UMEM Educational Pearls

POCUS in the Critically Ill Pregnant Patient

  • POCUS can be a valuable tool in the assessment and management of critically ill pregnant patients.
  • Conditions to consider in the critically ill pregnant patient who presents with acute RUQ pain include acute fatty liver of pregnancy (AFLP), liver infarction, liver hematoma, and Budd-Chiari Syndrome.
  • POCUS findings for these conditions include:
    • AFLP: a "bright" liver
    • Infarction: a wedge-shaped hypoechoic area (late finding)
    • Hematoma: a heterogeneous fluid collection below the capsule or intraparenchymal
    • Budd-Chiari Syndrome: lack of blood flow or thrombus in a hepatic vein or within the IVC.

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Long head of biceps tendon (LHBT) Testing

 

Overhead activities can cause anterior shoulder pain due to LHBT instability. A review of 3 physical exam maneuvers for bedside evaluation.

 

Speed test

Shoulder at 90° of flexion with arm fully supinated and elbow extended

Patient attempts to fwd. elevate arm against a downward force

Positive test is pain localized to bicipital groove.

Sensitivity 54% and specificity 81% for biceps pathology

https://youtu.be/N00gA4Pvsbw

 

Yergason test

Elbow at 90° of flexion with arm fully pronated and held against thoracic wall. Examiner grips patient’s hand and resists attempts at supination.

Positive test is pain localized to bicipital groove or LHBT subluxation.

Sensitivity 41% and specificity 79% for biceps pathology

https://youtu.be/_ot2S75mZ3o

 

Upper Cut test

Shoulder neutral with Elbow at 90° of flexion, arm fully supinated and hand in a fist. Patient moves hand toward chin in an uppercut motion like a boxer. Examiner places hand over patient’s fist and resists upward movement.

Positive test is pain localized to bicipital groove or LHBT subluxation.

Sensitivity 73%, specificity 78%, +LR 3.38 for biceps pathology

https://youtu.be/EE-WhlWFZvk

 

 

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Category: Toxicology

Title: Human errors involving "push dose pressors"

Keywords: push dose pressor, phenylephrine, epinephrine, human error (PubMed Search)

Posted: 7/11/2019 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

“Push dose pressors” – administration of small doses of vasopressors in the emergency room has become a common practice. A recently published study investigated the incidence of human error and adverse hemodynamic events.

Push dose pressors were defined as:

  • Phenylephrine (any dose)
  • Epinephrine (<= 100 mcg) 

Adverse hemodynamic event was defined as:

  • Extreme tachycardia (HR > 140 bmp)
  • New bradycardia (HR < 60 bmp)
  • Hypertension (SBP > 180 mmHg)
  • Ventricular tachycardia

249 out of 1522 patients were identified and analyzed from Jan 2010 to November 2017

  • median initial epinephrine dose (20 mcg; IQR: 10-100; range 1-100)
    • recieved more than one dose: 78 (57%)
  • median initial phenylephrine dose (100 mcg; IQR: 100-100; range 25 to 10,000)
    • received more than one dose: 62 (56%)

Adverse event

  • Phenylephrine group (n=110): 30 (27%; 95% CI: 19-36%)
  • Epinephrine group (n=139): 68 (50%; 95% CI: 41-58%)

Errors

  • Human error: 47 (19%) - similar proportion of human error between two agents.
  • Dosing error: 7 (3%; 2.5 to 100-fold)
  • Documentation error: 43 (17%)
  • Only one dosing error occurred when a pharmacist was present

 

Conclusion

  • Human errors and adverse hemodynamic event were common when “push dose pressors” were administered.
  • Consultation with a pharmacist can/may reduce dosing error.

