Podcast # 459 Clonidine Ingestion

Author:  Julian Orenstein, MD

Educational Pearls:

 

  • Severe clonidine ingestion can present as a fluctuating mental status between typically accompanied by changes in vital signs (hypotension/bradycardia)
  • Respiratory depression requiring intubation is not uncommon

 

References

Isbister GK, Heppell SP, Page CB, Ryan NM. Adult clonidine overdose: prolonged bradycardia and central nervous system depression, but not severe toxicity. Clin Toxicol (Phila). 2017 Mar;55(3):187-192. doi: 10.1080/15563650.2016.1277234. Epub 2017 Jan 20. PubMed PMID: 28107093.

Spiller HA, Klein-Schwartz W, Colvin JM, Villalobos D, Johnson PB, Anderson DL. Toxic clonidine ingestion in children. J Pediatr. 2005 Feb;146(2):263-6. PubMed PMID: 15689921.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 458: A Tylenol a Day Keeps the Delirium Away?

Author: Nick Hatch, MD

Educational Pearls:

 

  • A recent study investigated the effect of scheduled IV acetaminophen on the incidence of delirium in post-CABG patients in the ICU
  • The use of scheduled IV acetaminophen reduced the rate of delirium in these patients compared to placebo
  • This may be due to the analgesic effect of acetaminophen and/or less requirement on other deliriogenic medications (opiates)

 

References

Subramaniam B, Shankar P, Shaefi S, Mueller A, O’Gara B, Banner-Goodspeed V, Gallagher J, Gasangwa D, Patxot M, Packiasabapathy S, Mathur P, Eikermann M, Talmor D, Marcantonio ER. Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial. JAMA. 2019 Feb 19;321(7):686-696. doi: 10.1001/jama.2019.0234. PubMed PMID: 30778597.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 455: Hunting for PeeCP

Author: Michael Hunt, MD

Educational Pearls:

 

  • Like all tests, urine toxicology (utox) screens can have false positives
  • Prescription medications such as demerol, antipsychotics, ketamine, and tramadol can all produce a false positive utox for PCP
  • Over-the-counter medication such as dextromethorphan also mimic PCP on utox

 

References

Doyon S. (January 2014). False Positive Urine Screens for Phencyclidine. ToxTidbits. Retrieved from https://www.mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2014/January%202014%20ToxTidbits.pdf

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 454: Tylenol Overdose

Educational Pearls:

 

  • Acetaminophen overdose can also present in patients taking too much over the course of days to weeks – not just intentional ingestions
  • If acute overdose is suspected, refer to the Rumak-Matthew nomogram to guide treatment based on time of ingestion and the time of level
  • In chronic overdose, Tylenol levels will not guide treatment
  • NAPQI is the toxic metabolite of acetaminophen
  • N-acetylcysteine (NAC) can be effective treatment in both acute and chronic overdoses
  • 7.5 g is the daily toxic dose of Tylenol in adults, 150mg/kg in children

 

 

References:

Smilkstein MJ. Acetaminophen. In: Goldfrank’s Toxicologic Emergencies, Goldfrank LR, Flomenbaum NE, Lewin NA, et al (Eds), Appleton & Lange, Stamford 1998. P.541.

Chiew AL, Gluud C, Brok J, Buckley NA. Interventions for paracetamol (acetaminophen) overdose. Cochrane Database Syst Rev. 2018 Feb 23;2:CD003328. doi: 10.1002/14651858.CD003328.pub3. Review. PubMed PMID: 29473717.

Lancaster EM, Hiatt JR, Zarrinpar A. Acetaminophen hepatotoxicity: an updated review. Arch Toxicol. 2015 Feb;89(2):193-9. doi: 10.1007/s00204-014-1432-2. Epub 2014 Dec 24. Review. PubMed PMID: 25537186.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 451: NSAIDs

Author: Don Stader, MD

Educational Pearls:

  • Non-steroidal anti-inflammatory drugs (NSAIDs) are effective pain relievers but come with important side effects
  • NSAIDs inhibit COX-1 and/or COX-2, which decreases the production of prostaglandins, which reduce pain and inflammation
  • Side effects of NSAIDS include increased rates myocardial infarction, stroke, and gastrointestinal bleeding, CVA
  • Effective pain reliever doses of many NSAIDs are lower than typically prescribed (i.e. ibuprofen 400 mg is as effective as 800 mg but with less risk of side effects)
  • Topical NSAIDs can be an alternative to reduce systemic effects
  • Selective Cox-2 inhibitors have less GI side effects

Editor note: What is ALTO? It’s alternative to opioids and consists of multi-modal pain control to reduce exposure to opioids. Check out more here and here.

 

References:

Derry S, Wiffen PJ, Kalso EA, Bell RF, Aldington D, Phillips T, Gaskell H, Moore RA. Topical analgesics for acute and chronic pain in adults – an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017 May 12;5:CD008609. doi: 10.1002/14651858.CD008609.pub2. Review. PubMed PMID: 28497473.

