of STIs in the United States. Despite this guidance, the incidence of infection has continued to grow. In October 2016, an in-depth analysis reported that 20 million new infections occur annually in the United States. With this growing burden of disease, it is pertinent that health-care providers optimize their treatment strategies to improve upon the management of STIs. Focusing on identification of asymptomatic- and symptomatic-infected persons, treatment, education, effective follow-up, and counseling for patients and sexual partners, emergency medicine pharmacists and providers can help minimize the negative long-term health consequences of STIs. Conclusion In the emergency department setting, clinical pharmacists and providers can play a crucial role in preventing and treating STIs and should continue to expand and keep current their knowledge of this topic.

Topical tranexamic acid for the treatment of acute epistaxis in the emergency department

Objective: To evaluate the effectiveness and potential benefits of topical tranexamic acid (TXA) in the management of acute epistaxis. Methods: Retrospective review was performed among all patients presenting to the institutions emergency department (ED) with epistaxis between September 2014 and August 2016. Patients achieving hemostasis with standard of care agents, such as oxymetazoline, lidocaine, or epinephrine were excluded. The primary outcome was the ED length of stay (LOS). Secondary outcomes included the incidence of hospital admission, otolaryngologist consultation, nasal packing, prophylactic antibiotic use, and ED visit for rebleeding within seven days of treatment. Results: Among 122 patients, 30 received topical TXA (500 mg injectable solution soaked onto packing material and applied to the affected nostril) and 92 were managed with standard care. Nearly half (46.7%) of TXA‐treated subjects received TXA either alone or in combination with standard of care agents as their initial treatment strategy. No significant difference was observed in the ED LOS (272 vs 232 min in TXA and standard care arms, respectively, p = 0.26). However, TXA was associated with a significant reduction in otolaryngologist consults (30.0% vs 65.2%, p = 0.002) and nasal packing (16.7% vs 23.9%, p = 0.003). Conclusions: This investigation did not demonstrate a significant difference in ED LOS among patients with acute epistaxis treated with topical TXA or standard care. However, this data does add to existing evidence that TXA may be associated with a reduction in resource utilization, suggesting it may provide more effective bleeding control. Overall, more data is needed to confirm the potential benefits of this practice.

Achieving ventricular rate control in patients taking chronic beta-blocker therapy

ABSTRACT Study Objective. The objective of this study is to evaluate the difference in response to ventricular rate control with intravenous (IV) metoprolol compared to IV diltiazem in patients taking chronic beta‐blocker therapy who present to the emergency department (ED) in atrial fibrillation (AF) with rapid ventricular rate (RVR). Methods: This was a single‐center, retrospective study of adult patients taking chronic oral metoprolol. Chronic metoprolol therapy was defined as patients prescribed and taking oral metoprolol within 5 days of study inclusion. Rate control was defined as either a decrease in ventricular rate < 100 bpm or < 120 bpm if the decrease was at least 20% from the presenting heart rate. Results: A total of 332 patients were included, with 16 patients in the IV diltiazem group and 316 patients in the IV metoprolol group. In the diltiazem arm, 68.8% of patients achieved successful rate control compared to 42.4% of patients in the metoprolol group (p = 0.067). Treatment with IV metoprolol resulted in more hospital admissions (58% vs. 6.25% with diltiazem, p < 0.001). Treatment with diltiazem was associated with a greater incidence of bradycardia compared to IV metoprolol (13% vs. 0%, p = 0.002). Conclusions: The use of IV diltiazem was associated with a higher rate of successful response to rate control compared to IV metoprolol in patients in AF with RVR on chronic beta‐blocker therapy, however the difference between groups was not statistically significant.

Comparing Three Eras of Hepatic Coagulopathy Normalization Using Coagulation Factor Concentrates

