Roneet Lev

Prophylactic lidocaine use preintubation: A review

This article is a review of the use of prophylactic lidocaine as a preintubation medication. Intubation is associated with a cardiovascular response of elevated blood pressure and pulse, cough reflexes, occasional dysrhythmias, increased intracranial pressure, and increased intraocular pressure. In patients with atherosclerotic heart disease, potential intracranial lesions, and potential penetrating eye injuries, these responses to intubation are of greater risk. Various studies have reviewed the effect of lidocaine to blunt these responses. It is agreed that lidocaine blunts cough reflexes and dysrhythmias. Some studies note a response of lidocaine in blunting rises in pulse, blood pressure, intracranial and intraocular pressure. No studies document any harmful effects of prophylactic lidocaine given preintubation. A dose of prophylactic lidocaine of 1.5 mg/kg given intravenously 3 minutes before intubation is optimal. For suctioning of intubated patients, lidocaine can be given endotracheally in a 5-6 mg/kg dose diluted in 6 cc via simple administration at the entrance to the endotracheal tube.

Neuroleptic malignant syndrome presenting without fever: Case report and review of the literature

The case of a patient with neuroleptic malignant syndrome (NMS) and delayed fever is presented. The patient was on lithium and trilafon before presentation to the emergency department with altered sensorium, rigidity, drooling, and tachycardia. The patient remained afebrile for 9 hours in the emergency department. He responded to treatment involving discontinuation of neuroleptics and bromocriptine. Typically NMS presents with a tetrad of fever, rigidity, altered sensorium, and autonomic dysfunction. This case is an example of NMS with delayed fever. A review of the literature on neuroleptic malignant syndrome is also presented.

Who is prescribing controlled medications to patients who die of prescription drug abuse

BACKGROUND Prescription drug-related fatalities remain a significant issue in the United States, yet there is a relative lack of knowledge on the specialty-specific prescription patterns for drug-related deaths. METHODS We designed a study that investigated medical examiner reports of prescription drug-related deaths that occurred in San Diego County during 2013. A Prescription Drug Monitoring Program search was performed on each of these cases to ascertain which physician specialties had prescribed controlled substances to these patients. The data were analyzed for each specialty, including pills per prescription, type of prescription, doctor shoppers (4 physicians + 4 pharmacies over 1 year), and chronic users (≥3 consecutive months of medications). MAIN FINDINGS In 2013, 4.5% of all providers in San Diego County wrote a prescription for a patient who died a prescription-related death. There were a total of 713 providers who prescribed 4366 medications totaling 328928 pills. Overall, emergency physicians gave the lowest number of prescriptions per provider (1.6), whereas pain management provided the highest amount per provider (12.9). Most prescriptions went to doctor shoppers (>50%) and chronic users (95.8%). Hydrocodone was the most frequently prescribed medication to those patients whose deaths were related to prescription drugs. CONCLUSIONS Emergency physicians appear to provide fewer prescriptions to those patients who die due to prescription drugs. Emergency physicians do, however, account for a significant proportion of total providers in this study. These results highlight the need to use Prescription Drug Monitoring Program data to closely monitor prescription patterns and to intervene when necessary.

