Risk of Bleeding After Antiplatelet or Oral Anticoagulant Overdose

What is the risk of bleeding after an acute (or acute-on-chronic) overdose of the newer oral antiplatelet and anticoagulant agents? A new study in the Annals of Emergency Medicine set out to answer this question.
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Don’t be Afraid of Physostigmine

Physostigmine gets a bad rap, in my opinion. I remember back to my PGY-1 pharmacy residency at UMass when we had a teenage female present with AMS after being found in the woods (Clin Toxicol 2006). She was clearly anticholinergic and the suspected medication, by history, was olanzapine. Physostigmine transformed a delirious patient into one with normal mentation telling us exactly what happened. It was like watching pharmacology in action. It was also the moment when I confirmed the genius of Dr. Ed Boyer and decided to pursue a fellowship in clinical toxicology.

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Hemodialysis and Survival in Intubated Salicylate-Poisoned Patients

Salicylate-poisoned patients can be incredibly complex and severely ill. Secondary to the significant acid-base abnormalities that can accompany salicylate poisoning, hemodialysis (HD) is sometimes required to facilitate removal and correct acid-base status. In addition, if intubation is needed, hyperventilation on the vent is crucial to match the patient’s minute ventilation prior to insertion of the endotracheal tube.

A new study from the Illinois Poison Center evaluated the relationship between salicylate level, intubation, HD, and mortality.

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How to Administer Low-Dose IV Ketamine for Pain in the ED

Back in 2015, Dr. Sergey Motov’s (@painfreeED) group published a study demonstrating the efficacy of low-dose ketamine compared to morphine for analgesia in the ED. Here’s my quick analysis of that study as a UMEM pearl. The question, though, is how best to administer the 0.3 mg/kg IV ketamine dose while minimizing the risk of adverse effects.

Fortunately, Dr. Motov’s group has just published a follow-up study addressing that exact question.
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Ketamine as a First-Line Treatment for Severe Agitation in the ED

Ketamine is steadily gaining traction as a treatment option for excited delirium and/or severe agitation in both the prehospital and ED settings. We published a summary of the available data back in 2015 on Academic Life in EM. Last year in 2016, two prospective studies added important information to our understanding of the role of ketamine; one in the prehospital setting by Dr. Jon Cole’s group out of Minnesota and one in the ED from Dr. Geoffrey Isbister’s group in Australia. I was invited to write a commentary along with the Cole study, also published in 2016.

Hot off the press in 2017 is another prospective study, this time from Dr. Jeff Riddell’s group in California (@Jeff__Riddell).
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Are Vasopressors Useful for Toxin-Induced Cardiogenic Shock?

Toxin-induced cardiogenic shock is a life-threatening condition characterized by severe hypotension and ineffective tissue perfusion. Many drugs can lead to cardiogenic shock in overdose, for example beta blockers or calcium channel blockers. Given the poor prognosis of these cases AND theoretically-sound reasoning, vasoactive agents make sense as a therapeutic option. A detailed, comprehensive review, just published online in Clinical Toxicology, asks the question “Are vasopressors useful in toxin-induced cardiogenic shock?”
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Preventing Interruptions During IV NAC Therapy

Background

The FDA-approved dosing for IV acetylcysteine (NAC) for acetaminophen overdose is complicated: a 1-hour loading dose, followed by a 4-hour maintenance infusion at a different rate, followed by a second maintenance infusion for 16 hours at yet a different rate. Back during my clinical toxicology fellowship, we published a study that found there was an interruption in antidotal therapy > 1 hour in 18.6% of cases (and medication errors in 33% of cases overall). [1]
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