UMEM Educational Pearls

Category: Critical Care

Title: OHCA in Pregnancy

Keywords: OHCA, cardiac arrest, resuscitation, maternal cardiac arrest, pregnancy (PubMed Search)

Posted: 1/29/2019 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

Takeaways

 

Historically, there has been very limited data regarding the epidemiology of OHCA in pregnant females. Two recently-published studies tried to shed some light on the issue.

Both Maurin et al.1 and Lipowicz et al.2 looked at all-cause out-of-hospital maternal cardiac arrest (MCA) data in terms of numbers and management, in Paris and Toronto respectively, from 2009/2010 to 2014. Collectively, they found: 

  • MCA was relatively rare: 0.8 MCA per 1000 OHCA (Maurin) and 1.71 MCA per 100,000 pregnant females (Lipowicz)
  • Low incidence of bystander CPR in witnessed MCA (33% and 0%)
  • Adherence to PMCS guidelines was poor 
  • Maternal survival was lower than what has been previously quoted for in-hospital CA: 12.5 and 16.7% compared to 40-50%3,4

A few reminders from the 2015 AHA guidelines for the management of cardiac arrest in pregnancy: 

  • Hand location for chest compressions should be in the center of the chest as for nonpregnant patients (previous recommendations had been to shift upward to accommodate for the gravid uterus but there is no data to support this).
  • Chest compressions should be performed with the patient supine, using manual lateral uterine displacement for aortocaval decompression. Left lateral tilt position is no longer recommended due to poorer quality of cardiac compressions, the lack of full aortocaval decompression, and further complication of other procedures such as airway management.
  • IV or IO access should be obtained above the diaphragm, to ensure no interference to flow to the heart by the gravid uterus.
  • Rate and depth of chest compressions, ACLS drugs and doses, and defibrillation all remain the same as in nonpregnant OHCA patients.
    • NB: As opposed to nonpregnant patients periarrest, oxygen saturation in the pregnant female should be maintained at 95% or greater, or PaO2 > 70mmHg, to ensure appropriate oxygen delivery to the fetus. The goal PCO2 is ~28-32 mmHg, to facilitate fetal CO2 removal.6  
  • If advanced airway is pursued, the most experienced provider should perform intubation due to the higher intrinsic difficulties, more rapid decompensation, and propensity for airway trauma and bleeding in the pregnant female.
  • Perimortem c-section should occur within the first 5 minutes of cardiac arrest / arrival to the ED in ongoing arrest. 

 

Bottom Line: Although maternal cardiac arrest is relatively rare, survival in OHCA is lower than perhaps previously thought. Areas to improve include public education on the importance of bystander CPR in pregnant females, and appropriate physician adherence to PMCS recommendations, with decreased on-scene time by EMS in order to decrease time to PMCS. 

 

 

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Category: Airway Management

Title: Hook of hamate fracture

Keywords: had, wrist, carpal (PubMed Search)

Posted: 1/26/2019 by Brian Corwell, MD (Updated: 9/23/2019)
Click here to contact Brian Corwell, MD

Hook of hamate fracture

Often missed fracture despite classic history

A frequent athletic injury

Seen in stick sports (golf, baseball, hockey)

Typically caused by a direct blow (grounding a gold club)

https://upload.orthobullets.com/topic/6035/images/hamate_baseball.jpg

Patient presents with hypothenar pain and pain with tight gripping

https://upload.orthobullets.com/topic/6035/images/hamate_golf.jpg

Presentation may be subacute with longstanding wrist or palmer pain

Physical exam: Tender to palpation over hook of hamate

Specialized test: hook of hamate pull test

Supinated hand held in ulnar deviation. Ask patient to actively flex 4th and 5th digits against resistance at DIP.
 

https://www.youtube.com/watch?v=A-mjRnC1yWQ

 

Radiology: Consider adding carpal tunnel view to standard wrist series if diagnosis is suspected

CT sometimes needed to image the fracture

 

Tx: Immobilize in a short arm splint

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Therapeutic use or overdose of tramadol has been associated with seizure.  However, it is unknown if there are any specific predisposing factor that increases a patient’s risk of seizure after tramadol use/overdose.

