Regan A. Baum

Characterization and Management of Patients with Heroin versus Nonheroin Opioid Overdoses: Experience at an Academic Medical Center

To characterize the differences between patients who had heroin and nonheroin opioid overdoses and to determine whether there were any significant differences in their management with regard to the naloxone use.

Being prepared: emergency treatment following a nerve agent release.

Nerve agents are extremely toxic and are some of the most lethal substances on earth. This group of chemicals consists of sarin, cyclosarin, soman, tabun, VX, and VR. It is currently unknown how many countries possess these chemicals and in what quantities. These agents work through altering the transmission and breakdown of acetylcholine by binding to, and inactivating, acetylcholinesterase. This results in an uncontrolled and overwhelming stimulation of both muscarinic and nicotinic receptors. Receptor activation at these sites can lead to a wide variety of clinical symptoms, with death frequently resulting from pulmonary edema. Antidotal therapy in this setting largely consists of atropine, pralidoxime, and benzodiazepines, all of which must be administered emergently to limit the progression of symptoms and prevent the enzyme inactivation from becoming permanent. This article reviews the mechanism of action of the nerve agents and their effects on the human body, the currently available therapies to mitigate their impact, and important therapeutic considerations for health care practitioners in the emergency department.

Review of Intranasally Administered Medications for Use in the Emergency Department

BACKGROUND Intranasal (IN) medication delivery is a viable alternative to other routes of administration, including intravenous (IV) and intramuscular (IM) administration. The IN route bypasses the risk of needle-stick injuries and alleviates the emotional trauma that may arise from the insertion of an IV catheter. OBJECTIVE This review aims to evaluate published literature on medications administered via the IN route that are applicable to practice in emergency medicine. DISCUSSION The nasal mucosa is highly vascularized, and the olfactory tissues provide a direct conduit to the central nervous system, bypass first-pass metabolism, and lead to an onset of action similar to IV drug administration. This route of administration has also been shown to decrease delays in drug administration, which can have a profound impact in a variety of emergent scenarios, such as seizures, acutely agitated or combative patients, and trauma management. IN administration of midazolam, lorazepam, flumazenil, dexmedetomidine, ketamine, fentanyl, hydromorphone, butorphanol, naloxone, insulin, and haloperidol has been shown to be a safe, effective alternative to IM or IV administration. As the use of IN medications becomes a more common route of administration in the emergency department setting, and in prehospital and outpatient settings, it is increasingly important for providers to become more familiar with the nuances of this novel route of medication delivery. CONCLUSIONS IN administration of the reviewed medications has been shown to be a safe and effective alternative to IM or IV administration. Use of IN is becoming more commonplace in the emergency department setting and in prehospital settings.

High-Dose Adenosine for Treatment of Refractory Supraventricular Tachycardia in an Emergency Department of an Academic Medical Center: A Case Report and Literature Review

BACKGROUND Symptomatic tachycardia is a common admission diagnosis in the emergency department (ED). This can be a life-threatening condition and requires immediate attention. Supraventricular tachycardia (SVT) is commonly treated with adenosine, and successful treatment is limited to atrioventricular (AV) node-dependent SVTs as adenosine causes a transient heart block. However, there are limited data available for instances when the recommended dosing regimen (6 mg, 12 mg, 12 mg) fails to terminate SVT. CASE REPORT A 33-year old man was evaluated in the ED with an electrocardiogram revealing a regular narrow complex tachycardia with a heart rate of 180 beats/min and a rhythm consistent with SVT. He reported experiencing 3 days of fatigue, myalgias, palpitations, and dyspnea on exertion, but was otherwise hemodynamically stable. Attempts at chemical cardioversion with standard doses of adenosine (6 mg, 12 mg, and 12 mg) were given without success. After consultation with the cardiology service, additional doses of 24 mg and then 36 mg of adenosine were administered. The last dose of 36 mg produced sustained conversion and return to a normal sinus rhythm. The patient later underwent radiofrequency ablation of a left-sided orthodromic reciprocating accessory pathway. After 3 months of medical management, the patient had an implantable cardiac defibrillator placed for prevention of sudden cardiac death. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Each case of SVT demands immediate attention from an emergency physician. It is imperative that providers be aware of the limitations of adenosine and when it may be appropriate to deviate from standard dosing recommendations. This is in addition to collaborating with an expert in cardiac electrophysiology when initial management tactics are not successful.

