The effect of the menstrual cycle on asthma presentations in the emergency department.

BACKGROUND: Seventy-five percent of all adult hospital admissions for asthma are women. OBJECTIVE: To determine whether a relationship exists between phases of the menstrual cycle and asthma exacerbations in adult females. METHODS: Data were analyzed from 182 nonpregnant, adult females with asthma aged 13 years to menopause. Date of presentation, patient age, duration of asthma attack, date of last menstrual period, regular interval between menses, presenting peak expiratory flow rate, and admission and discharge decision were recorded prospectively. Treatment interventions abstracted retrospectively from patient charts included use of oxygen, xanthines, beta-adrenergic agonists, corticosteroids, and magnesium sulfate. The menstrual cycle was divided into 4 phases based on fluctuations in serum estradiol levels. The 4 intervals were preovulatory (days 5-11), periovulatory (days 12-18), postovulatory (days 19-25), and perimenstrual (days 26-4). RESULTS: Data were analyzed with a goodness-of-fit chi 2. Between June 1991 and May 1992, 182 females (mean +/- SD age, 28.5 +/- 8.0 years) were surveyed. No significant differences were noted for use of oxygen, beta-adrenergic agonists, xanthines, or magnesium among members of the 4 menstrual groups. Intervention with corticosteroids was least in the postovulatory interval (y:n) 0.5:1 and greatest in the preovulatory interval 3.0:1 (alpha = .03) Presentations by menstrual interval were as follows: preovulatory, 36 (20%); periovulatory, 43 (24%); postovulatory, 18 (10%); and perimenstrual, 85 (46%) (alpha < .01). CONCLUSIONS: Asthma presentations are least frequent when serum estradiol levels are at a sustained peak. We observed a 4-fold variation in asthma presentations during the perimenstrual interval, when serum estradiol levels decrease sharply after that prolonged peak. These findings suggest that monthly variations in serum estradiol levels may influence the severity of asthma in adult females.

Predictors of coronary artery disease in patients with cocaine-associated myocardial infarction. Cocaine-Associated Myocardial Infarction (CAMI) Study Group.

PURPOSE: To identify clinical criteria predictive of underlying coronary artery disease in patients with cocaine-associated myocardial infarction. PATIENTS AND METHODS: Using a retrospective cross-sectional study design at 29 acute care hospitals, we identified 70 patients with cocaine-associated myocardial infarction who had a determination of the presence or absence of coronary artery disease. Clinical characteristics of patients with coronary artery disease (> 50% stenosis on cardiac catheterization or reversible ischemia on stress test) were compared with patients without coronary artery disease (< 50% stenosis on cardiac catheterization). RESULTS: Compared with patients without coronary artery disease (n = 21), patients with coronary artery disease (n = 49) were older (42 versus 31 years; P < 0.001), had more traditional cardiac risk factors (2.3 versus 1.5; P < 0.001), more frequent history of hypertension (odds ratio [OR], 5.3; 95% confidence interval [CI], 1.4 to 20.4); more frequent family history of myocardial infarction (OR, 4.4; 95% CI, 1.3 to 15.1), more bradydysrhythmias (OR, 8.0; 95% CI, 1.0 to 65.5), and more likely to have an inferior infarct location (P = 0.04). CONCLUSION: Age, number of cardiac risk factors, location of myocardial infarction, and bradydysrhythmias predict underlying coronary artery disease in patients with cocaine-associated myocardial infarction. If validated, this knowledge may be used to develop a medically appropriate, cost-effective evaluation strategy for patients following cocaine-associated myocardial infarction.

Antihyperlipidemic activity of amine cyanoboranes, amine carboxyboranes, and related compounds.

A series of amine cyanoboranes and amine carboxyboranes were observed to be antihyperlipidemic agents in mice; i.e., they lowered serum cholesterol and triglyceride levels significantly. These compounds appeared to inhibit lipid synthesis in the early stages. The ability to lower serum cholesterol levels appeared to correlate with the suppression of the regulatory enzyme of cholesterol synthesis, beta-hydroxy-beta-methylglutaryl-CoA reductase activity. The reduction of serum triglycerides correlated with ability of the borane compound to suppress liver fatty acid synthetase activity.

Anti-inflammatory activity of amine cyanoboranes, amine carboxyboranes, and related compounds.