In a recently published study, eighty patient data with single ingestion of tramadol were reviewed.

  • 52.5% of the patient developed seizure
  • 11% developed serotonin syndrome

 

Risk of seizure

  • Higher risk of seizure were found in Asian patients (OR=7.1, 95% CI: 1.9 – 27.3) and patients with abuse/misuse of tramadol (OR=3.2, 95% CI: 1.2-8.3)
  • Patients who presented with opioid toxidrome were less likely to develop seizure (OR=0.12, 95% CI: 0.02 – 0.71) 
  • Acute overdose and age were not associated with increased risk of seizure.

 

Conclusion

In this small study, Asian patients and patients with abuse/misuse were at higher risk of developing seizure compared to patients who overdose tramadol.

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Takeaways

Intravenous (IV) thrombolytics for stroke remain a controversial topic for emergency medicine (EM) physicians, with numerous editorials and articles questioning the strength of the recommendations by the AHA in 2018. Nevertheless, it is prudent for the emergency medicine provider to be aware that administration of IV tPA is a Level I recommendation in any stroke patient with a time of onset (or last known normal) up to 4.5 hours in patients with no contraindications. Clinical judgement should always direct care, and documentation for deviation from the guidelines (if any) should be done.

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Respiratory Complications of ICIs

  • Acute respiratory failure (ARF) is the leading cause of ICU admission for immunocompromised patients.
  • While infectious etiologies remain the most common cause of ARF in these patients, there is an increasing prevalence of non-infectious, treatment-related causes.
  • Immune check-point inhibitors (ICIs) are now used with increasing frequency, and can cause severe pulmonary toxicity in approximately 6% of patients.
  • Pearls for ICI pulmonary toxicity include:
    • Acute pneumonitis is the most common presentation
    • Median time of onset of approximately 4 months after treatment initiation
    • Symptoms include dry cough, hypoxemia, and infiltrates not c/w CHF, infection, or progression of malignancy
    • Treatment is to DC the ICI and initiate steroids

 

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Category: Orthopedics

Title: Anesthestic Pearls

Keywords: anesthetic, orthopedics, wound (PubMed Search)

Posted: 1/19/2019 by Michael Bond, MD
Click here to contact Michael Bond, MD

When caring for a patient with a laceration we often do lcoal infiltration prior to suturing but remember the benefits of regional nerve blocks

Benefits of Regional Nerve Blocks

  • Less Painful
  • Prevents distortion of the wound which can help with cosmetic closure
  • Allows for a greater area to be anesthesized with less anesthetic use (prevents toxic levels)
  • Can allow for longer anesthetic time

Quick reminder of properities of common anesthetic

Anesthetic Onset of Action Duration of Action Max Dose 
No Epi
Max Dose
With Epi
Lidocaine Seconds 1 hr  4mg/kg 7mg/kg
Bupivicaine Seconds + > 6 hrs  2mg/kg 3mg/kg

Final reminder:  There is no evidence that epinephrine causes necrosis and it can be used safely in digital blocks. Duration of action is max 90 minutes. Even individuals that have injected themselves with EpiPens into their hands have not had any long term sequelue or necrosis seen. Vast majority required no treatment at all.

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Category: Pediatrics

Title: TXA use in pediatric patients for post tonsillectomy bleeding

Keywords: Post-tonsillectomy, bleeding, airway (PubMed Search)

Posted: 1/18/2019 by Jenny Guyther, MD (Updated: 9/23/2019)
Click here to contact Jenny Guyther, MD

Post tonsillectomy hemorrhage occurs and 0.1-3% of post tonsillectomy patient's.  It occurs typically greater than 24 hours after surgery and up to 4-10 days postoperatively.  A survey of otolaryngologists showed that ED management strategies for active bleeding have included direct pressure, clot suction, silver nitrate, topical epinephrine, and thrombin powder.

This article was a case study demonstrating the use of nebulized tranexamic acid (TXA) for post tonsillectomy hemorrhage in a 3-year-old patient.  The patient had a copious amount of oral bleeding and had failed treatment with nebulized racemic epinephrine and direct pressure was not an option due to the patient's cooperation and small mouth.  250 mg of IV TXA was given via nebulizer with a flow rate of 8 L.  Bleeding stopped 5-7 minutes after completion of the nebulizer.  The patient was then taken to the OR for definitive management.  No adverse effects were noticed.

