Double-blind, randomized study of nalmefene and naloxone in emergency department patients with suspected narcotic overdose.

STUDY OBJECTIVES: To compare the efficacy, safety, and withdrawal symptoms in emergency department patients with suspected narcotic overdose treated with nalmefene, an opioid antagonist with a 4- to 10-hour duration of action, with those treated with naloxone. METHODS: Adults in 9 centers who would otherwise receive naloxone for altered consciousness levels were randomly assigned to receive intravenous study drug (1 mg nalmefene, or 2 mg nalmefene or 2 mg naloxone, double-blinded) every 5 minutes as needed for up to 4 doses in a 4-hour study. Outcomes were 20-minute and 4-hour posttreatment changes in respiratory rates, Neurobehavioral Assessment Scale scores, Opioid Withdrawal Scale scores, and incidences of adverse events. RESULTS: Opioid positivity was recorded for 30 of 63 (1-mg nalmefene), 23 of 55 (2-mg nalmefene), and 24 of 58 (naloxone) cases, 75% of whom also had nonopioid central nervous system depressants. Most patients received only 1 dose of study drug. Similar, clinically meaningful improvements in respiratory rates and Neurobehavioral Assessment Scale scores were seen with all treatments. No statistical differences in efficacy or withdrawal outcomes were seen between treatment groups, and no significant overall time-treatment interactions occurred, in either the entire patient group or among opioid-positive cases (P >.21, all comparisons). Adverse events occurred in 30.9% (2 mg nalmefene), 15.9% (1 mg nalmefene), and 15.5% (naloxone) of patients (P >.08); none were associated with morbidity. CONCLUSION: In this study of patients with varied potential causes of altered consciousness, nalmefene (1 mg and 2 mg) and naloxone (2 mg) appeared to be efficacious, safe, and to yield similar clinical outcomes.

The 1989 Loma Prieta earthquake: impact on hospital patient care.

STUDY OBJECTIVE: To provide an overview of the Loma Prieta earthquake regarding patient care in affected hospitals. DESIGN: A retrospective review of medical records using International Classification of Disease, ninth revision (ICD-9) codes and a personal interview questionnaire. SETTING: Fifty-one hospitals in the six-county area most affected by the earthquake. TYPE OF PARTICIPANTS: Patients seeking care in emergency departments of study hospitals and supervising emergency physicians and ED nurses at the time of the earthquake. MEASUREMENTS: ED census data, complaint and diagnosis, disposition, and operative procedures for patients seen during the study period. MAIN RESULTS: Affected hospitals experienced a 15% increase in ED census during the study period. Minor trauma was the most common patient complaint. Open wound (870-897), contusion (920-924), and fracture (800-829) were the most common ICD-9 diagnostic categories. The percentage of patients presenting to EDs during the study period who were hospitalized increased slightly compared with baseline. Seventy-five percent of operative procedures were earthquake related; 63.7% of these were for fracture reduction. Physicians and nurses had somewhat conflicting opinions on adequacy of ED staffing. A small number of emergency physicians had difficulty in obtaining diagnostic tests on the night of the earthquake. Physicians noted no differences in diagnosis or treatment resulting from the earthquake. CONCLUSION: The Loma Prieta earthquake resulted in minimal negative impact on patient care in hospitals in the study area. The use of the ICD-9 classification deserves further consideration and study to improve the predictive value of disaster illness and injury reporting. The event has provided the stimulus for Bay Area hospitals to further improve plans for patient care during a disaster.

SARA (Superfund Amendments and Reauthorization Act), Title III: implications for emergency physicians.

Practically every community has one or more industries that use or produce hazardous chemicals. The release of these chemicals into that community's environment has the potential of causing serious health problems. Previously, physicians have not had information about what hazardous chemicals were in their community or a warning that release of a hazardous chemical had occurred. The Emergency Planning and Community Right-to-Know Act of 1986, known as Title III of the Superfund Amendments and Reauthorization Act (SARA), now mandates that every facility using, storing, or manufacturing hazardous chemicals make public its inventory and report every release of a hazardous chemical to public officials and health personnel. Every facility also must cooperate with physicians who are treating victims of exposure. Emergency physicians, both in their role in their community's emergency medical services system and as physicians in emergency departments, will soon be involved in many aspects of SARA's numerous ramifications. This report is intended to familiarize the emergency physician with the basic components of Title III of SARA.

Juvenile rheumatoid arthritis.

