High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series.

Sympathetic crashing acute pulmonary edema (SCAPE) describes the most severe presentation of acute heart failure (AHF). Immediate intervention is required to prevent hemodynamic decompensation and endotracheal intubation. Although high-dose nitroglycerin (>100 µg/min) has been described for this clinical scenario in limited case reports, the concern for adverse effects such as hypotension and syncope limit providers comfortability in initiating nitroglycerin at these doses. Described here is a case series of four patients who safely and effectively received high-dose nitroglycerin infusions for the management of SCAPE.

Cannabinoid toxicity in pediatrics.

PURPOSE OF REVIEW: The advent of legalized cannabis in multiple regions of the United States has rendered the drug more accessible to pediatric patients. Pediatricians and Pediatric Emergency Medicine Providers face new challenges in counseling both patients and their parents, diagnosing exploratory ingestions of cannabinoids in toddlers, and managing complications of prolonged, heavy cannabis use in adolescents. The purpose of this review article is to provide clinicians a succinct summary of recent literature regarding tetrahydrocannabinol (THC) pharmacokinetics, pharmacodynamics, impacts on development, as well as presentations of acute and chronic toxicity. RECENT FINDINGS: Many young children being admitted to the hospital for cannabis toxicity have been exposed to high concentration products, such as edibles, resins, or vaping fluid. These products contain extremely high concentrations of cannabinoids, and lead to sedation, respiratory depression, and other adverse effects. Chronic toxicity associated with cannabis consumption includes neurocognitive changes and cannabinoid hyperemesis syndrome. SUMMARY: Clinicians should provide guidance for pediatric patients and their caregivers to reduce the risk of accidental cannabis exposure, particularly with high concentration products. In addition, clinicians should consider chronic cannabis exposure when evaluating certain complaints, such as chronic vomiting or educational performance at school.

Recognition and Management of Pediatric Salt Toxicity.

OBJECTIVES: Immediate recognition of salt toxicity and aggressive resuscitative measures are critical in the treatment of this lethal poisoning. Despite heroic measures, pediatric deaths due to salt toxicity still occur from irreversible neurological damage. The objective of this article is to review the relevant literature and offer a therapeutic algorithm for the management of pediatric patients presenting with salt toxicity. METHODS: A literature search for cases of salt toxicity was conducted. Articles in English that were available electronically through PubMed and Google Scholar were reviewed. RESULTS: Nineteen cases and case series of salt toxicity were located using our search strategy. Salt poisoning has a distinct pathophysiology compared with hypernatremia, most notable for the lack of formation of idiogenic osmoles. CONCLUSIONS: The approach to treatment differs between salt toxicity and hypernatremia, focusing on rapid correction of serum osmolality rather than gradual normalization of serum sodium concentrations. Consultation of nephrology and child protection services are strongly recommended in the comprehensive treatment approach.

The association of cannabis use and cardiac dysrhythmias: a systematic review.

Introduction: Cannabis use results in elevation of heart rate and blood pressure immediately after use, primarily due to sympathetic nervous system stimulation and parasympathetic nervous system inhibition. These effects may precipitate cardiac dysrhythmia. The objective of our study was to analyze systematically the pertinent medical literature regarding the putative association between cannabis use and cardiac dysrhythmia.Methods: We queried PubMed, Google Scholar, and OpenGrey, and reviewed results for relevance. We graded clinical trials, observational and retrospective studies, case series and reports using Oxford Centre for Evidence-Based Medicine guidelines.Results: The relevant publications identified included one Level I systematic review and meta-analysis of six human studies, 16 Level II studies with 6,942 subjects, nine Level III studies with 3,797,096 subjects and two systematic and scoping reviews with 30 cases. Cannabis-induced tachycardia was highlighted in 17 of 28 (61%) Level I-III articles followed by a generalized description of dysrhythmia in eight (29%). Specific dysrhythmias noted in the Level I-III articles included atrial fibrillation, atrial flutter, atrioventricular block, premature ventricular contractions, premature atrial contractions, ventricular tachycardia, and ventricular fibrillation. Other reported findings on electrocardiogram included ST segment elevation, P, and T wave changes. Only one Level III study reported a decreased risk of atrial fibrillation from cannabis use in patients hospitalized for heart failure (Odds ratio = 0.87). There were 39 case series (Level IV) and case reports (Level V) with 42 subjects. Average age was 30 ± 12 years, and only ten (24%) were female. The most common dysrhythmia mentioned in the Level IV and V articles was ventricular fibrillation (21%), followed by atrial fibrillation (19%), ventricular tachycardia (12%), third degree atrioventricular block (12%), and asystole (12%). There were four cases (10%) of symptomatic bradycardia. Notable electrocardiographic changes included ST segment elevation (29%), Brugada pattern in leads V1, V2 (14%), and right bundle branch block (12%). There were eight cases of cardiac arrest, of whom five expired.Conclusion: Cannabis use is associated with increased risk of cardiac dysrhythmia, which is rare but may be life-threatening. Clinicians and nurses should inquire about acute and chronic cannabis use in their patients presenting with tachycardia, bradycardia, dysrhythmia, chest pain, and/or unexplained syncope. Patients who use cannabis should be educated on this deleterious association, especially those with underlying cardiac disease or risk factors.

Fatal Tension Hemothorax Combined With Exanguination: A Rare Complication of Neurofibromatosis.