TXA in the pediatric population has been shown to decrease surgical blood loss and transfusions in cardiac, spine and craniofacial surgeries.  Studies have also been done in pediatric patients with diffuse alveolar hemorrhage using doses of 250 mg for children less than 25 kg and 500 mg for those who are greater than 25 kg.

Bottom line: There are case reports of nebulized TXA use in the pediatric population with no adverse outcomes noted.  More research is needed.

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Category: Critical Care

Title: Late Awakening After Cardiac Arrest

Keywords: Cardiac arrest, neruo (PubMed Search)

Posted: 1/15/2019 by Daniel Haase, MD (Updated: 1/19/2019)
Click here to contact Daniel Haase, MD

--Late awakening (>48h after sedation held) was common (78/402) in patients with cardiac arrest in prospective cohort study

--Poor prognostic signs of discontinuous (10-49% suppression) EEG and absent brain stem reflexes were independently associated with late awakening. Use of midazolam also associated with late awakening

--Late awakeners had good functional outcome when compared to early awakeners

DON'T NEUROPROGNOSTIC EARLY (OR IN ED)!

And traditional poor prognostic signs may not be as poor as previously thought!

------------------

Rey A, Rossetti AO, Miroz JP, et al. Late Awakening in Survivors of Postanoxic Coma: Early Neurophysiologic Predictors and Association With ICU and Long-Term Neurologic Recovery. Critical Care MedicineJanuary 2019 - Volume 47 - Issue 1 - p 85–92

 

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Category: Orthopedics

Title: Epidemiology of Alpine Skiing Injuries

Keywords: Skiing, gamekeeper (PubMed Search)

Posted: 1/12/2019 by Brian Corwell, MD (Updated: 9/23/2019)
Click here to contact Brian Corwell, MD

Epidemiology of Alpine Skiing Injuries

 

Mean age of injury 30.3 (range 24 to 35.4 years)

Populations at greatest risk are children and adolescents and possibly adults over 50 (increased risk of tibial plateau fractures)

Sex: Males> females

              Knee injuries, esp to ACL, are higher among females

              Fractures greater in males

Injury location greatest at lower extremity (primarily to knee)

              Primarily sprains to MCL and ACL (increasing incidence)

14% occur to upper extremity and primarily involve the thumb and shoulder

              Skiers thumb – FOOSH with thumb Abducted gripping pole

              Pole is implicated as this injury is rare among snowboarders

The pole acts as a lever to amplify the forced Abduction of the thumb as the outstretched hand hits the ground.

Let go before you hit the ground!!

13% occur to head and neck

The number of all type injuries has decreased over time with advances in equipment and helmet use

Proportion of skiers wearing a helmet exceeds 80%        

However, the number of traumatic fatalities has remained constant

              Accidents involving fatalities exceed the protective capacity of helmets

              Helmets likely decrease risk of mild and moderate head injury

 

 

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Acute Disseminated Encephalomyelitis (ADEM) is primarily a pediatric disease and can cause a wide variety of neurologic symptoms. As such, should always be in the differential for pediatric patient presenting with vague neurologic symptoms including altered mental status. It is an immune-mediated, demyelinating disease that can affect any part of the CNS; usually preceding a viral illness or rarely, immunizations.

The average age of onset is 5-8 years of age with no gender predilection. It usually has a prodromal. That includes headache, fever, malaise, back pain etc. Neurological symptoms can vary and may present with ataxia, altered mental status, seizures, focal symptoms, behavioral changes or coma.

MRI is the primary modality to diagnose this condition. Other possible indicators may be mild pleocytosis with lymphocyte predominance, and elevated inflammatory markers such as ESR, CRP. These findings, however, are neither sensitive nor specific.

First-line treatment for ADEM is systemic corticosteroids, typically 20-30 mg/kg of methylprednisolone for 2-5 days, followed by oral prednisone 1-2 mg/kg for 1-2 weeks then 3-6-week taper. For steroid refractory cases, IVIG and plasmapheresis may be considered.