Methadone related deaths compared to all prescription related deaths

BACKGROUND Methadone is increasingly implicated in unintentional overdose deaths. Despite major interventions, rates continue to remain high. One primary intervention, Prescription Drug Monitoring Programs (PDMP) are limited in their ability to impact this epidemic due to federal law restricting Opioid Treatment Programs (OTPs) from sharing data to PDMPs, despite being a major source of Methadone dispensing. METHODS This retrospective, observational study analyzed all prescription-related deaths occurring in San Diego County during the year 2013 with a specific focus on methadone-related deaths. All patients designated by medical examiner to have died by unintentional prescription were then referenced in the California PDMP, the Controlled Substance Utilization Review and Evaluation System (CURES). RESULTS As a whole, patients who died had a high number of average prescriptions, 21, and averaged 4.5 different providers, and three different pharmacies. Methadone-related deaths (MRD) accounted for 46 out of the 254 total patient deaths (18.1%). Methadone prescriptions were found in 14 patients with PDMP reports, 10 of who had methadone on toxicology report. Notably, 100% of methadone prescribed by primary care specialists. MRD patients were less likely to have toxicology reports matching PDMP data compared to other related drug deaths (20.6 vs. 61.2%, p<0.0001). Of the 46 methadone deaths, only 10 (29.4%) had prescriptions for methadone recorded in the database. Out of the 51 patients with only one drug recorded at death, methadone was most common (n=12; 23.5%). While all deaths had a notably high rate of chronic prescriptions at death (68.8% compared to 2% for all patients in CURES), there was no significant difference between MRD and other drug-related deaths (73.5 vs. 67.8%, p=0.68, respectively). MRD patients were less likely than other drug patients to have matching PDMP data without any illicit substance or alcohol (14.7 vs. 41.4%, p=0.003, respectively). CONCLUSION Methadone is a long-acting opioid that carries a higher risk profile than other opioids. In San Diego, the great majority of MRD had no data on methadone in the statewide PDMP database, bringing to question the restriction of OTP clinics from uploading information into the database. A risk-benefit analysis should be made to consider changing laws that would allow for OTP to input data into PDMP. OTP should make it standard of care to check PDMP data on their patients. Methadone prescribed for pain management should be limited to the most compliant patients.

A description of Medical Examiner prescription-related deaths and prescription drug monitoring program data

BACKGROUND The Centers of Disease Control and Prevention have declared prescription drug abuse an epidemic in the United States. However, demographic data correlating prescription-related deaths with actual prescriptions written is not well described. The purpose of this study is to compare toxicology reports on autopsy for prescription-related deaths with Prescription Drug Monitor Program (PDMP) data. METHODS This is a retrospective analysis comparing 2013 San Diego Medical Examiner data on 254 unintentional prescription-related deaths obtained for 12 months before death with data from the California PDMP. Data were analyzed on age, sex, whether there was information on the PDMP, types and quantities of prescribed medications, number of pharmacies and providers involved, and whether there was a match between the Medical Examiner toxicology report and data from the PDMP. RESULTS In 2013, there were 254 unintentional prescription-related deaths; 186 patients (73%) had PDMP data 12 months before death. Ingesting prescription medications with illicit drugs, alcohol, and/or over-the-counter medications accounted for 40% of the unintentional deaths. Opioids were responsible for the majority of single medication deaths (36; 70.6%). The average number of prescriptions was 23.5 per patient, and the average patient used 3 pharmacies and had 4.5 providers. Chronic prescription use was found in 68.8% of patients with PDMP data. CONCLUSIONS The PDMP data highlight important patterns that can provide valuable insight to clinicians making decisions regarding types and amounts of medications they prescribe. Although there is no guaranteed solution to prevent prescription-related deaths, PDMP data can be useful to prevent coprescribing and medication interaction and by following best clinical practices.

COMMUNITYTRIAL TODECREASEAMBULANCEDIVERSION OFPATIENTS ANDHOURS

the study site. Patients arriving by EMS had prehospital ECGs obtained, with the decision to activate the catheterization lab often made prior to patient arrival. Patients were grouped according to whether they presented during weekday working hours (0800 to 1800) or during off-hours (all other times). Catheterization lab personnel were typically on duty during business hours, but had to be called in during off-hours. Time intervals from emergency department arrival to balloon inflation were measured. Patients with nondiagnostic initial ECGs were excluded. Statistical analysis was performed using the Mann-Whitney U test. Results: A total of 142 AMI patients were taken for emergent angioplasty during the study period. Of these, 23 had nondiagnostic initial ECGs. Of the remaining 119 patients, 50 were treated during weekday business hours and 69 were treated during off-hours. The mean door to balloon time during business hours was 69 minutes (median 65 minutes, range 36–227 minutes). The mean door to balloon time during off-hours was 107 minutes (median 90 minutes, range 46–595 minutes). These differences are significant (p, 0.0000). Conclusion: The mean and median door to balloon times differ significantly between business hours and off-hours. Because these differences may impact outcome, it is imperative that EMS provide advance notification of arrival so that the cardiac catheterization lab can be readied for patient arrival. This need for advance notification is especially important during off hours.