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Shanahan KM, Thomas MA, Walker EN, Downs JW. Forage and You Shall Find: Cardiac Glycoside Poisoning and the Danger of Foraging. Mil Med 2023; 188:e2812-e2815. [PMID: 36208203 DOI: 10.1093/milmed/usac287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/30/2022] [Accepted: 09/15/2022] [Indexed: 11/15/2022] Open
Abstract
Amateur foraging, which can be described as the gathering of uncultivated plants for sustenance or recreation, supports many benefits for the forager and the environment; however, it can also present the hazard of unintentional poisoning. Asclepias syriaca, or common milkweed, is a potentially edible plant that also contains cardioactive steroids akin to digoxin. A 38-year-old female amateur forager boiled and sautéed 8-10 milkweed pods before ingesting them. She developed vomiting and heart palpitations within 1 hour and presented to an emergency department 3 hours after ingestion. Her exam was within normal limits with exception of heart rate in the 40-50s without hypotension. ECG was notable for sinus bradycardia. Laboratory analysis was notable for a detectable serum digoxin concentration. Life-threatening toxicity did not occur. Recently, some military services have advocated for foraging as a means to sustain far-forward troops. However, misidentification of plants by inexperienced foragers can result in severe toxicity or death. If mass foraging becomes part of expeditionary operations, military clinicians must be trained and prepared for the potentially severe plant-related poisonings.
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Affiliation(s)
- Kevin M Shanahan
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Mary A Thomas
- Department of Psychiatry, National Capital Consortium Combined Internal Medicine and Psychiatry Residency Program, Bethesda, MD, 20889-5632, USA
| | - Erika N Walker
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
| | - John W Downs
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Hockstein MA, Singam NS, Papolos AI, Kenigsberg BB. The Role of Echocardiography in Extracorporeal Membrane Oxygenation. Curr Cardiol Rep 2023; 25:9-16. [PMID: 36571660 DOI: 10.1007/s11886-022-01827-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Extracorporeal membrane oxygenation (ECMO) is increasingly used to temporarily support patients in severe circulatory and/or respiratory failure. Echocardiography is a core component of successful ECMO deployment. Herein, we review the role of echocardiography at different phases on extracorporeal support including candidate identification, cannulation, maintenance, complication vigilance, and decannulation. RECENT FINDINGS During cannulation, ultrasound is used to confirm intended vascular access and appropriate inflow cannula positioning. While on ECMO, echocardiographic evaluation of ventricular loading conditions and hemodynamics, cannula positioning, and surveillance for intracardiac or aortic thrombi is needed for complication mitigation. Echocardiography is crucial during all phases of ECMO use. Specific echocardiographic queries depend on the ECMO type, V-V, or V-A, and the specific cannula configuration strategy employed.
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Affiliation(s)
- Maxwell A Hockstein
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Narayana Sarma Singam
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.,Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St., NW, Room A121, Washington, DC, 20010, USA
| | - Alexander I Papolos
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.,Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St., NW, Room A121, Washington, DC, 20010, USA
| | - Benjamin B Kenigsberg
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA. .,Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St., NW, Room A121, Washington, DC, 20010, USA.
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Cole JB, Lee SC, Prekker ME, Kunzler NM, Considine KA, Driver BE, Puskarich MA, Olives TD. Vasodilation in patients with calcium channel blocker poisoning treated with high-dose insulin: a comparison of amlodipine versus non-dihydropyridines. Clin Toxicol (Phila) 2022; 60:1205-1213. [DOI: 10.1080/15563650.2022.2131565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Jon B. Cole
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Samantha C. Lee
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Matthew E. Prekker
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Nathan M. Kunzler
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
| | | | - Brian E. Driver
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Michael A. Puskarich
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Travis D. Olives
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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Alshaya OA, Alhamed A, Althewaibi S, Fetyani L, Alshehri S, Alnashmi F, Alharbi S, Alrashed M, Alqifari SF, Alshaya AI. Calcium Channel Blocker Toxicity: A Practical Approach. J Multidiscip Healthc 2022; 15:1851-1862. [PMID: 36065348 PMCID: PMC9440664 DOI: 10.2147/jmdh.s374887] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022] Open
Abstract
Calcium channel blockers (CCBs) are widely prescribed medications for various clinical indications in adults and children. They are available in both immediate and long-acting formulations and are generally classified into dihydropyridines and nondihydropyridines, with nondihydropyridines having more cardioselectivity. CCB toxicity is common given the widespread use which leads to serious adverse clinical outcomes, especially in children. Severe CCB toxicities may present with life-threatening bradycardia, hypotension, hyperglycemia, and renal insufficiency. Dihydropyridine toxicity, however, may present with reflex tachycardia instead of bradycardia. Initial patient evaluation and assessment are crucial to identify the severity of CCB toxicity and design the best management strategy. There are different strategies to overcome CCB toxicity that requires precise dosing and close monitoring in various patient populations. These strategies may include large volumes of IV fluids, calcium salts, high insulin euglycemia therapy (HIET), and vasopressors. We hereby summarize the evidence behind the management of CCB toxicity and present a practical guide for clinicians to overcome this common drug toxicity.
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Affiliation(s)
- Omar A Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Correspondence: Omar A Alshaya, Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, P.O. Box 3660, Riyadh, 11481, Saudi Arabia, Email
| | - Arwa Alhamed
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Nursing, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sara Althewaibi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Lolwa Fetyani
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shaden Alshehri
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Fai Alnashmi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shmeylan Alharbi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mohammed Alrashed
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmacy Department, Northwest Medical Center, Tucson, AZ, USA
| | - Saleh F Alqifari
- Department of Pharmacy Practice, College of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
| | - Abdulrahman I Alshaya
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pharmaceutical Care, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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