ADEM usually has a favorable long-term prognosis in the majority of patients. However, some may experience residual neurological deficits including ataxia, blindness, clumsiness, etc.

Take home points:

  • Always keep ADEM on the differential for any pediatric patient presenting with any neurologic symptoms
  • MRI is the diagnostic modality of choice.
  • If ADEM diagnosed, start treatment early in conjunction with pediatric neurology.

 

 

 

 
 

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Take home naloxone (THN) programs have been expanded to help reduce the opioid overdose-related deaths. A study was done in Australia to characterize a cohort of heroin overdose deaths to examine if there was an opportunity for a bystander to intervene at the time of fatal overdose.

235 heroin-overdose deaths were investigated during a 2 year study period in Victoria, Australia.

  • 79% (n=186) of fatality occurred at a private residence
  • 83% (n=192) of the decedents were alone at the time of the fatal overdose
  • In 34 cases, decedent was with someone else.
    • Half of these witnesses were also significantly impaired at the time of the fatal overdose.
  • The opportunity for intervention by a bystander was present in only 19 cases.

Conclusion

  1. There was no witness or bystander in majority of overdose deaths.
  2. THN alone may only lead to modest reduction in fatal heroin overdose.

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  • Intracerebral hemorrhage (ICH) volume is a predictor of mortality and clinical outcome.
  • Communicating ICH volume to neurosurgical and neurocritical care consultants can help direct treatment decisions.
  • ICH volume can be estimated using the ABC/2 formula:
    • Select the CT slice with the largest area of the hemorrhage (reference slice)
    • A = Measure the largest diameter
    • B = Measure the largest diameter perpendicular to A
    • C = Multiply the number of CT slices with the hemorrhage by the slice thickness
      • Slices with 25-75% of the hematoma volume compared to the reference slice count as 1/2 slice
      • Slices with <25% of the hematoma volume compared to the reference slice do not count

  • A recent study by Dsouza et al. found that EM attendings as well as EM trainees were reliable in estimating ICH volume using ABC/2 compared to radiologists.

Bottom Line:  EPs can reliably estimate ICH volume using the ABC/2 formula.  Communicating ICH volume to neurosurgical and neurocritical care consultants can help direct treatment decisions.

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Category: Critical Care

Title: Renal Transplant Patients

Posted: 1/8/2019 by Mike Winters, MD (Updated: 9/23/2019)
Click here to contact Mike Winters, MD

Critically Ill Renal Transplant Patients

  • Renal transplant patients are at high risk of critical illness from a variety of etiologies.
  • Sepsis is the most common reason for critical illness and ICU admission.  
  • Due to their immunosuppression, renal transplant patients are at risk of a multitude of infections.
  • Notwithstanding, acute bacterial pyelonephritis of the transplant is the most frequent cuase of sepsis, followed by bacterial pneumonia.
  • Be sure to consider these two etiologies when faced with a critically ill, septic renal transplant patient.

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Category: Pharmacology & Therapeutics

Title: Flu Season is Upon Us: Treatment with Oseltamivir

Keywords: Flu, Treatment, Oseltamivir (PubMed Search)

Posted: 1/8/2019 by Wesley Oliver (Updated: 9/23/2019)
Click here to contact Wesley Oliver

Takeaways

---Early antiviral treatment can shorten the duration of fever and illness symptoms, and may reduce the risk of some complications from influenza.

---Early treatment of hospitalized adult influenza patients with oseltamivir has been reported to reduce death in some observational studies.

---Clinical benefit is greatest when antiviral treatment is administered within 48 hours of influenza illness onset.

 

Antiviral treatment is recommended for patients with confirmed or suspected influenza who:

---are hospitalized;

---have severe, complicated, or progressive illness; or

---are at higher risk for influenza complications. (See below for in-depth information)

Oral oseltamivir is the recommended antiviral for patients with severe, complicated, or progressive illness who are not hospitalized, and for hospitalized influenza patients.