The early diagnosis of JRA rests on the recognition of three distinct modes of onset that are important in preventing deformity, blindness, and even death. Systemic onset is characterized by typical systemic manifestations, particularly high spiking fever and the rheumatoid rash, polyarticular onset is noted by arthritis of more than four joints, and pauciarticular onset is distinguished by involvement of four joints or less, most often a knee initially. In JRA, fundamental to the heart of successful management is patient and parental education regarding both the nature of the disease and goals of therapy. Whereas the NSAIDs are adequate for the control of active disease in most patients, two key issues must be resolved. First, it is important to recognize that the choice of drug for the individual patient is frequently a matter of trial and error. Second, it is critical to prescribe antiinflammatory quantities of a given drug. The slow-acting (remittive) agents, such as intramuscular or oral gold, are reserved for patients with prolonged active polyarthritis, which affects 15 per cent of all patients with JRA. There are several drawbacks to the use of remittive agents. They must be tried for several months, often in the presence of rapidly developing joint limitation and erosions on radiograph, before their effectiveness can be determined. Also, when using these drugs, one must often follow a meticulously graduated dosage regimen, while carefully monitoring the patient for toxic and potentially lethal side effects. It follows, therefore, to never use these agents unless you are familiar with their administration and potential toxicity and to seek help from a specialist.

Late death in tricyclic antidepressant overdose revisited.

We report a late death following the ingestion of amitriptyline. A 46-year-old woman presented to the emergency department with coma, hypotension, tachycardia, and a prolonged QRS interval after the ingestion of a large quantity of Elavil. She was managed with aggressive supportive care, multiple doses of oral charcoal, and charcoal hemoperfusion. The patient's ECG and hemodynamic status returned to normal within 24 hours. Despite an apparent total recovery, she suddenly sustained a cardiorespiratory arrest and died 33 hours after ECG normalization (at 57 hours after admission). This case brings into question the feasibility of ceasing ECG monitoring in tricyclic antidepressant overdoses once the ECG has stabilized, especially in patients with a history of chronic usage. A possible explanation for late sequelae is the myocardial cell binding and depressant effect of preexisting therapeutic TCA medication.

Fibromyalgia (fibrositis) in children.

The features of fibromyalgia (fibrositis) in children are similar to those in adults with the syndrome. Both juveniles and adults report diffuse musculoskeletal aches and/or stiffness with typical modulating factors. Moreover, they have no systemic manifestations, and routine laboratory studies yield normal results. On physical examination in both children and adults, multiple soft-tissue tender points are evident at characteristic, symmetric sites but with no evidence of arthritis.

Contemporary management of ankylosing spondylitis.

The comprehensive management of ankylosing spondylitis has both immediate and long-term objectives. The physician must first suppress the patient's articular discomfort and inflammation with NSAIDs, then begin long-range supportive measures such as postural training and daily exercise in order to prevent, delay, or correct deformity. Acute anterior uveitis and other systemic manifestations must be promptly recognized and treated, often with the help of specialists. While the capacity to function and work can be adequately maintained for most patients, it depends largely on patient education and compliance. Educational material for patients with AS may be obtained from either a local chapter or the national headquarters of the Arthritis Foundation (17 Executive Park Drive, NE, Suite 480, Atlanta, GA 30329), as well as the Ankylosing Spondylitis Association (ASA). Patients should be urged to join the ASA in order to receive the monthly newsletter. The address for ASA membership is 3985 Witzel Drive, Sherman Oaks, CA 91403.

The seronegative spondyloarthropathies. A graduated approach to management.

The seronegative spondyloarthropathies can create multiple and complex therapeutic problems. Consequently, the primary care physician needs to offer continuous encouragement and support to the patient, who must maintain a lifelong regimen of antiinflammatory drug therapy, daily exercise, and other supportive measures to retain mobility. With comprehensive care, the vast majority of patients can lead full, productive lives. However, management can succeed only with active participation of patients who have been adequately educated about their disease.

Efficacy of diclofenac in ankylosing spondylitis.

Ankylosing spondylitis is a systemic rheumatic disorder characterized by inflammation of the spine, sacroiliac, and large peripheral joints. Effective management demands both immediate and long-term objectives. The physician must first relieve joint inflammation and discomfort with nonsteroidal anti-inflammatory drugs, then begin long-range planning with daily exercise and other supportive measures to prevent, delay, or correct deformity. Diclofenac sodium, a nonsteroidal anti-inflammatory drug that is used worldwide in ankylosing spondylitis, has not yet been marketed in the United States. This article highlights two American studies with diclofenac: (1) a short-term, double-blind comparison with indomethacin, and (2) a 38-week extension with diclofenac for long-term efficacy and safety data. The results of these trials demonstrate diclofenac to be effective and safe for both short- and long-term treatment. When compared with indomethacin, a standard reference drug in trials of ankylosing spondylitis, diclofenac was comparable in efficacy but had a more favorable side-effect profile.

Addisonian crisis in an adolescent female: a case report.

Acute adrenal insufficiency is rarely diagnosed in the pediatric age group. In this case report, an 11-year-old female with three previous admissions for dehydration was seen for dehydration and shock. Adrenal insufficiency was considered as a working diagnosis in the emergency department. Rapid intervention with intravenous hydrocortisone and fluid resuscitation resulted in a good outcome.