Objective: To evaluate the efficacy and safety of three different normalization strategies utilizing coagulation factor concentrates (CFCs) in patients with hepatic coagulopathy of either acute or chronic etiology experiencing a life-threatening bleed or need for normalization of coagulopathy prior to invasive procedure. Design: Retrospective analysis. Setting: University-affiliated academic medical center. Patients: Adult patients admitted with hepatic dysfunction who received CFC for treatment of an active bleed or to normalize coagulopathy prior to an invasive procedure. Interventions: None. Measurements and main results: Patients were stratified into three treatment groups dependent upon which CFC was administered: recombinant factor VIIa (rfVIIa), three factor prothrombin complex concentrate (3F-PCC)/rfVIIa, or four factor prothrombin complex concentrate (4F-PCC). Fifty patients were included who received rfVIIa (n=19, 38%), 3F-PCC/rfVIIa (n=9, 18%), or 4F-PCC (n=22, 44%) during the study period. The groups were well-matched regarding age, weight, sex, hospital and ICU length of stay, baseline coagulation labs, and characteristics of liver dysfunction. All patients in the rfVIIa and 3F-PCC/rfVIIa groups achieved an INR <1.6 within four hours of first CFC use. Eight patients (36.4%) in the 4F-PCC group met the same endpoint within four hours of administration. Transfusion requirements did not differ before and after CFC administration in all groups. TE complications occurred in eight (16%) patients. Conclusions: CFCs appear to be effective for the normalization of INR in patients with hepatic coagulopathy in the setting of active bleeding or prior to invasive procedures.

Rapid Ventricular Response or Tachycardia? The Three Faces of Atrial Fibrillation ☆ ☆☆

The commenters raise excellent points. We also share their perspective that several different disease processes can independently result in atrial fibrillationwith rapid ventricular response. It is clinically important to distinguish the underlying etiologies in order to select the appropriate treatment. This author considers 3 physiologic stateswhen facedwith atrialfibrillation (Afib) with rapid ventricular response (RVR). The first mechanism is increased demand. Sepsis, gastrointestinal bleed, and trauma will all appropriately activate the renin-angiotensinaldosterone axis as well as stimulate a hyperadrenergic state. It is prudent to regard Afib with RVR in these cases akin to sinus tachycardia. The treatment primarily involves volume resuscitation and addressing the underlying stressor. Atrioventricular (AV) nodal blocking agents such as metoprolol are likely to be harmful, although esmolol has been shown in one study to improve outcomes in septic shock [1]. The second mechanism is decreased cardiac output. Patients in decompensated heart failure will often become tachycardic to compensate decreased myocardial contractility. In these cases, the renin-angiotensinaldosteronesystemandadrenergic systemare inappropriatelyhyperactivated. These patients tend to be in a fluid overload state with very high left ventricular end-diastolic pressure that compromises left ventricular perfusion. The primary treatment here is diuresis, afterload reduction, and addressing reversible causes of cardiomyopathy like ischemia. The roles of AV nodal blocking agents are debated in decompensated heart failure. β-Blocker improves long-term outcomes, but short-term, risks cardiogenic shock [2]. The decision for rate control must be made on a case-by-case basis and achieved gently. Diltiazem can be harmful for the diseased heart, which is much more sensitive to calcium flux for contractility [3]. The thirdmechanism is increased conduction. This is themechanism often taught inmedical school. A healthy AV nodewhen facedwith atrial fibrillation will permit rapid conduction leading to rapid ventricular response. The ideal solution here is AV nodal blocking agents such as metoprolol or diltiazem. The first 2 mechanisms should not be thought of as Afib with RVR but rather Afib with tachycardia. Only the third mechanism is truly Afib with RVR. It can be difficult to determine the underlying etiology. However, it is vital to do so as the treatments are dramatically different and can even be mutually exclusive.

Respiratory depression in the intoxicated trauma patient: are opioids to blame?

Providing effective pain management to acutely intoxicated trauma patients represents a challenge of balancing appropriate pain management with the risk of potential respiratory depression from opioid administration. The objective of this study was to quantify the incidence of respiratory depression in trauma patients acutely intoxicated with ethanol who received opioids as compared with those who did not and identify potential risk factors for respiratory depression in this population. Retrospective medical record review was conducted for subjects identified via the trauma registry who were admitted as a trauma activation and had a detectable serum ethanol level upon admission. Risk factors and characteristics compared included demographics, Injury Severity Score, Glasgow Coma Score, serum ethanol level upon arrival, urine drug screen results, incidence of respiratory depression, and opioid and other sedative medication use. A total of 233 patients were included (78.5% male). Patients who received opioids were more likely to have a higher Injury Severity Score and initial pain score on admission as compared with those who did not receive opioids. Blood ethanol content was higher in patients who did not receive opioids (0.205 vs 0.237 mg/dL, P = .015). Patients who did not receive opioids were more likely to be intubated within 4 hours of admission (1.7% vs 12.1%, P = .02). Opioid administration was not associated with increased risk of respiratory depression (19.7% vs 22.4%, P = .606). Increased cumulative fentanyl dose was associated with increased risk of respiratory depression. Increased cumulative fentanyl dose, but not opioid administration alone, was found to be a risk factor for respiratory depression.