 

Treatment:

Doses: Oseltamivir 75 mg twice daily

Renal Impairment Dosing

CrCl >60 mL/minute: No dosage adjustment necessary

CrCl >30 to 60 mL/minute: 30 mg twice daily

CrCl >10 to 30 mL/minute: 30 mg once daily

ESRD undergoing dialysis: 30 mg immediately and then 30 mg after every hemodialysis session

 

Duration of Treatment:

Recommended duration for antiviral treatment is 5 days for oral oseltamivir. Longer daily dosing can be considered for patients who remain severely ill after 5 days of treatment.

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Dyspnea in the Intubated Patient

  • Dyspnea may occur in up to 50% of intubated patients and has been associated with prolonged mechanical ventilation.
  • A number of assessment tools are available to detect dyspnea in the intubated patient.
  • Regardless of the tool used, once dyspnea is diagnosed, consider the following;
    • When possible, reduce nonrespiratory stimuli of the respiratory drive (i.e., fever, acidosis, anemia)
    • Minimize respiratory impedance (i.e., bronchodilators, thoracentesis for pleural effusion)
    • Optimize ventilator settings (i.e., change modes if applicable, increase inspiratory flow, increase PEEP)
    • Pharmacologic treatment (i.e., opioids, benzodiazepines)

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Category: Critical Care

Title: Fluid Resuscitation in Shock

Keywords: circulatory dysfunction, hypotension, shock, fluid resuscitation, IV fluids (PubMed Search)

Posted: 1/1/2019 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

The European Society of Intensive Care Medicine (ESICM) recently released a review with recommendations from an expert panel for the use of IV fluids in the resuscitation of patients with acute circulatory dysfunction, especially in settings where invasive monitoring methods and ultrasound may not be available.

 

Points made by the panel include: 

  • Circulatory dysfunction should be identified not only by HR and BP, but by other indicators of poor perfusion: altered mentation, decreased urine output, and skin abnormalities (poor skin turgor, mottling, delayed capillary refill)
  • The absence of arterial hypotension does not preclude hypovolemia
  • The lack of an increase in MAP (especially in patients with decreased vascular tone) does not exclude positive response to IVF
  • The purpose of IVF administration is to improve tissue perfusion by increasing cardiac output
  • Fluid "loading" as the rapid administration of large volumes of fluid to treat overt hypovolemia, while a fluid "challenge" is a test of fluid responsiveness
  • In elderly patients or those with arteriosclerosis or chronic arterial hypertension, a low pulse pressure (e.g. less than 40 mmHg) indicates that stroke volume is low. PP = SBP - DBP

 

Recommendations from the panel include:

  • The early measurement of lactate to incorporate in the assessment of perfusion
  • The use of crystalloids as initial resuscitation fluid (unless blood products are indicated)
  • When overt hypovolemia is unclear, the use of a fluid challenge of 150-350mL IVF within 15 minutes to help assess fluid responsiveness
  • Avoidance of using jugular venous distension alone as a guide for resuscitation
  • Avoidance of using acute urine output response alone as a guide for resuscitation, as renal response to fluids can be delayed
  • A recommendation against using CVP as a target for resuscitation; if CVP is being measured, a rapid increase with IVF should suggest poor fluid tolerance
  • Individualizing fluid resuscitation to the patient's current presentation, underlying comorbidities, and response to fluids

 

Bottom Line: Utilize all the information you have about your patient to determine whether or not they require IVF, and reevaluate their physical and biochemical (lactate) response to fluids to ensure appropriate IVF administration and avoid volume overload. 

 

 

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Taking a double-dose of a single medication is presumed to be safe in most cases. However, there is limited data to support this assumption.

 

A retrospective study of the California Poison Control System was performed to assess adverse effects of taking double dose of a single medication. During a 10-year period, 876 cases of double-dose ingestion of single medication were identified.

 

Adverse effects were rare (12 cases). However, medication classes that were involved in severe adverse effects included: 

  1. Propafenone: ventricular tachycardia and syncope
  2. Beta blockers (BB): bradycardia and hypotension
  3. Calcium channel blockers (CCB): bradycardia and hypotension
  4. Bupropion: seizure 
  5. Tramadol: ventricular tachycardia

Conclusion:

  • Adverse effect from double dosing is rare.
  • Cardiovascular collapse can occur with BB and CCB
  • Seizure can occur with tramadol and bupropion.

