When Too Much Is Enough: Pediatric Cyproheptadine Overdose with Confirmatory Level.

Cyproheptadine is an H-1 antihistamine with anticholinergic and antiserotonergic effects. Cyproheptadine's most common use has been in the management cold-induced urticaria. It is often used in primary care for its side effect of appetite stimulation. Recently there has been increasing interest in its use in the treatment of drug-induced serotonin syndrome. Cyproheptadine overdose is uncommonly reported in the medical literature. We report the rare case of a pediatric cyproheptadine overdose with a confirmatory cyproheptadine level.

Derivation and preliminary validation of a risk score to predict 30-day ED revisits for sickle cell pain.

BACKGROUND: Emergency department (ED) revisits and 30-day readmissions have been proposed as markers for quality of ED care for sickle cell disease (SCD). OBJECTIVE: To create a scoring system that quantifies the risk of 30-day revisit after ED discharge for SCD vaso-occlusive pain METHODS: This was a dual-center retrospective derivation and validation cohort study. The derivation was performed at an academic, tertiary care center and the validation at an urban community hospital. The primary outcome was revisit to the ED within 30 days after an ED discharge for SCD pain. Recursive partitioning was used to derive a scoring system to predict 30-day revisits. RESULTS: Of a total of 1456 ED visits for SCD pain, there were 680 ED discharges (admission rate of 53%) in 193 unique individuals included in the derivation cohort. There were 240 (35.3%) 30-day revisits. Of a total of 126 ED visits for SCD, there were 79 ED discharges in 41 unique individuals in the validation cohort. The final risk score included 4 variables: (1) age, (2) insurance status, (3) triage pain score, and (4) amount of opioids administered during the ED visit. Possible scores range from 0 to 6. The areas under the receiver operating characteristic curves were 0.746 (95% confidence interval, 0.71-0.78-derivation cohort) and 0.753 (95% confidence interval, 0.65-0.86-validation cohort). A cutoff of 4 or greater identified 60% of 30-day ED revisits in the derivation cohort and 80% of revisits in the validation cohort. CONCLUSIONS: A risk score can identify ED visits for SCD pain with high risk of 30-day revisit.

Use of 4-factor prothrombin complex concentrate in the treatment of a gastrointestinal hemorrhage complicated by dabigatran.

Target-specific oral anticoagulants (TSOACs) provide patients and healthcare providers with an alternative to vitamin K antagonists (VKA). The TSOACs are of similar or superior efficacy to warfarin, but unlike VKAs, there are no approved 'antidotes' for rapid reversal of life-threatening bleeding on therapy. We report here the case of an 83-year-old gentleman, who presented to the emergency department with severe gastrointestinal hemorrhage and coagulopathy (hemoglobin: 5.3 g/dL and INR: 2.2) while on the direct thrombin inhibitor dabigatran. His coagulopathy reversed rapidly after administration of 4-factor prothrombin complex concentrate (4 F-PCC), and after initial administration of 2 units of packed red blood cells, no further product transfusions were required. He was discharged 4 days later without further complications.