Treatment of Diabetic Ketoacidosis With Intravenous U-500 Insulin in a Patient With Rabson-Mendenhall Syndrome: A Case Report.

Rabson-Mendenhall syndrome is a rare genetic disorder resulting from mutations in the insulin receptor and is associated with high degrees of insulin resistance. These patients are prone to complications secondary to their hyperglycemia including diabetic ketoacidosis (DKA). We report the case of a 19-year-old male with Rabson-Mendenhall syndrome presenting with DKA who required doses of up to 500 U/h (10.6 U/kg/h) of insulin. The patient’s insulin infusion was originally compounded with U-100 regular insulin, although to minimize volume, the product was compounded with U-500 insulin. The DKA eventually resolved requiring infusion rates ranging from 400 to 500 U/h. Although numerous opportunities for medication errors exist with the use of U-500 insulin, this case outlines the safe use of concentrated intravenous insulin when clinically indicated for patients requiring extremely high doses of insulin to control blood glucose.

Suspected Synthetic Cannabinomimetic Intoxication: Case Series and Review:

Purpose: The purpose of this work was to retrospectively review patient cases presenting to the University of Kentucky Chandler Medical Center (UKCMC) emergency department (ED) with symptoms of suspected synthetic cannabinomimetic (SC) intoxication. These drugs, currently undetected by standard urine drug screen tests, comprise a structurally diverse group of compounds designed to mimic the psychoactive effects of Δ9-tetrahydrocannabinol (Δ9-THC), the primary psychoactive cannabinoid in marijuana. Summary: Fourteen cases of suspected SC intoxication were identified between July 1, 2015, through September 30, 2015. The median patient age was 25.5 years (range: 13-45 years), and most (64%) patients were males. The most common psychoactive symptom was agitation (n = 6, 42.9%), while the most common physical symptoms were altered level of consciousness (n = 9, 64.3%) and mydriasis (n = 3, 21.4%). Most cases resolved without complication in 24 hours; 2 patients required hospitalization. Conclusion: Recent legislation has failed to curb the public health concerns emanating from SC misuse. Education about the risks of SC use along with additional regulation may be required to remove the false sense of safety that some individuals, especially adolescents and young adults, may associate with these compounds, which are often misconstrued as “herbal marijuana.” Clinicians need to be prepared to identify and treat symptoms of SC intoxication as incidents of toxicity continue to rise.

Impact of an Antimicrobial Stewardship and Emergency Department Initiated Dalbavancin Guideline for Patients with Acute Bacterial Skin and Soft Tissue Infections

Abstract Background Acute bacterial skin and skin structure infections (ABSSI) are one of the most common reasons for patient hospitalization. These admissions may be solely for receipt of intravenous vancomycin due to concern for resistance to alternative agents or failure of oral therapy, providing a niche for long-acting agents like dalbavancin. The objective of this study was to evaluate patient outcomes following initiation of a dalbavancin guideline for ABSSI in the emergency department (ED). Methods This was a single-center, case series study evaluating adult patients with ABSSI from April 2016 to May 2017 who were screened for receipt of dalbavancin. Candidates were identified by a dalbavancin guideline implemented in the ED in April 2016 with hours from 7 am to 7 pm. Patients were assessed for inclusion by an ED pharmacist and physician. If the patient qualified for receipt of dalbavancin, the ED pharmacist contacted the Antimicrobial Stewardship Team (AST) for final approval. The guideline was revised in January 2017 to lessen restrictions. Patients were contacted via phone by an ED pharmacist for follow-up and the interaction documented in the electronic medical record. Patient data were collected using REDCap™. Results Overall, 22 patients (15 males/7 females) were evaluated for inclusion to receive dalbavancin. The average age of the patients was 38 years old, ranging from 21 to 61 years. Of these 22 patients, 7 received a single dalbavancin dose of 1,500 mg over 30 minutes for ABSSI (cellulitis {n = 5} and shooter’s abscess {n = 2}). The reasons for exclusion were: lack of systemic signs of infection (n = 5), risk of Gram-negative infection (n = 2), outside guideline time period (n = 2), required hospital support (n = 2), immunocompromised (n = 1), severe hepatic disease (n = 1), bacteremia (n = 1), and diabetic foot infection (n = 1). All patients received a follow-up visit (n = 4) or phone call from the ED pharmacist (n = 3). Only 1 patient required a later hospital admission due to further complications. Conclusion A multidisciplinary team approach to treating ABSSI in the ED was highly successful at our academic medical center. Further expansion of guideline hours should enhance the utilization of this guideline. Disclosures All authors: No reported disclosures.