Amine cyanoboranes and amine carboxyboranes (boron analogs of alpha-amino acids) were shown to inhibit inflammation. The analogs effectively blocked general inflammation, induced arthritis, and the writhing reflex associated with inflammation pain, while the inflammation associated with pleurisy was marginally inhibited. The boron analogs were shown in vitro to inhibit the release of lysosomal enzymes from liver and polymorphonuclear neutrophils. Furthermore, prostaglandin synthesis was blocked by these agents at a low concentration, i.e., 10(-6) M. Liver oxidative phosphorylation processes also were uncoupled by these agents, but the migration of polymorphonuclear neutrophils was unaltered at 10(-4) M. The elevation of cyclic adenosine monophosphate levels in polymorphonuclear neutrophils correlated positively with in vivo antiarthritic activity. Initial studies in rodents demonstrated that these boron analogs can be used at safe therapeutic doses.

Acute thermoregulatory disorders.

Symptoms and signs of impaired thermal homeostasis are protean. Clinical encounters with the geriatric patient, whether acute or chronic, are often marked by imprecise historical detail, ambiguous physical findings, differing laboratory values, and unexpected responses to therapeutic modalities. In addition, geriatric patients presenting with disorders of thermoregulation have a greater morbidity and mortality than other groups. This article briefly reviews thermoregulation as well as some of the causes and treatments for both hypothermia and hyperthermia.

Bicarbonate.

Bicarbonate is a laboratory value of considerable importance in emergency medicine. It is essential in the diagnosis of acid-base disorders, but must be interpreted in the context of a number of other parameters, including electrolytes, arterial blood gases, and renal function. As most laboratory evaluations, its prime importance is confirmation of impressions drawn from the history and physical examination. Still, in the emergency department, it is frequently found as an unsuspected component of a variety of pathologic processes. Except in extreme deviations from the normal range, the clinician is encouraged to seek an understanding of primary and compensatory processes before the initiation of therapy.

Hypothermia: an easy-to-miss, dangerous disorder in winter weather.

A variety of age-related physiologic factors and disease states predispose older patients to hypothermia. These include a decreased ability to produce heat, malnutrition, medications, infections, and social factors such as isolation and poverty. The subtle clinical signs and symptoms of mild hypothermia may mimic cognitive decline, cerebral vascular accident, hypothyroidism, or myxedema coma. The challenge for the physician is to clinically recognize hypothermia and provide prompt diagnosis and treatment. Medical management of the older patient with moderate to severe hypothermia requires in-hospital intensive care, as life-threatening conditions may arise during stabilization and resuscitation.

Container residue after activated charcoal administration in the emergency department.

We hypothesized that sources of activated charcoal (AC) used as a form of gut decontamination in the treatment of drug overdose may deliver significantly less charcoal than expected because of retained charcoal and sorbitol (ACS) from the treatment of 50 consecutive overdose patients were collected. Health care personnel delivering the dose were unaware of the study hypothesis. A total of 82 containers were obtained in this manner. Each container was labelled to contain 25 g AC and 48 g sorbitol. Five unused containers of ACS were obtained as controls. Each container was thoroughly cleaned, and the contents vacuum filtered and washed with 1 L of tap water. The tared filter paper and charcoal was dried for 24 h and weighed. The average amount of charcoal retained in each used container (retained) was 0.549 g (range 0.318-1.637 g). This accounts for 2.2% of the 25 g dose expected to be delivered. The average amount of charcoal found in each unused container (actual) was 25.892 g. The delivered dose (actual minus retained) may be calculated as 101.4% of the expected 25 g dose. When using this formulation of ACS there is no significant difference between the amount of charcoal given to an overdose patient and the amount ordered for gut decontamination. Despite the poor suspension of charcoal in sorbitol and the less than ideal conditions under which it is given, the patient receives an adequate dosage of AC if it is ordered.

Toxicology screening of the trauma patient: a changing profile.

STUDY OBJECTIVES: To determine the current ingestants found in the multiply injured trauma patient and to determine if this select group of ingestants affected the resuscitation, evaluation, or convalescent management of these patients. DESIGN: A one-year retrospective analysis was performed on all patients who were admitted to an urban trauma center with a discharge diagnosis of multiple trauma and who received a comprehensive toxicology screening test. MAIN RESULTS: One hundred twenty-seven of the 177 patients (72%) who fulfilled the criteria had positive toxicology screens. Ethyl alcohol was the only drug present in 26 of these patients (20%); 57 (45%) were positive for drugs other than ethyl alcohol. A combination of ethyl alcohol and at least one other drug was quantified in 44 patients (35%). The most often encountered substances were ethyl alcohol (55%), marijuana (24%), and cocaine (21%). Twelve drug screens (9%) demonstrated pharmaceuticals (eg, acetylsalicylic acid, acetaminophen, or cyclic antidepressants) that may require specific antidotal treatment. CONCLUSION: The ingestant profile found in this subgroup of trauma patients differed from those of previous studies. Although a select group of these ingestants requires specific treatment or affects the physical assessment of the patient, none of these trauma patients received more than supportive care.