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Category: Neurology

Title: SNOOP for Headache Red Flags

Keywords: secondary headache, features, risk factors, red flags (PubMed Search)

Posted: 7/10/2019 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

 

  • Symptoms/signs that suggest serious underlying conditions causing headaches are summarized by the mnemonic SNOOP:
    • Systemic symptoms/signs/disease
      • e.g. fever, weight loss, HIV, malignancy, pregnancy
    • Neurologic symptoms/signs
      • e.g. altered mental status, diplopia, pulsatile tinnitus, loss of consciousness
    • Onset sudden, abrupt, thunderclap
      • i.e. pain reaches maximal intensity instantly after onset
    • Older age of onset, especially > 50 years
    • Pattern change
      • e.g. change in frequency, severity, clinical features, precipitated by Valsalva, aggravated by postural change
  • Consider structural pathologies, vascular disorders, infectious and inflammatory conditions in the evaluation of secondary headache syndromes.

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Category: Critical Care

Title: Push dose epinephrine alternatives

Keywords: Critical Care, Hypotension, Shock, Vasopressors (PubMed Search)

Posted: 7/9/2019 by Mark Sutherland (Updated: 7/18/2019)
Click here to contact Mark Sutherland

With a shortage of push dose epi, this may be an opportune time to review alternative options (see also Ashley's email on the subject).

The dose of vasopressor required to reverse hypotension has been most studied in pregnant women undergoing c-section who get epidurals and experience spinal-induced vasoplegia and hypotension (not necessarily our patient population, but we can extrapolate...)  

Phenylephrine was found to reverse hypotension 95% of the time at a dose of 159 micrograms (a neo stick has 100 ug/mL, so around 1-2 mL out of the stick)

Norepinephrine reversed hypotension in 95% of patients at a dose of 5.8 ug.  The starting dose for our norepi order in Epic is 0.01 ug/kg/min, so if you have a levophed drip hanging and have an acutely hypotensive patient, you may want to briefly infuse at a higher rate such as 0.1 ug/kg/min (for a typical weight patient), or bolus approximately 3-7 ug for a typical patient.  Of course the degree of hypotension, particular characteristics of your patient and clinical context should be taken into consideration.  When your a lucky enough to have this resource, always consult your pharmacist.

 

Bottom Line: To reverse acute transient hypotension you may consider:

-A bolus of phenylephrine 50-200 ug (0.5-2 mL from neo-stick)

-A bolus of norepinephrine 3-7 ug

-Briefly increasing your norepinephrine drip (if you have one) to something around 0.1 ug/kg/min in a typical weight patient

-Always search for other causes of hypotension and consider clinical context.

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Category: Pharmacology & Therapeutics

Title: Alteplase for Pulmonary Embolism

Keywords: alteplase, pulmonary embolism (PubMed Search)

Posted: 7/6/2019 by Wesley Oliver
Click here to contact Wesley Oliver

Alteplase may be considered in some patients with a presumed or confirmed pulmonary embolism.  Below is a list of the different patient populations and the associated alteplase dosing.

-Hemodynamically Stable/Submassive: Alteplase usually not indicated.

-Hemodynamically Unstable/Massive: Alteplase IV 100 mg as an infusion over 2 hours.

-Cardiac Arrest: Alteplase IV/IO 50 mg bolus over 2 minutes.  Can repeat a second 50 mg bolus 15 minutes later if unable to achieve return of spontaneous circulation.

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Category: Toxicology

Title: Sudden Sniffing Death

Keywords: Sudden sniffing death, Inhalants, Fluoridated Hydrocarbons (PubMed Search)

Posted: 6/27/2019 by Kathy Prybys, DO (Emailed: 7/5/2019) (Updated: 7/5/2019)
Click here to contact Kathy Prybys, DO

Volatile inhalants such as glue, lighter fluid, spray paint are abused by "sniffing" (from container), "huffing" (poured into rag), or "bagging" (poured into bag). "Dusting" is the abuse of canned air dust removal products. These inexpensive easliy accessible products are so dangerous  that manufacturers include product warnings regarding lethal consequences from misuse and even may indicate that a bitterant is added to discourage use. Common duster gases include the halogenated hydrocarbons, 1,1-difluoroethane or 1,1,1-trifluroethane which are highly lipid soluble and rapidly absorbed by alveolar membranes and distributed to CNS. Desired effect of euphoria and disinhibition rapidly occur but unwanted side effects include confusion, tremors, ataxia, pulmonary irritation, asphyxia and, rarely, coma.

"Sudden sniffing death" is seen within minutes to hours of use and is due to ventricular arrhythmias and cardiovascular collapse. Available experimental evidence postulates the following mechanisms: Inhibition of cardiac sodium, calcium, and repolarizing potassium channels hERG and I(Ks) causing reduced conduction velocity and altered refractory period leading to reentry arrythmias or myocardial "sensitiization" to catecholamines resulting in after depolarizations and enhanced automaticity. Treatment should include standard resuscitation measures but refractory arrythmias to defibrillation have been reported and use of amiodarone and beta blockers should be considered.

 

Bottom Line:

  • Volatile Inhalant Abuse is common and dangerous 
  • SSD can occur even with first use
  • Ventricular arrythmias can be refractory to electricity. Consider amiodarone and beta blockers.

 

 

Ultra Duster Aerosol with Trigger, 12 oz

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Category: Critical Care

Title: Don't miss the injecting drug users with botulism!

Keywords: IVDA, AMS, botulism, Tox, ID (PubMed Search)

Posted: 7/2/2019 by Robert Brown, MD (Updated: 7/18/2019)
Click here to contact Robert Brown, MD

Takeaways

Wound botulism presents as descending paralysis when Clostridium botulinum spores germinate in anaerobic necrotic tissue. There have been hundreds of cases in the last decade, but it is poorly reported outside of California.

Black tar heroin and subcutaneous injection (“skin popping”) carry the highest risk, but other injected drugs and other types of drug use suffice. C botulinum spores are viable unless cooked at or above 85°C for 5 minutes or longer and this is not achieved when cooking drugs. 

Early administration of botulism anti-toxin (BAT) not only saves lives but can prevent paralysis and mechanical ventilation. An outbreak of 9 cases between September 2017 and April 2018 cost roughly $2.3 million, in part because patients didn’t present on average until 48 hours after symptom onset and it took an additional 2-4 days before the true cause of their respiratory depression and lethargy were understood. One patient died.

PEARL: talk to your injecting drug users about the symptoms of botulism: muscle weakness, difficulty swallowing, blurred vision, drooping eyelids, slurred speech, loss of facial expression, descending paralysis, and difficulty breathing. Consider botulism early in your patients who inject drugs but who do not respond to naloxone or who exhibit prolonged symptoms. Testing at the health department is performed with mouse antibodies to Botulism Neurotoxin (BoNT) combined with the patient’s serum.

 

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Cyanide poisoning, while uncommon, is frequently fatal. Current antidotes include methemoglobinemia inducers (nitrites), sulfur donators (thiosulfate), and hydroxocobalamin. Each has risks and benefits that must be considered. Three new potential antidotes, including sodium tetrathionate, have recently been evaluated in swine models.

 
Intramuscular sodium tetrathionate1

  • Sodium tetrathionate can bind and eliminate two cyanide molecules compared to one cyanide molecule by thiosulfate.
  • Studied in a large (50 kg) female swine model of cyanide poisoning.
  • All pigs were given cyanide via IV until 6 minutes post-onset of apnea, then given an approximately 1.5 mL IM injection of sodium tetrathionate (18 mg/kg).
  • Survival at 90 minutes was 100% (6/6) in the treated group and 16% in the control arm (1/6). 

Advantages:

  • Small volume injection (~1.5-2 mL in humans)
  • No interference with routine laboratory tests.
  • Ease of administration in pre-hospital or potential mass casulty setting.

Bottom line:

  • New cyanide antidotes are being developed.
  • The FDA does NOT require human trials of efficacy for cyanide antidotes.
  • It is unclear where these drugs are in the approval process at this time, but look for them in the future.

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Category: Neurology

Title: All this is giving me a headache!

Keywords: analgesia, headache, opioids (PubMed Search)

Posted: 6/26/2019 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

Primary headaches (not secondary to a life-threatening disease) can be challenging to manage. Remember the following pearls:

  • Things that DO NOT work: IV fluids, 5-HT3 Antagonists (aka Zofran), diphenhydramine (aka Benadryl), opioids

  • Things that KINDA work: oxygen for all headaches, sphenopalatine ganglion block (4% lido spray) 

  • Things that REALLY work: ketorolac, metoclopramide, prochlorperazine, triptans and ergots, oxygen for cluster headaches
  • Things that PREVENT recurrence: dexamethasone for migraine headaches 


Category: Orthopedics

Title: Pediatric back pain

Keywords: Disc, infection, back pain (PubMed Search)

Posted: 6/22/2019 by Brian Corwell, MD (Updated: 7/18/2019)
Click here to contact Brian Corwell, MD

Children are prone to inflammation and infection of the intervertebral discs

-Mean age 3-5years at presentation.

 

Lumbar region frequently involved

 

Although disc biopsy is not necessary for diagnosis, as many as 60% of biopsied discs grow bacteria

-Usually Staphylococcus aureus.

 

Untreated - may spontaneously resolve or progress to vertebral osteomyelitis or abscess

 

Chief complaint: Back pain and irritability, often associated with a limp or refusal to crawl or walk.

Fever is absent or low grade. 

Physical examination findings are nonspecific and may include a tendency to lie still and percussion tenderness over the involved spine.

Blood culture is generally sterile,

WBC count can be normal early in the disease course

 

However, the ESR is elevated in >90% of patients.

 

Plain radiographs are normal at the start of the illness, and generally take 2-3 weeks to demonstrate narrowing of the intervertebral space.

 

Therefore imaging study of choice is MRI.

 

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Category: Pediatrics

Title: When to operate for complicated pediatric appendicitis

Keywords: appendicitis, hospitalization, operative management (PubMed Search)

Posted: 6/21/2019 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

The 30-day adverse event rate is 11% after surgical removal of acute appendicitis.  Some experts believe that acute appendicitis actually consists of 2 types: Uncomplicated appendicitis and complicated appendicitis.  Complicated appendicitis can be broken down into appendicular abscess, appendicular phlegmon, and free perforated appendicitis with generalized peritonitis.
No consensus exists among surgeons regarding the optimal treatment of complicated acute appendicitis in children.  This study hoped to differentiate the complication rates between perforated appendicitis, appendicular abscess, and appendicular phlegmon with regards to early appendectomy versus conservative management.
14 studies were included in this meta-analysis for a total of 1288 patients. 
- Children with appendicular abscess and appendicular phlegmon had fewer complication rates and readmission rates if treated with nonoperative management.  
- Children with free perforated appendicitis showed lower complication rate and readmission rate if treated with operative management.  
- The costs were not significantly different between nonoperative management and operative management.

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Category: Toxicology

Title: Intranasal administration of naloxone for suspected opioid overdose

Keywords: intranasal naloxone, opioid overdose, reversal (PubMed Search)

Posted: 6/19/2019 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

Naloxone distribution programs have been expanding to promote the naloxone adminstration by laypersons, usually intranasal (IN) device, to victims of opioid overdose. A recent study analyzed the reports of prehospital naloxone administration reported to a regional poison center.

  • 1139 cases of prehospital naloxone administrations were identified between 2015 and 2017.
  • 98.2% had ventilatory depression
  • 97% were unresponsive
  • Law enforcement officers administered 91% of the naloxone, 97.9% via IN route

 

Opioid toxicity revesal:

  • Opioid-induced ventilatory or CNS depression was reversed in 79.2% after administering a mean naloxone dose of 3.12 mg. 
  • EMS administered additional naloxone (mean dose: 2.2 mg) to 291 due to lack of or partial reversal of opioid toxicity. 
  • 254 out of 291 (92.4%) regained normal/improved mental and ventilatory status.  
  • 95.9% of the overdose victims survived.

 

However, between 2015 and 2017, the reversal rate decreased (82.1% to 76.4%) while mean administered naloxone dose increased (2.12 mg to 3.63 mg). The cause of this trend is unknown but the dose of commercially available IN naloxone kit increased from 2 mg to 4 mg in 2016.

 

Bottom line:

  • IN naloxone administration is an effective intervention to reverse opioid toxicity.
  • However, larger naloxone doses were administered between 2015 and 2017 while the reversal rate decreased.
  • It is essential for bystander/witness of overdose to notify EMS as overdose victims may require additional naloxone administration/medical attention.

 

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Post-Arrest Prophylactic Antibiotics?

  • Pneumonia is the most common infective complication in post-cardiac arrest patients. It may develop in up to 60% of patients and is associated with an increased ICU length of stay.
  • Given the challenges in diagnosing pneumonia in the post-cardiac arrest patient, many clinicians consider prophylactic antibiotic administration.
  • A recent systematic review and meta-analysis sought to evaluate the effect of early antibiotic use on survival and survival with good neurologic outcome in adult patients resuscitated from cardiac arrest. Key study results include:
    • 11 studies (3 RCTs, 8 observational trials)
    • 6149 patients
    • No change in overall survival or survival with good neurologic outcome
  • Take Home Point: Current data does not support the prophylactic administration of antibiotics to adults resuscitated from cardiac arrest.

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Category: Toxicology

Title: Prevalence of fentanyl exposure in Baltimore

Keywords: opioid use disorder, fentanyl exposure, baltimore, (PubMed Search)

Posted: 6/13/2019 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

Since 2013, the availability of fentanyl has been increasing in the illicit drug supply, especially in heroin supply. Fentanyl and its analogs have been responsible for the dramatic increase in opioid overdose death over the past 5 years. 

Two recent cross-sectional studies screened ED patients with opioid use disorder for fentanyl exposure.

Study 1:

  • Of 165 patients, urine samples were obtained from 129 participants.
  • 80.6% tested positive for fentanyl from urine sample when over 95% reported preference for heroin in the fentanyl positive group.
  • 85.7% of the overdose group (n=42) was positive for fentanyl.
  • Over 84% recognized fentanyl’s high potency and high risk of death in overdose.
  • 29.7% (n=49 of 165) intentionally purchased fentanyl for use.  
  • Intentional fentanyl purchase was more common in non-overdose group(34.1% vs. 16.7%).

Study 2: 

  • 76 ED patients were screened.
  • 83% showed presence of fentanyl in urine.
  • 5% reported knowledge of using fentanyl (i.e. intentional use).

Bottom line:

  • Fentanyl exposure is common among opioid users in Baltimore
  • Up to 30% of ED patients with opioid use disorder intentionally purchase fentanyl although majority recognize the higher risk of overdose death from fentanyl compared to other opioids.

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Category: Neurology

Title: Are We Underdosing Benzodiazepines in Status Epilepticus?

Keywords: seizure, status epilepticus, benzodiazepine, antiepileptic, failure (PubMed Search)

Posted: 6/12/2019 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

  • Benzodiazepines are first-line treatment for status epilepticus.
  • Guidelines for the treatment of status epilepticus recommend dosing as:
    • 10 mg midazolam IM for patients > 40 kg or 5 mg midazolam IM for patients 13-40 kg
    • 0.1 mg/kg lorazepam IV (max 4 mg/dose), can repeat x 1
    • 0.15-0.2 mg/kg diazepam IV (max 10 mg/dose), can repeat x 1
  • The recent Established Status Epilepticus Treatment Trial (ESETT) compared the treatment of patients who did not respond to benzodiazepines.
    • Overall, 29.8% of the first dose of benzodiazepines given in the ED met minimum dose recommendations.
    • Dosing for patients < 40 kg more frequently met minimum dose recommendations.
    • This study found a pattern of multiple, small doses instead of a single full dose of benzodiazepine as recommended by guidelines.

Bottom Line: Underdosing of benzodiazepines in status epilepticus may contribute to treatment failure.

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Category: Critical Care

Title: Do Little People Have Little Lungs?

Keywords: Achondroplasia, vertebral arteries, mechanical ventilation (PubMed Search)

Posted: 6/11/2019 by Robert Brown, MD (Updated: 7/18/2019)
Click here to contact Robert Brown, MD

Takeaways

Little people (patients with achondroplasia or "dwarfism") have little lungs. Even though the trunk may appear to be a normal size with small limbs, the vital capacity is actually about 75% the predicted value based on the patient's sitting height. Macrocephaly and a decreased anterior-posterior depth are the cause for this. When you want to mechanically ventilate a little person, you can estimate their height based on a typical person with the same sitting height, but their actual volume will be about 3/4 the tidal volume predicted.

When intubating, remember these patients also have a high risk of basicranial hypoplasia (the foramen magnum may be small and key-hole shaped). These patients will be predisposed to compress the vertebral arteries when you tilt the head back and this itself can cause ischemia of the medulla and pons leading to central apnea.

Stokes DC, Wohl ME, Wise RA, et al. The lungs and airways in Achondroplasia. Do little people have little lungs? CHEST. 1990; 98(1):145-52

Pauli RM. Achondroplasia: A comprehensive review. Orphanet Journal of Rare Diseases. 2019; 14(1): 

 

 

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Category: Orthopedics

Title: Acute transverse myelitis (ATM)

Keywords: Spine, Autonomic Dysfunction (PubMed Search)

Posted: 6/8/2019 by Brian Corwell, MD (Updated: 7/18/2019)
Click here to contact Brian Corwell, MD

Acute transverse myelitis (ATM) refers to inflammation of gray and white matter in one or more adjacent spinal cord segments leading to acute/subacute dysfunction of all cord functions (i.e., motor, sensory, and autonomic).

 

There is a bimodal peak between ages 10-19 years and ages 30-39 years.

Most cases are idiopathic

Some patients may have had a preceding viral infection or autoimmune disorder.

The thoracic cord is most commonly involved.

Onset is characterized by acute/subacute development of neurologic signs and symptoms consistent with motor weakness, sensory changes or autonomic dysfunction.

Pain in the head, neck, and/or back may occur.

Motor and sensory changes occur below the level of the lesion and are more likely to be bilateral.

Motor symptoms include a rapidly progressing paraparesis.

Autonomic dysfunction may include urinary urgency or difficulty voiding, bowel or bladder incontinence, tenesmus, constipation, and sexual dysfunction.

Despite its low incidence, consider in a patient presents with a classic constellation of symptoms,

Rapid identification, and early initiation of treatment predicts the best outcomes

Diagnosis: whole spine MRI with and without gadolinium

Management: goals include reducing cord inflammation (IV glucocorticoids), alleviating symptoms (pain management, bladder decompression), and treating underlying causes (e.g., infections, autoimmune) as appropriate.

 

 


Category: Toxicology

Title: Online market place for toxic substances

Keywords: toxic substance, online retailers, amazon.com, (PubMed Search)

Posted: 6/6/2019 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

Many chemicals and substances - both legal and illegal - can be purchased from an online retailer. A recent study searched Amazon.com to see if any of the "extremely hazardaous substances" identified by Environmental Protection Agency (EPA) were available for purchase.

Amazon.com was searched over 10-month period.

Result:

  • 79 of 340 substances listed as "extremely hazardous by the EPA were available for purchse. 
  • 1/3 of the products/substances possess sufficient dose to be considered toxic in single unit purchase
  • Only 4 substances required a bussiness account to be purchase. 

 

Bottom line:

Toxic substances are readily available from many online retailers that can potentially cause serious toxicity. Online retailers should consult with experts and governmental agencies to limit the availability of such products.

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Some patients with severe pulmonary hypertension receive continuous infusions at home of prostacyclins, such as epoprostanol (flolan).  These are generally delivered via a pump that the patient wears, which is attached to an indwelling catheter.  As with any indwelling device, they are at risk for infection and other complications, including malfunction.

Interruption of delivery of the medication can result in rapid cardiovascular collapse, sometimes within minutes.  In this instance, the medication should be resumed as quickly as possible (by a traditional IV if the catheter is not functional), and the patients should be treated as one would approach a patient with decompensated right heart failure.

I once saw a patient in the ED whose listed chief complaint was "medication refill", but was actually there for dislodgement of her prostacyclin catheter (thankfully she was ok).  With more patients receiving devices they are dependent upon (insulin pumps, AICDs, prostacyclin catheters), be wary of chief complaints such as "medication refill" or "device malfunction."

 

Bottom Line: Interruption of continuous prostacyclin therapy for pulmonary hypertension can be rapidly fatal and should be addressed immediately.

 

 

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