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Category: Neurology

Title: Medication Overuse Headaches

Keywords: headache, post concussion syndrome (PubMed Search)

Posted: 12/16/2018 by Brian Corwell, MD (Emailed: 12/23/2018) (Updated: 12/23/2018)
Click here to contact Brian Corwell, MD


A previous pearl discussed medication-overuse headache (MOH).

MOH is also known as analgesic rebound headache, drug-induced headache or medication-misuse headache.

It is defined as headache… occurring on 15** or more days per month in a patient with a preexisting headache disorder who has been overusing one or more acute treatment drugs for headache with symptoms for three or more months.

The diagnosis is clinical, and requires a hx of chronic daily headache with analgesic use more than 2-3d per week.

The diagnosis of MOH is supported if headache frequency increases in response to increasing medication use, and/or improves when the overused medication is withdrawn.

The headache may improve transiently with analgesics and returns as the medication wears off. The clinical improvement after wash out is not rapid however, patients may undergo a period where their headaches will get worse. This period could last in the order of a few months in some cases.

The meds can be dc’d cold turkey or tapered depending on clinical scenario.

Greatest in middle aged persons. The prevalence rages from 1% to 2% with a 3:1 female to male ratio.

Migraine is the most common associated primary headache disorder.

** Each medication class has a specific threshold.

Triptans, ergot alkaloids, combination analgesics, or opioids on ten or more days per month constitute medication overuse.

Use of simple analgesics, including aspirin, acetaminophen and NSAIDS on 15 or more days per month constitutes medication overuse. 

Caffeine intake of more than 200mg per day increases the risk of MOH.

 

Consider MOH in patients in the appropriate clinical scenario as sometimes doing less is more!

 

 


Category: Pediatrics

Title: Pediatric intubation: Cuffed or uncuffed tubes?

Keywords: Intubation, ETT, cuffed, airway management (PubMed Search)

Posted: 12/21/2018 by Jenny Guyther, MD (Updated: 9/23/2019)
Click here to contact Jenny Guyther, MD

Historically uncuffed endotracheal tubes were used in children under the age of 8 years due to concerns for tracheal stenosis.  Advances in medicine and monitoring capabilities have resulted in this thinking becoming obsolete.  Research is being conducted that is showing the noninferiority of cuffed tubes compared to uncuffed tubes.  Multiple other studies are looking into the advantages of cuffed tubes compared to uncuffed tubes.

The referenced study is a meta-analysis of 6 studies which compared cuffed to uncuffed endotracheal tubes in pediatrics.  The pooled analysis showed that more patients needed tube changes when they initially had uncuffed tubes placed.  There was no difference in intubation duration, reintubation occurrence, post extubation stridor, or racemic epinephrine use between cuffed and uncuffed tubes.

Bottom line: There is no difference in the complication rate between cuffed and uncuffed endotracheal tubes, but uncuffed endotracheal tubes did need to be changed more frequently.

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Category: Toxicology

Title: Bupropion overdose in adolescents

Keywords: Bupropion, TCAs, adolescents (PubMed Search)

Posted: 12/20/2018 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

Selective serotonin reuptake inhibitors are the most common anti-depressant used today. However, the use bupropion in adolescents is increasing due the belief that it has fewer side effects than TCAs.

Using the National Poison Data System (2013 – 2016), the adverse effects of bupropion were compared to TCA in adolescents (13 – 19 years old) with a history of overdose (self harm). 

Common clinical effects were:

TCA:  n=1496; Bupropion: n=2257

Clinical effects

TCAs

Bupropion

Tachycardia

59.9%

70.7%

Drowsiness/lethargy

51.5%

18.1%

Conduction disturbance 

22.2%

15.6%

Agitation

19.1%

16.4%

Hallucination/delusions

4.2%

23.9%

Seizure

3.9%

30.7%

Vomiting

2.7%

20.0%

Tremor

3.7%

18.1%

Hypotension

2.7%

8.0%

Death

0.3%

0.3%

 

Conclusion:

Bupropion overdose results in significant adverse effects in overdose; however, death is relatively rare.

 

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