Poison center utilization in nosocomial toxicologic exposures: a prospective study.

Accidental toxicologic exposures that occur within health care facilities (HCFs) have the potential to increase morbidity and mortality as well as enhance medicolegal liability. By contacting the poison center immediately on recognition of these events, health care providers may ultimately lessen eventual toxic effects through appropriate intervention. Exposures of this nature reported to the poison center over a 12-month period were collected and tabulated for specific occurrences. Six categories of therapeutic mis-adventure were delineated: 1. Right patient/wrong medication (18%); 2. Right patient, right medication/wrong dose or route (16%); 3. Lack of patient education (2%); 4. Proximity of potentially harmful substances to confused persons (54%); 5. Incorrect equipment management (6%); and 6. Pharmacologic treatment based on lab error (4%). This study seeks to increase awareness of poison center ability to assist in management of the "therapeutic misadventure".

Poison center utilization in nosocomial toxicologic exposures: a prospective study.

Accidental toxicologic exposures that occur within health care facilities (HCF's) have the potential to increase morbidity and mortality, as well as enhance medicolegal liability. By contacting the poison center immediately on recognition of these events, health care providers may ultimately lessen eventual toxic effects through appropriate intervention. Exposures of this nature reported to the poison center over a twelve month period were collected and tabulated for specific occurrences. Six categories of therapeutic misadventure were delineated: Right patient/wrong medication (18%); Right patient, right medication/wrong dose or route (16%); Lack of patient education (2%); Proximity of potentially harmful substances to confused persons (54%); and Incorrect equipment management (4%). This study seeks to increase awareness of poison center ability to assist in management of the "therapeutic misadventure."

Anaphylactoid reaction following ketorolac tromethamine administration.

OBJECTIVE: To report a case of an anaphylactoid reaction to injectable ketorolac tromethamine in a patient with no prior history of allergies or risk factors associated with nonsteroidal anti-inflammatory drug-induced hypersensitivity reactions. CASE SUMMARY: A 37-year-old man without a significant medical history presented to an emergency department with vague, dull, left-sided chest pain. Myocardial infarction was ruled out based on an unremarkable electrocardiogram, chest X-ray, and laboratory data that were within normal limits. Sublingual nitroglycerin 0.4 mg, magnesium/aluminum hydroxide gel 30 mL, and intravenous ranitidine 50 mg were administered without resolution of symptoms. Ketorolac tromethamine 60 mg was administered intramuscularly with resolution of symptoms. The patient was discharged; however, within 30 minutes, he returned to the emergency department with facial swelling, shortness of breath, and chest tightness. Multiple doses of aerosolized albuterol and intravenous methylprednisolone and diphenhydramine were administered, resulting in a slight improvement of symptoms. The patient was admitted for a complete cardiac evaluation that proved negative. The allergic symptoms resolved and the patient was discharged without medication after a three-day hospitalization. DISCUSSION: Ketorolac tromethamine is the first injectable nonsteroidal antiinflammatory drug approved for short-term pain management. A review of the literature revealed no similar cases of anaphylactoid reaction. CONCLUSIONS: Healthcare professionals must be aware of the potential risks of anaphylactoid reactions, especially in light of the increased use of injectable ketorolac in the ambulatory setting and availability of the oral formulation.

Allergic reaction to sulfiting agents.

Sodium metabisulfite (MBS) is a commonly used food and drug preservative. We report the case of a 32-year-old man with a documented history of allergy to MBS who developed an anaphylactic reaction after ingestion of MBS-treated foods. The patient had a prolonged clinical course requiring two emergency department visits and three weeks of outpatient steroid therapy. It is believed that this patient's relapse and delayed recovery may have been related to his continued exposure to sulfites during treatment. The emergency physician should be aware that some medications commonly used to treat allergic reactions and asthma contain MBS.

Gastrointestinal transit times of a charcoal/sorbitol slurry in overdose patients.

Gut decontamination with a slurry of activated charcoal and sorbitol is one of the methods presently available to decrease total body burden of ingested drug. This one year retrospective audit of patients presenting with a history of recent toxic ingestion was designed to determine the time to stool of a charcoal/sorbitol slurry (CSS) when used for differing ingestants. A total of 69 patients received a CSS. 50.7% took less than 6 hours for their first charcoal stool, while 26.1% had emesis of the CSS within 30 minutes of administration. Ingestion of drugs which may increase gastrointestinal transit time (i.e. opioids, cyclic antidepressants) correlated with prolonged time to stool despite treatment with the CSS. Though a prospective, controlled study needs to be performed, variation in dosage of the CSS may be appropriate in select patient groups to offset the effects of the ingestant on bowel motility.

Berry identification by emergency health care providers.

Emergency Department (ED) visits due to environmental toxins increase during summer and autumn months for multiple factors, including outdoor activities which permit proximity to wild berries and seeds. The Poison Center (PC) may be involved in this exposure by initial referral or by contact with emergency medicine personnel on patient arrival. Berry identification can be enhanced by considering the month and the basic berry description; positive identification can be made only be visual inspection. When, and if, the berry is identified, appropriate treatment can be instituted (as gastric emptying may not be indicated for every plant/wild berry ingestion). Regional AAPCC data was reviewed, and the most common berry exposures in this locale comprised the basis for the testing vehicle. Slides from the authors' collections were utilized in the examination. Examinees included emergency medicine physicians and nurses at an urban teaching hospital who attended a 40-minute presentation and discussion. Zero percent correctly identified all 10 specimens. Less than 10% of the berries were identified correctly by common name, and fewer examinees were able to correctly determine the presence/absence of potential toxicity. No difference in scores based on sex or professional experience was noted. An obvious implication is to increase emergency health care providers' education in locale-specific medical botany.

Emergency department daily record review: a quality assurance system in a teaching hospital.

A system of daily patient chart review of 11 categories of physician documentation and patient care was implemented over a 36-month period at Allegheny General Hospital in Pittsburgh. A total of 108,317 charts of emergency patients were reviewed. Feedback on errors in all categories were given to the physicians responsible, and necessary corrective actions were taken as soon as possible. All new resident physicians rotated in two-month blocks and received orientation to patient care and chart documentation expectations prior to starting the service. All physicians' charts underwent the same thorough chart review. Not only did the percentage of errors decrease from the first months to the second months of the residents' rotations, but the yearly percentage of total errors decreased as the study progressed, from 5.47% to 3.57%.

Identification of common houseplants in the emergent care setting.

One of the many bonds shared by poison center and emergency medicine staffs is the fear of plant misidentification. Although serious plant ingestions are uncommon, with all plant exposures totaling 8.3% of the American Association of Poison Control Centers' (AAPCC) 1985 data, it remains advisable to evaluate the ability of emergency medicine health care personnel to identify common houseplants and their toxic principles. Comparison of popular (based on sales) common houseplant lists obtained from two local nurseries and AAPCC 1985 reported plant exposure data enabled formulation of a 12-plant test vehicle. Specimens were photographed and the color slides viewed by the participants in a 40-minute presentation. Fifty-six health care professionals from 2 teaching institutions were tested. None of the participants (0%) were correct on all 12 specimens presented. Only 17% of the plants were identified correctly by common name. A mere 13% were correctly identified as being toxic or nontoxic. Although fewer females were tested (N = 14), they did better proportionately than males in visual identifications (28% vs 12% of all data points correct). Overall study results indicate a significant need for further staff education in medical botany and phytotoxins.

The use of ondansetron in the treatment of nausea and vomiting associated with acetaminophen poisoning.

BACKGROUND: Nausea and vomiting associated with poisoning can complicate treatment and in some cases delay potential antidote administration. Side effect such as lowering the seizure threshold may at times discourage the use of traditional phenothiazine and butyrophenone antiemetics. METHODS: We performed a prospective, single arm, observational study examining the effectiveness of the 5HT3 receptor antagonist ondansetron in the management if nausea and vomiting associated with acetaminophen poisoning. Patients with a history or laboratory evidence of acetaminophen poisoning were eligible for inclusion in the study. Exclusion criteria included age less than 18 or greater than 65, use of other antiemetic therapy within the previous 12 hours, history of preexisting hepatic or hematologic disease, pregnancy, or significant ingestion of other substances. Upon meeting entry criteria, patients were administered 8 mg of intravenous ondansetron. Nausea was graded on a 100 mm scale with number of emetic episodes recorded before and after treatment. RESULTS: Six patients were entered in the study. All patients had nausea and at least one emetic episode prior to ondansetron and prior to administration of N-acetylcysteine. All patients reported relief of nausea after ondansetron. The degree of nausea decreased by an average of 52% at 30 min and 88% at 60 min following ondansetron administration. No significant vital sign changes were recorded in any patient, and there were no complications related to therapy. Three patients were administered N-acetylcysteine, and all tolerated this therapy without vomiting after ondansetron. CONCLUSIONS: Ondansetron appears to be a potentially useful adjunct in the management of nausea and vomiting associated with acetaminophen poisoning.