Coxib and traditional NSAID Trialists’ (CNT) Collaboration., Bhala N, Emberson J, Merhi A, Abramson S, Arber N, Baron JA, Bombardier C, Cannon C, Farkouh ME, FitzGerald GA, Goss P, Halls H, Hawk E, Hawkey C, Hennekens C, Hochberg M, Holland LE, Kearney PM, Laine L, Lanas A, Lance P, Laupacis A, Oates J, Patrono C, Schnitzer TJ, Solomon S, Tugwell P, Wilson K, Wittes J, Baigent C. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet. 2013 Aug 31;382(9894):769-79. doi: 10.1016/S0140-6736(13)60900-9. Epub 2013 May 30. PubMed PMID: 23726390; PubMed Central PMCID: PMC3778977.

Kaufman DW, Kelly JP, Battista DR, Malone MK, Weinstein RB, Shiffman S. Exceeding the daily dosing limit of nonsteroidal anti-inflammatory drugs among ibuprofen users. Pharmacoepidemiol Drug Saf. 2018 Mar;27(3):322-331. doi: 10.1002/pds.4391. Epub 2018 Jan 26. PubMed PMID: 29372579.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 450: Probiotics in Gastroenteritis

Author: Sam Killian, MD

Educational Pearls:

  • Viral gastroenteritis alters the gut microbiome and it is theorized that probiotics may help reduce the duration and severity of the disease.
  • Double-blind randomized controlled trial involving almost 900 children with viral gastroenteritis compared 5 days of probiotics to a control group.
  • There was no difference in the rates of severe gastroenteritis between the two groups
  • Probiotics are likely unhelpful for kid with viral gastroenteritis

References:

Freedman SB, Williamson-Urquhart S, Farion KJ, Gouin S, Willan AR, Poonai N, Hurley K, Sherman PM, Finkelstein Y, Lee BE, Pang XL, Chui L, Schnadower D, Xie J, Gorelick M, Schuh S; PERC PROGUT Trial Group.. Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis. N Engl J Med. 2018 Nov 22;379(21):2015-2026. doi: 10.1056/NEJMoa1802597. PubMed PMID: 30462939.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast #447:  IV Tylenol

Author: Dylan Luyten, MD

Educational Pearls:

  • Recent randomized controlled trial compared intravenous to oral acetaminophen in emergency department patients
  • There was no difference in pain relief between the groups
  • While the actual acquisition cost of these drugs are not significant, the cost multipliers that are passed onto patients lead to real dollars
  • With the significant cost of IV acetaminophen, it may not be the best choice given the lack of superiority to other formulations

References:

Furyk J, Levas D, Close B, Laspina K, Fitzpatrick M, Robinson K, Vangaveti VN, Ray R. Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial.Emerg Med J. 2018 Mar;35(3):179-184. doi: 10.1136/emermed-2017-206787. Epub 2017 Dec 15. PubMed PMID: 29247042.

Summarized by Will Dewsipelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 439 : Oops I did it again

Author: Aaron Lessen, MD

Educational Pearl:

  • A double ingestion of a single pill is typically a benign event but several drug classes may cause problems
  • A published review of 10 years of single medication double dose ingestion found 12 out of 876 cases had adverse events. The drugs and events were:
    • Propafenone ingestion leading to ventricular tachycardia
    • Beta blocker ingestion leading to bradycardia and hypotension
    • Calcium channel blocker leading to bradycardia and hypotension
    • Bupropion ingestion leading to seizures
    • Tramadol ingestion leading to ventricular tachycardia

Editor’s Note:

References:

Correia MS, Whitehead E, Cantrell FL, Lasoff DR, Minns AB. A 10-year review of single medication double-dose ingestions in the nation’s largest poison control system. Clin Toxicol (Phila). 2019 Jan;57(1):31-35. doi: 10.1080/15563650.2018.1493205. Epub 2018 Nov 28. PubMed PMID: 30484705.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 438 : tPA for Frostbite

Author: Aaron Lessen, MD

Educational Pearls:

 

  • Several studies have shown administration of tPA can improve outcomes and reduce need for amputation
  • tPA is considered in grade III and IV frostbite
  • tPA cannot be given until after the warming process
  • Administration is systemically, not catheter directed or intra-arterial

References:

Jones LM, Coffey RA, Natwa MP, Bailey JK. The use of intravenous tPA for the treatment of severe frostbite. Burns. 2017 Aug;43(5):1088-1096. doi: 10.1016/j.burns.2017.01.013. Epub 2017 Jan 31. PubMed PMID: 28159151.

Wexler A, Zavala S. The Use of Thrombolytic Therapy in the Treatment of Frostbite Injury. J Burn Care Res. 2017 Sep/Oct;38(5):e877-e881. doi: 10.1097/BCR.0000000000000512. PubMed PMID: 28296671.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 436 : Epinephrine Autoinjectors

Author: Charleen Gnisci, PharmD

Educational Pearls:

 

  • Between 2011 to 2016, Mylan increased EpiPen prices by 400% ($700 for 2 packs)
  • AUVI-Q was recalled in 2012, which left the market share to the EpiPen until recently
  • Teva announced last year it will be making a generic version of the EpiPen retailing around $300 but expected to decrease

 

References:

Kaplan, S. F.D.A. Approves Generic EpiPen That May Be Cheaper. The New York Times, The New York Times, 2018. Retrived from www.nytimes.com/2018/08/16/health/epipen-generic-drug-prices.html.

Tirrell, M.  FDA approves Teva’s generic EpiPen after yearslong delay. 2018. Retrieved from https://www.cnbc.com/2018/08/16/fda-approves-tevas-generic-epipen-after-years-long-delay.html

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD