Over the past year, a group of physicians and pharmacists with expertise in emergency medicine, toxicology, and addiction medicine developed a white paper for the American Academy of Emergency Medicine (AAEM) on Management of Opioid Use Disorder in the Emergency Department. It is our attempt to share current best practices and provide comprehensive evidence-based recommendations for providers in acute care settings managing patients being harmed-or at risk to be harmed-by opioids.
The guideline is set up as 48 discrete, commonly-encountered questions with extensively-referenced, high-yield answers answer based on available evidence and expert consensus within our group.
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Activated charcoal is a funny intervention. There is plenty of data, with various drugs, demonstrating decreased absorption after its administration (much of it in healthy volunteers). However, there is a lack of quality evidence demonstrating benefit in clinically meaningful outcomes, such as mortality. In fact, the most recent Position Paper on Single-Dose Activated Charcoal (from 2005) suggests charcoal “should not be administered routinely in the management of poisoned patients.” This may be an oversimplification and I think Drs. Lotte Hoegberg and Anne-Bolette Gude astutely address this point in Goldfrank’s Toxicologic Emergencies:
“These opinions are unfortunately biased by the fact that most ‘routinely’ poisoned patients have low-risk exposures and do well with minimal intervention. Despite little scientific basis or support from clinical trials, less severely poisoned patients might benefit from activated charcoal in terms of reduced need for life support, monitoring, and antidotes.” (Isbister 2011)
And, there is data demonstrating a lower risk of seizures (venlafaxine, Kumar 2011), QT prolongation (citalopram, Friberg 2006), and delirium (promethazine, Page 2009) after charcoal administration. [Thanks, Dr. Martin Caravati, via Twitter!]
Conventional teaching is that the most benefit will be gained if charcoal is administered within the first hour after an overdose. This is important because we know that if charcoal is not administered in the prehospital setting, patients arriving to the Emergency Department are unlikely to receive it within that time frame.
The purpose of this brief post is to draw your attention to two recent articles that may change our thinking in when/how to use charcoal.
Continue reading “Don’t Completely Dismiss Charcoal’s Potential Benefit in 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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LAST UPDATED July 2, 2019
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 (Weizberg 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.
Continue reading “Don’t be Afraid of Physostigmine”
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.
Continue reading “Hemodialysis and Survival in Intubated Salicylate-Poisoned Patients”