Podcast # 463: Buproprion Overdose

Author: Erik Verzemnieks, MD

Educational Pearls:

  • Buproprion is used as an antidepressant and for smoking cessation
  • Severe buproprion overdoses can cause seizures and lead to cardiac dysrhythmias
  • Benzodiazepines are treatment of choice for seizures
  • Bicarbonate and Interlipid are also possible treatment options with less evidence

References

Stall N, Godwin J, Juurlink D. Bupropion abuse and overdose. CMAJ. 2014 Sep 16;186(13):1015. doi: 10.1503/cmaj.131534. Epub 2014 Apr 28. PubMed PMID: 24778361; PubMed Central PMCID: PMC4162783.

Balit CR, Lynch CN, Isbister GK. Bupropion poisoning: a case series. Med J Aust. 2003 Jan 20;178(2):61-3. PubMed PMID: 12526723.

Bruccoleri RE, Burns MM. A Literature Review of the Use of Sodium Bicarbonate for the Treatment of QRS Widening. J Med Toxicol. 2016 Mar;12(1):121-9. doi: 10.1007/s13181-015-0483-y. Review. PubMed PMID: 26159649; PubMed Central PMCID: PMC4781799.

Podcast # 462: Death after OD

Author: Don Stader, MD

Educational Pearls:

  • 10% of patients seen in the emergency department for opioid overdose patients will die within a year
  • Half of these overdoses will occur in the next month
  • This mortality rate is higher than patients with STEMI, of which 7% will die within one year
  • Take-home naloxone, as well as medication assisted treatment like buprenorphine can save lives

References

Olfson M, Crystal S, Wall M, Wang S, Liu SM, Blanco C. Causes of Death After Nonfatal Opioid Overdose. JAMA Psychiatry. 2018 Aug 1;75(8):820-827. doi: 10.1001/jamapsychiatry.2018.1471. PubMed PMID: 29926090; PubMed Central PMCID: PMC6143082.

Olfson M, Wall M, Wang S, Crystal S, Blanco C. Risks of fatal opioid overdose during the first year following nonfatal overdose.Drug Alcohol Depend. 2018 Sep 1;190:112-119. doi: 10.1016/j.drugalcdep.2018.06.004. Epub 2018 Jul 4. PubMed PMID: 30005310.

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

Podcast # 461: Breath Stacking

Author: Gretchen Hinson, MD

Educational Pearls:

  • Breath stacking occurs when a patient is unable to expire fully before another inspiration
  • In intubated/ventilated patients, this is because adequate time has not passed before exhalation
  • Asthmatics are susceptible due to the prolonged expiratory phase
  • Complications can include reduction in cardiac preload and cardiovascular collapse
  • Pursed-lip breathing can help in the spontaneously breathing patient
  • Intubation may be required when patients present with status asthmaticus and breath stacking

References

Phipps P, Garrard CS. The pulmonary physician in critical care . 12: Acute severe asthma in the intensive care unit. Thorax. 2003 Jan;58(1):81-8. Review. PubMed PMID: 12511728; PubMed Central PMCID: PMC1746457.

Pohlman MC, McCallister KE, Schweickert WD, Pohlman AS, Nigos CP, Krishnan JA, Charbeneau JT, Gehlbach BK, Kress JP, Hall JB. Excessive tidal volume from breath stacking during lung-protective ventilation for acute lung injury. Crit Care Med. 2008 Nov;36(11):3019-23. doi: 10.1097/CCM.0b013e31818b308b. PubMed PMID: 18824913.

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

Podcast # 460: Hunting for PE in Syncope

Author:  Michael Hunt, MD

Educational Pearls:

 

  • Most causes of syncope are benign
  • Pulmonary embolism can result in syncope and is life threatening
  • A recent study of Canadian and US ED patients with syncope showed that 0.4% of patients had a PE at 30 day follow-up
  • PE should always be considered in cases of syncope but overall is a rare cause

 

Editor’s note: this study puts to rest a previous study from 2016 that reported a rate of PE in syncope as high as 1 in 6 in patients admitted to syncope – which was met with much skepticism based on clinical practice.

References

Roncon L, Zuin M, Casazza F, Becattini C, Bilato C, Zonzin P. Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism. Eur J Intern Med. 2018 Aug;54:27-33. doi: 10.1016/j.ejim.2018.04.004. Epub 2018 Apr 11. PubMed PMID: 29655808.

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

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 # 457: Stroke Scores

Author: Jared Scott, MD

Educational Pearls:

 

  • Modified Rankin Score:  measure of disability often used to qualify outcomes following stroke  = no disability, 6=dead, 0-1 indicate good outcome)
    • 0-6 Scale
    • 0-1 indicative of good outcome
  • ASPECT score: uses CT to quantify the extent of changes in the brain due to ischemia
    • 0-10 Scale
    • 10 areas are assessed on non-contrast CT to assess for early stroke changes
    • -1 for each area with these findings
    • 8-10 is indicative of better outcomes

 

References

Aviv RI, Mandelcorn J, Chakraborty S, Gladstone D, Malham S, Tomlinson G, Fox AJ, Symons S. Alberta Stroke Program Early CT Scoring of CT perfusion in early stroke visualization and assessment. AJNR Am J Neuroradiol. 2007 Nov-Dec;28(10):1975-80. Epub 2007 Oct 5. PubMed PMID: 17921237.

https://manual.jointcommission.org/releases/TJC2018A/DataElem0569.html

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

Podcast # 456 Hypoglycemia: Not feeling so sweet

Author: Jared Scott, MD

Educational Pearls:

 

  • Beta-blockers can mask the effects of hypoglycemia
  • Prolonged/refractory hypoglycemia should raise a suspicion for sulfonylurea (or other oral hypoglycemic) overdose
  • Interventions to reverse hypoglycemia include feeding the patient, IV dextrose, glucagon
  • Octreotide can be used as an antidote with sulfonylurea ingestion 

Editor’s note: Here is an interesting case report on using steroids for severe hypogylcemia caused by insulin overdose. Perhaps another treatment modality to keep in your back pocket?

References

Alsahli M, Gerich JE. Hypoglycemia. Endocrinol Metab Clin North Am. 2013 Dec;42(4):657-76. doi: 10.1016/j.ecl.2013.07.002. Review. PubMed PMID: 24286945.

Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.Emerg Med J. 2005 Jul;22(7):512-5. PubMed PMID: 15983093; PubMed Central PMCID: PMC1726850.

Fasano CJ, O’Malley G, Dominici P, Aguilera E, Latta DR. Comparison of octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia. Ann Emerg Med. 2008 Apr;51(4):400-6. Epub 2007 Aug 30. PubMed PMID: 17764782.

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