Phenelzine-induced myocardial injury: a case report.

INTRODUCTION: Phenelzine is an irreversible monoamine oxidase inhibitor (MAOI). Hypertensive reactions after ingestion of tyramine-rich foods such as cheese are well known. However, a review of the available medical literature found no previous reports of myocardial infarction resulting from the ingestion of cheese by a patient taking a MAOI. CASE REPORT: A 34-year-old female taking phenelzine for depression developed severe chest pain 1 h after eating cheese. She was hypertensive and the electrocardiography showed ischemic changes in the antero-lateral chest leads. The chest pain and elevated blood pressure were relieved with intravenous morphine and nitroprusside. The initial serum troponin I level was normal, but serial repeat levels showed a rising trend with a peak at 4.89 ug/L (reference range <0.05 ug/L) 6 h after the initial blood draw, suggestive of a non-ST elevation myocardial infarction. The patient subsequently developed hypotension 4 h after another therapeutic dose of phenelzine was served to the patient 4 h after her admission to the ED. This was corrected with at least 2 L of intravenous normal saline boluses. Subsequent EKGs and Sestamibi scan showed no evidence of cardiac ischemia. She was discharged home after a hospital stay of 3 days. DISCUSSION: We believe this to be the first reported case of myocardial infarction resulting from ingestion of cheese in a patient taking a MAOI. It might be expected that hypertensive crisis could lead to a myocardial infarction, but a review of the medical literature found no such cases reported.

Intraosseous vascular access in adults using the EZ-IO in an emergency department.

BACKGROUND: Intraosseous (IO) access is an alternative to conventional intravenous access. AIMS: We evaluate the use of the EZ-IO as an alternative vascular access for patients in the emergency department. METHODS: A non-randomized, prospective, observational study was performed in adults using the EZ-IO powered drill device. RESULTS: Twenty-four patients were recruited. There were 35 intraosseous insertions, including 24 tibial and 11 humeral insertions. All EZ-IO insertions were achieved within 20 s and were successful at the first attempt except for one. Of the intraosseous insertions, 88.6% were reported to be easier than intravenous cannulation. We found flow rates to be significantly faster using a pressure bag. The seniority of operators did not affect the success of insertion. Complications included a glove being caught in the drill device and extravasation of fluid although they were easily preventable. CONCLUSION: The use of the EZ-IO provides a fast, easy and reliable alternative mode of venous access, especially in the resuscitation of patients with no venous vascular access in the emergency department. Flow rates may be improved by the use of pressure bags.

An observational, prospective study comparing tibial and humeral intraosseous access using the EZ-IO.

INTRODUCTION: Intraosseous (IO) access is an alternative to conventional intravenous access. The proximal tibia and proximal humerus have been proposed as suitable sites for IO access. METHODS: A nonrandomized, prospective, observational study comparing flow rates and insertion success with tibial and humeral IO access in adults using the EZ-IO-powered drill device was conducted. The tibia was the first site of insertion, and a second IO was inserted in the humerus if clinically indicated for the same patient. RESULTS: Twenty-four patients were recruited, with 24 tibial and 11 humeral insertions. All EZ-IO insertions were successful at the first attempt except for 1 tibial insertion that was successful on the second attempt. All insertions were achieved within 20 seconds. Mean ease of IO insertion score (1=easiest to 10=most difficult) was 1.1 for both sites. We found tibial flow rates to be significantly faster using a pressure bag (165 mL/min) compared with those achieved without a pressure bag (73 mL/min), with a difference of 92 mL/min (95% confidence interval [CI]: 52, 132). Similarly, humeral flow rates were significantly faster using a pressure bag (153 mL/min) compared with humeral those achieved without pressure bag (84 mL/min), with a difference of 69 mL/min (95% CI: 39, 99). Comparing matched pairs (same patient), there was no significant difference in flow rates between tibial and humeral sites, with or without pressure bag infusion. CONCLUSIONS: Both sites had high-insertion success rates. Flow rates were significantly faster with a pressure bag infusion than without. However, we did not find any significant difference in tibial or humeral flow rates.

Should a benzodiazepine antagonist be used in unconscious patients presenting to the emergency department?

UNLABELLED: Patients in coma with suspected drug poisoning are commonly encountered in the emergency department. Benzodiazepines are one of the most commonly used drugs in self-poisoning. Flumazenil, a benzodiazepine antagonist has been suggested as a diagnostic and treatment tool in suspected poisoning of unclear cause, but caution is required due to potential side effects. No systemic review of this literature has been done on this topic. OBJECTIVES: The aim of this study is to examine if flumazenil should be used in patients with coma from suspected drug poisoning. SEARCH STRATEGY: Randomised controlled trials were identified from the Cochrane Library, Pubmed and EMBASE. Bibliographies from included studies, known reviews and texts were searched. Content experts were contacted. SELECTION CRITERIA: Randomised controlled trials were eligible for inclusion. Studies were included if patients who presented with altered mental state from suspected drug poisoning were treated with intravenous flumazenil as compared to placebo. DATA COLLECTION AND ANALYSIS: Data were extracted and methodological quality was assessed independently by two reviewers. MAIN RESULTS: Seven randomised controlled trials were included. A total of 466 patients were involved. Flumazenil was found to reverse coma from suspected drug poisoning with a relative benefit of 4.45 (95% CI 2.65, 7.45). In terms of major side effects, there was no statistical difference between flumazenil and placebo (RR 2.86, 95% CI 0.12-69.32). However, in terms of minor side effects, flumazenil was associated with a higher incidence of anxiety (RR 2.84, 95% CI 1.28-6.30) and other side effects (RR 3.73, 95% CI 2.078-6.73). There was no difference in the incidence of vomiting (RR 4.28, 95% CI 0.95-19.35). CONCLUSION: Current evidence shows that flumazenil may be effective in the reversal of coma in patients presenting to the emergency department with coma from suspected drug poisoning.

Thyrotoxic heart disease.

Patients with tachyarrythmias as a result of thyroid storm have been typically treated with beta-blockers to decrease the heart rate and alleviate beta-receptor mediated symptoms such as anxiety and tremulousness. We report an unusual case of a previously well young man presenting to the emergency department with atrial flutter and who was clinically hyperthyroid. The patient was treated with propanolol to control his heart rate but suffered cardiovascular collapse. Although the patient was successfully resuscitated, he required inotropic support and intra-aortic balloon pump. The use of propanolol should be carefully considered in patients with thyrotoxic cardiomyopathy especially in those with heart failure because of the risk of exacerbation.