Neurofibromatosis (NF) is a common autosomal dominant disorder that can be subdivided into type 1, type 2, and schwannomatosis. Patients with NF1 typically develop café-au-lait spots, scoliosis, and benign neurofibromas. In addition, NF1 predisposes to vascular complications including stenosis, arterial ectasia, and aneurysms. Here, we report the case of an otherwise healthy 32-year-old man who developed a fatal tension hemothorax due to vertebral artery aneurysm rupture. Based on the available literature, we discuss the presentation, workup, and available therapeutic approaches to this complication of neurofibromatosis.

Drug-induced hyperlactatemia.

BACKGROUND: Hyperlactatemia is common in critically ill patients and has a variety of etiologies. Medication toxicity remains an uncommon cause that providers often fail to recognize. In this article, we review several medications that cause hyperlactatemia in either therapeutic or supratherapeutic dosing. When known, the incidence, mortality, pathophysiology, and treatment options are discussed. METHODS: We performed a literature search using PUBMED and Google Scholar for English language articles published after 1980 regarding medication induced hyperlactatemia and its management. Our search string resulted in 798 articles of which 138 articles met inclusion criteria and were relevant to the topic of our review. CONCLUSIONS: Hyperlactatemia is a relatively rare but life-threatening toxicity of various medication classes. Discontinuation of the drug is always advised, and some toxicities are subject to specific antidotal treatment. If there is no apparent medical cause for hyperlactatemia (sepsis, hypotension, hypoxia), clinicians should consider a toxicological etiology.

Resolution of cannabis hyperemesis syndrome with topical capsaicin in the emergency department: a case series.

BACKGROUND: Cannabinoid hyperemesis syndrome (CHS) is characterized by symptoms of cyclic abdominal pain, nausea, and vomiting in the setting of prolonged cannabis use. The transient receptor potential vanilloid 1 (TRPV1) receptor may be involved in this syndrome. Topical capsaicin is a proposed treatment for CHS; it binds TRPV1 with high specificity, impairing substance P signaling in the area postrema and nucleus tractus solitarius via overstimulation of TRPV1. This may explain its apparent antiemetic effect in this syndrome. PURPOSE: We describe a series of thirteen cases of suspected cannabis hyperemesis syndrome treated with capsaicin in the emergency departments of two academic medical centers. METHODS: A query of the electronic health record at both centers identified thirteen patients with documented daily cannabis use and symptoms consistent with CHS who were administered topical capsaicin cream for symptom management. RESULTS: All 13 patients experienced symptom relief after administration of capsaicin cream. CONCLUSION: Topical capsaicin was associated with improvement in symptoms of CHS after other treatments failed.

Unsuspected Clenbuterol Toxicity in a Patient Using Intramuscular Testosterone.

Clenbuterol is a beta-agonist that has been abused by fitness-oriented individuals for muscle growth and weight loss. We report a case of a 46-year-old man who presented tachycardic, hypokalemic, and hyperglycemic after injecting testosterone obtained from Brazil. He developed refractory hypotension and was started on an esmolol infusion for suspected beta-agonist toxicity. Laboratory analysis showed a detectable clenbuterol serum concentration. Analysis of an unopened ampule contained boldenone undecylenate, clenbuterol, and vitamin E. This case illustrates a novel exposure that caused beta-agonist toxicity and was treated successfully with rapid-onset beta blocker.

Canagliflozin-associated diabetic ketoacidosis: a case report.

Canagliflozin is a novel sodium-glucose cotransporter-2 (SGLT-2) inhibitor approved for the management of diabetes. We report the presentation and management of two cases of canagliflozin associated diabetic ketoacidosis (DKA) and discuss the mechanism of canagliflozin associated DKA. Patient 1, a 55 year old woman maintained on canagliflozin for diabetes mellitus II presented to the emergency department (ED) with 24 hours of nausea and vomiting. She was diagnosed with DKA featuring hypotension, hyperglycemia, ketosis and acidosis. A second 54 year old man also maintained on canagliflozin for diabetes mellitus I presented to the ED with 24 hours of nausea and vomiting. He was diagnosed with DKA with similar manifestations as patient 1. Both patients underwent massive volume resuscitation and intravenous insulin therapy with resolution of ketosis and acidosis. By inhibiting SGLT-2, canagliflozin promotes glucosuria, which in turn can produce up to a 10% decrease in total plasma volume rendering patients maintained on canagliflozin susceptible to dehydration. Inhibition of SGLT-2 also leads to glucagon secretion, which in the volume deplete individual, can exacerbate DKA. Physicians should be aware of the rapid onset of DKA in patients maintained on canagliflozin after just minor additional fluid losses.

Medical marijuana and driving: a review.

Medical marijuana remains a highly debated treatment regimen despite removal of state penalties against care providers prescribing the drug and patients treated with the drug in many areas of the USA. The utility of marijuana in specific medical conditions has been studied at length, but its effects on driving performance and risk of motor vehicle collision remain unclear. As with other medications that affect psychomotor function, the healthcare provider should be informed of the potential risks of driver safety prior to prescribing this psychotropic drug to give appropriate anticipatory guidance for appropriate use. The goal of this narrative review is to assess the current literature regarding marijuana as it relates to driving performance and traffic safety. With a foundation in the pharmacology of cannabinoids, we consider the limitations of testing cannabinoid and metabolite concentration. In addition, we will review studies on driving performance and epidemiological studies implicating marijuana in motor vehicle collisions. The increasing prevalence of medical marijuana laws in the USA suggests that clinicians should be aware of marijuana's influence on public safety. Patients should abstain from driving for 8 h if they achieve a subjective "high" from self-treatment with smoked marijuana and should be aware of the cumulative effects of alcohol and other psychoactive xenobiotics.