Antiemetic Use in the Emergency Department

Nausea and vomiting are 2 of the most common complaints of patients presenting to the emergency department (ED). In addition, antiemetics are the most commonly prescribed medications in the ED behind analgesics. Treating these conditions can be complex, especially as one considers that nausea and/or vomiting could be the primary presenting illness or simply a symptom of a more complex etiology. Although there is a wide variety of pharmacotherapeutic options in the armamentarium to treat these conditions, very few consensus recommendations exist to help guide the use of antiemetic agents in the ED, leading to wide variability in medication use. Contributing to these variations in practice is the extended spectrum of etiologies and potential physiological factors that contribute to the development of nausea or vomiting. A thorough understanding of the pharmacology and administration of these agents can help practitioners devise tailored antiemetic regimens based upon the underlying etiology.

Chemotherapy in the Emergency Department? There Is a Role for That: Methotrexate for Ectopic Pregnancy.

Approximately 1.6% of all emergency department (ED) visits in the United States are for vaginal bleeding in early pregnancy, translating to around 500,000 ED visits per year. A potentially life-threatening condition, ectopic pregnancy occurs in 1.5%–2% of pregnancies. Many patients will require either surgical or pharmacological intervention following a positive diagnosis. With regard to pharmacological options, methotrexate, largely known for its use in the oncology arena, has emerged as the most effective nonsurgical option and the pharmacological agent of choice. However, this therapy is not without its own unique adverse event profile and patients should be adequately educated on the monitoring parameters of this pharmacotherapy.

Four-factor prothrombin complex concentrate-associated hypotension.

Warfarin is a vitamin K antagonist used to treat patients with hypercoagulable disease states but increases the risk of life-threatening bleeding. Prothrombin complex concentrate has been recommended if these bleeds occur. Kcentra, a 4-factor prothrombin complex concentrate, has been Food and Drug Administration approved for the urgent reversal of vitamin K antagonist–associated major bleeding. Hypotension has been reported with Kcentra use, but limited information is available about these reactions. Such events may be catastrophic in critically ill patients. Further description of these adverse events may be warranted to guide management. We report the case of a 76-year-old man who was transferred to our institution for management of a cerebellar hemorrhage. The patient was on chronic anticoagulationwithwarfarin for chronic venous thromboembolisms. His workup was notable for an international normalized ratio of 3.6. The patient experienced a sudden decline in mental status, suggestive of expanding bleed, and the decision was made to administer Kcentra. During administration, the patients mean arterial pressure fell to the high 40s despite resuscitative efforts. Because of persistent hypotension, Kcentra was discontinued before receipt of the intended dose. The patient remained hypotensive on vasopressors for an hour after discontinuation. Ultimately, the injury was deemed nonsurvivable. Assessment using the Naranjo scale indicates a possible adverse drug reaction. To our knowledge, this is the first case report describing hypotension potentially associated with Kcentra administration leading to early discontinuation. Recognition of this side effect is important in weighing the risks and benefits of therapy. Prothrombin complex concentrate (PCC) is currently used for the reversal of vitamin K antagonist (VKA)–associated major bleeding [1,2]. Kcentra (CSL Behring, Marburg, Germany) is a Food and Drug Administration–approved 4-factor PCC (4F-PCC) containing factors II, VII, IX, and X used for the reversal of such bleeds [3]. Hypotension is a poorly defined side effect of Kcentra, and the impact on patient outcomes is unclear [3–6]. In patients with intracranial hemorrhages, decreases in systemic pressure could alter cerebral perfusion, causing ischemic damage. To our knowledge, there are no published case reports of 4F-PCC–associated hypotension. We report the case of a patient who developed refractory hypotension while receiving Kcentra. The patient was a 76-year-old man whose history included multiple venous thromboembolisms requiring chronic anticoagulation with warfarin. He presented to an outside hospital with an acute decline in mental status, where imaging revealed a cerebellar bleed. Per report, the patientwas responsive, although no objective neurologic Conflicts: The above authors have no conflicts of interest to disclose regarding this